Research Article - Current Pediatric Research (2021) Pediatric Critical Care and Emergency Medicine

Analysis of miscarriage management from medical and Islamic perspective.

Siti Fatimah Salleh^1,2* , Siti Khatijah Ismail² , Tengku Fatimah Muliana Tengku Muda¹ , Lukman Abdul Mutalib2, Nadhirah Nordin1

¹Department of Islamic Contemporary Studies, University Sultan Zainal Abidin (UniSZA), Kuala Nerus Terengganu, Malaysia

²Department of Shariah and Law, Islamic Science University of Malaysia (USIM), Negeri Sembilan, Malaysia

Corresponding Author:

Siti Fatimah Salleh
Faculty of Shariah and Law
Islamic Science University of Malaysia (USIM)
E-mail: sitifatimah@unisza.edu.my

Abstract

Despite certain medical treatment following miscarriage, there are also religious implications discussed by the Muslim jurists concerning the mother and the fetus. This article aims to analyze the miscarriage management according to medical and sharia perspective through qualitative approach and case study design. Data was obtained through document analysis and interviews. The study found that medical care management following miscarriage focuses on postpartum treatment of the mother. Meanwhile, the sharia emphasizes on the worshipping aspect of the mother and on the burial management the fetus.

Keywords

Miscarriage, Fetal management, Worship, Childbirth.

Introduction

Islam as a comprehensive religion has provided guidelines and stipulations in various aspects on women issues, including miscarriage issues. Miscarriage refers to termination of pregnancy before the fetus is capable of survival outside the uterus. It has been reported that the percentage of miscarriages for pregnant mothers is between 8% to 20% of the total number of pregnant mothers [1].

Spontaneous miscarriage or medical (therapeutic) abortions are two different conditions. Spontaneous miscarriage is due to natural factors while medical (therapeutic) abortion is performed for some medical reason. Other than these two situations, another type of miscarriage is intentional miscarriage or so-called induced or forced abortion.

Spontaneous miscarriage is due to natural factors such as abnormal chromosome replication, environmental factors or trauma to the pregnancy that are unavoidable. Therapeutic abortion is performed to save the mother's life, maintain the mother's physical and mental health, or to prevent the birth of fetuses that are detected to have severe defects [2]. On the other hand, induced or forced abortion is performed due to unwanted pregnancy which resulted from a variety factors such as child conceived by rape victims or incestors.

Problem statement

The main target of the study is to resolve fiqh issues related to Obstetrics and Gynecology (O&G). It will provide a guideline and will serve as reference for O&G in midwifery treatment for the handling of miscarriage cases, especially issues related to their worshipping practices. According to Faizan Irdawati Endut, obstetrician and gynecologists experience difficulties during and after handling miscarriage cases, especially to determine the status of the mothers’ worshipping practice. As such, detailed studies on miscarriage management guidelines are very much needed by their department in explaining the right position on the mothers’ worshipping issues.

Methodology

This qualitative study employed a case study design whereby it examines the forms of miscarriage and its implications. Research data were obtained through literature review by analyzing medical documents as well as works of classical and contemporary fiqh, articles and other related works. Data were also obtained through interviews of physicians as well as local and abroad scholars. Data on miscarriage according to medical and Islamic perspectives were then analyzed with the objective of explaining the provisions of Islamic law on the management of miscarriage involving the mother and the fetus.

Literature Review

According to a study by Ibrahim in his thesis entitled: “Ahkam al-Ijhadh fi al-Fiqh al-Islami, University of al-Imam Muhammad bin Su’ud al-Islamiyyah on the law of abortion and miscarriage, he stated in detail the beginning of the phases of fetal formation, fetal preservation according to Islam, the law related to ijhadh (abortion), and legal implications of abortion and miscarriage in the aspects of crime, property, diat,and kafarah [3]. One aspect that was not discussed in his study was the status of postpartum bleeding according to medical perspective. The determination of this blood category is paramount for women experiencing miscarriage in order to ascertain the position of the demands of worship on themselves.

In a study on abortion according to Islamic and legal perspectives in Malaysia, Jamil et al. focusing his writing on the definition and concept of abortion technically according to medical and Islamic sciences, the causes of abortion as well as the legal implications of illegal abortion [4].

Findings Analysis

Miscarriage from medical aspect

Miscarriage is defined as removal or expulsion of an embryo or fetus from the uterus, resulting in or caused by its death. According to medical science in the field of obstetrics and gynecology, abortion means the removal of the fertilization product or conception before the end of a normal pregnancy. Abortion occurs when a pregnant uterus becomes empty prematurely and is known as intentionally unwanted termination of pregnancy. Among physicians, the term abortion usually refers to the termination of an illegal pregnancy (abortion), on the other hand for abortions that are allowed for medical reasons; the term commonly used by doctors is termination of pregnancy.

