Introduction

Fasting is the willful abstinence of food, water, or both. It is practised globally for therapeutic, religious, political or cultural reasons.1 It can be broadly categorized into complete or partial fasting, intermittent fasting, and fasting based on duration.2
Ramadan is a month of prayer, community, reflection, and fasting for Muslims, which falls on the ninth month of the Islamic calendar.3,4 Abstaining from sinful behaviors and RF are believed to cleanse the soul, divert the heart from worldly activities and instil self-discipline.4 RF is a form of intermittent fasting lasting from sunrise to sunset, but unlike intermittent fasting where consuming zero-calorie fluids is allowed, RF is more intense, entailing total abstention from food and water.4 There is a major shift from normal eating habits to exclusively nocturnal eating.5 It is non-mandatory for those who are ill, elderly, travelling, menstruating, breastfeeding, and pregnant. However, they are compelled to substitute missed days.3 Ideally, fasting during pregnancy is not advised, but there are some who still practise it during Ramadan.6
As the oldest and most commonly employed method to evaluate fetal well-being, maternal awareness of fetal movements is reliable and done without medical equipment.7 It is linked with improved perinatal outcomes, as concerned mothers present themselves for assessment once reduced fetal movement is detected. At least 10 fetal movements in 12 hours is considered normal.8Nevertheless, a decrease in fetal activity during Ramadan appears less uncommon. Studies have hypothesized that nutritional deficit may contribute to reduced fetal movements to conserve energy as it compensates for lack of nutrient transfer across the placenta.9
There are concerns that RF during pregnancy may cause adverse maternal or neonatal outcomes. For this review, we centred around fetal health rather than maternal health. To date, there is insufficient evidence linking RF and pregnancy. Existing evidence do not show significant association.10,11 Considering that normal fetal movement is highly specific and objective measurement of fetal viability, it is reasonable to include fetal movement as an outcome measure.
Before suggesting that RF during pregnancy is safe, it is important to have conclusive data that allows health professionals to provide firm recommendations. Consequently, we conducted this systematic review to gain clearer insights into the effects of RF on fetal health.