Although there are differences in the use of terms commonly used by medical practitioners, both terms abortion and termination of pregnancy carry the same meaning and effect of the removal of the fetus from the mother's uterus at a time when medically, the fetus does not have the ability to survive either with the help of tools or not. What distinguishes the two is only from a legal, moral and ethical point of view, between lawful and prohibited actions.

Miscarriage from Islamic perspective

According to IbnFaris, miscarriage means an abrupt loss of something out of its place [5]. Ibrahim formulates the definition of miscarriage among linguists, namely: Abortion of the infant (fetus) before the complete term of his creation, or before the complete term of pregnancy whether the soul is blown into the fetus or otherwise, as well as whether the fetus is male or female.

According to him, if a woman miscarried prematurely and the fetus is alive, it is not recognized as a miscarriage. However, if women miscarry at the first four months other pregnancy, it is referred as ijhadh. When a miscarriage occurs between the gestation period of four months to six months, it is termed as isqat. While after that period, it is referred to as wiladah which is premature birth [6,7].

According to al-Bajuri, miscarriage means that the infant (fetus) comes out of its mother's womb before is term, that is, before a sufficient period of six months or before the perfection of his creation [8].

Miscarriage Management in Medical Perspective

Since miscarriage can cause considerable distress, it has an adverse effect on the quality of life of many women. The National Institute for Health and Care Excellence (NICE) has provided a manual on the guidelines for the miscarriage management as follows [9]:

Threatened miscarriage

It is advised for a woman with vaginal bleeding and a confirmed intrauterine pregnancy with a fetal heartbeat that:

• If her bleeding gets worse, or persists beyond 14 days, she should return for further assessment.

• If the bleeding stops, she should start or continue antenatal care routine.

Medical management

• Do not offer mifepristone as a treatment for missed or incomplete miscarriage.

• Offer vaginal misoprostol for the medical treatment of missed or incomplete miscarriage. Oral administration is an acceptable alternative if this is the woman's preference.

• For women with a missed miscarriage, use a single dose of 800 micrograms of misoprostol.

• Advise the woman that if bleeding has not started 24 hours after treatment, she should contact her healthcare professional to determine ongoing individualized care.

• For women with an incomplete miscarriage, use a single dose of 600 micrograms of misoprostol. (800 micrograms can be used as an alternative to allow alignment of treatment protocols for both missed and incomplete miscarriage).

• Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed.

• Inform women undergoing medical management of miscarriage about what to expect throughout the process, including the length and extent of bleeding and the potential side effects of treatment including pain, diarrhoea and vomiting.

• Advise women to take a urine pregnancy test 3 weeks after medical management of miscarriage unless they experience worsening symptoms, in which case advise them to return to the healthcare professional responsible for providing their medical management.

• Advise women with a positive urine pregnancy test after 3 weeks to return for a review by a healthcare professional to ensure that there is no molar or ectopic pregnancy.

Miscarriage Management according to Islamic Perspective

The sharia has outlined guidelines both in terms of the necessity and prohibition of abortion as well as miscarriage management. It covers the implementation of worship, fetal and placenta management as well as several other issues related to miscarriage.

Prayer and fasting management for miscarried mothers

In cases of miscarriage, there are certain implications on the management of a mother’s worship which are related to things that are obligatory or forbidden for her to practice. It is thus obligatory for a mother to identify any prenatal blood she is experiencing according to the following situations:

First situation: For mothers who experience bleeding before knowing the status of miscarriage. The jurists differ in this regard into two views. First view: bleeding that occurs during pregnancy is categorized as menstrual blood, if it meets the conditions of menstruation according to the Malikisand Syafi'i (qauljadid) [10-12]. Consequently, the mother is prohibited from performing all acts of obligatory oworship that are forbidden in the case of menstruating woman. The second view asserts that a pregnant woman does not menstruate, and it follows that the bleeding is categorized as fasad blood. Therefore, a woman who suffers from prenatal bleeding is considered in a state of purity and obliged to fulfill all the commands such as prayer, fasting and all the required worship. This is the view of the Hanafis, Syafi'is (qaulqadim) and Hanbalis[12-15].

Second situation: For a mother who has been confirmed miscarry by the physician and the fetus is still in the uterus. According to the jurists who viewed that such bleeding is considered menses, it is not obligatory for the mother to perform any acts of worship. In contrary, where such bleeding is considered fasad blood the mother should perform all obligatory worship.

Third situation: In cases of complete miscarriage, the blood that emerges after birth is called as nifas. In this situation, the mother is not obliged to pray and she must leave all the required acts of worship during the period of nifas [16,17].

There is a lengthy discussion of jurists on the status of miscarriage blood [18]. According to the Hanafis, postpartum blood is called nifas when the fetus has already formed, and it will be not considered as nifas if there is scarcely any formation of a fetus. According to the Malikis, an alaqah, that is, a clot of blood that shall grow into a fetus and a baby is considered as nifas [19]. The Syafi'is decides that blood emerges from the uterus is considered nifas even if what comes out is a perfect or imperfect formation of child, whether it comes out alive or dead, or even merely nutfah; which is the first stage of human creation after fertilization between ovum and sperm or alaqah. As for the Hanbalis, the postpartum blood is considered nifas if the fetus has formed, and not in the phase of nutfah or alaqah.

According to the deputy mufti of Perak, postpartum blood is considered nifas if most of the fetus is delivered from the mother's womb or when there is incomplete miscarriage [20].

Fetal management

Miscarriages involving the fetus of age over six months should be bathed, shrouded, prayed and buried. Similarly, miscarriages that involve the fetus of age below six months and the fetus is delivered alive should be bathed, shrouded, prayed and buried. Meanwhile, for births of six months and below, where the fetus is not delivered alive and the fetus has a clear human feature, the management is bathing, shrouding, burying and without the need for funeral prayers on the fetus. However if the fetus is not delivered alive and there is no obvious human feature, it is only commendable for him to be wrapped and buried (Table 1).

Placenta management

The placenta is an organ that develops in uterus during pregnancy. This structure provides oxygen and nutrients to the fetus and removes waste products from the fetus blood [21]. The placenta serves as an intermediate structure for the pregnant host organism and the fetus. The placenta is an important temporary organ in the process of pregnancy. The human placenta is the result of the attachment of the fetus at the trophoblast level through the cytotrophoblast portion of the maternal uterine wall. The growth of trophoblasts in the uterine wall produces an intermediate medium that plays the function of blood exchange between the fetus and the mother. This includes the delivery of the smallest protein molecules namely amino acids, glucose, mineral salts, as well as essential gases such as oxygen and carbon dioxide. All of this occurs from the placenta through the baby’s umbilical cord which also carries stem cells with its various functions. Through this umbilical cord, waste products are passed from the baby to the mother before being removed from the body. In addition to carrying the function of a nutrient provider, the placenta also serves as hormone seepage. This is very important to ensure a healthy pregnancy, especially when this endocrine function is no longer carried out by the mother's ovaries when the buds of the corpus luteum in the eighth week of pregnancy.

According to the view of Abdul Malik al-Saadi, he stated that placenta is a substance that is counted as impurities and has no value to be associated with the child born.

Conclusion

Spontaneous (natural) miscarriage, therapeutic abortion or forced abortion occurs for varied factors. Spontaneous miscarriage occurs as a result of abnormalities that lead to unhealthy fetal conditions or unsatisfactory maternal health conditions. It is different from a therapeutic abortion when it refers to an act of removing the fetus on medical indications and there is no element of crime against life. While forced abortion is a crime against life whereby it is not due to medical indications. The implications of post-miscarriage and abortion from a medical aspect only focus on the management of bleeding as to prevent excessive bleeding that may endanger the life of the mother. However, from the Islamic perspective, miscarriage bleeding affects the law of worship of a woman. This is because the Islamic law classifies the blood that emerges after miscarriage into several categories according to its condition.

In order to determine the status of a woman's act of worship, the reference is made to state of the emptiness of the mother's uterus from any fetus and the differences of the jurists’ views in determining the status of her blood. If the condition of the blood is decided as fasad blood, i.e. disease blood, all the obligations must be performed by the mother. Nevertheless, if the blood is considered as menstrual blood or postpartum blood (nifas), it is forbidden for her to perform any acts of worship as in the case of menstruating woman. The management of the fetus, on the other hand, will be determined by his age.

Acknowledgments

This research was funded by the Ministry of Higher Education through Sultan ZainalAbidin University (UniSZA) with the approval of the Postdoctoral Scheme at Islamic Science University Of Malaysia (USIM).

Special thanks to the Faculty of Shariah and Law, Islamic Science University Of Malaysia (USIM) for the approval of the Post Doctoral Scheme in 2020/2021.

Greatest appreciations for UniSZA's Center for Research Excellence and Incubation Management (CREIM), Sultan ZainalAbidin University, (UniSZA) of the approval of the Research Grant Scheme (UniSZA/SRGS-FKI/2018/04) with the title “Development of A Holistic Maternity Treatment Management Model In Malaysia”.

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