Happiness, fear and hope are just a few of the sensations that may accompany the first pangs of labor. Not surprisingly, that equation often includes stress as one enters the sterile environment of a hospital and prepares for delivery.

There are forms to fill out, decisions to make and procedures to follow.

Some Muslim women will take on the additional task of educating those in charge of their care on issues such as hijab – modest dress that includes the headscarf or veil – halal food – food that is permissible to eat – and aspects of the sunnah – traditions of Prophet Muhammad, peace be upon him – they wish to practice, such as reciting the Muslim call to prayer in the newborn’s ear.

The issue of modesty is often the hardest to tackle.

When needed, Islam does not prevent doctors from examining patients of the opposite sex, but there is also a very strong preference for seeking out treatment from doctors of the same sex whenever possible.

Further, matters related to childbirth are, in many traditional cultures of some Muslims, regarded as a women’s-only affair.

"Although he was with me for my four births in the States, my husband would not stay with me in Morocco throughout labor and delivery, citing that he was uncomfortable culturally with it because his presence would be uncomfortable to the nurses," said Christine "Amina" Benlafquih, an American of Polish, German and Lithuanian ancestry and mother of six who delivered her last two children in her husband’s native Morocco.

Benlafquih, a revert to Islam and former PR director who now works as a freelance writer in Casablanca, said her husband also seemed uneasy when a male doctor had to deliver their second child in America. "He sat across the room from me, his head buried in a newspaper almost the entire time. He got up only at the moment of birth, and then assisted with cutting the cord," she said.

Many Muslim women giving birth for the first time will simply choose a female doctor or midwife, never giving a second thought to the issue of privacy from men in the hospital.

But this is no guarantee the baby will actually be delivered by the chosen provider. Kimberly Ben, for example, says she received prenatal care from a midwife when she was pregnant with her daughter Zaria, who is now six, because she was "comfortable" with her.

"My midwife was very good and listened," said Ben, a freelance writer of African American heritage who lives in Atlanta, Ga. and embraced Islam in 1998. "But she was not available when I gave birth."

Instead, a male doctor was called in to deliver the baby. "He did not have a good bedside manner and did not even look at my birth plan," recalled Ben, who says the experience soured how she handled her next pregnancy with twin boys. "I did not even bother to put together a birthing plan, as I felt there was no point after my (first) labor experience."

At the UCSD Child Birth Center in San Diego, Calif., where Roxana Yasmin gave birth to her son, Hasan, in 2004, the system is such that the doctor who delivers your baby "could be any resident physician, which is not a very friendly system."

Yasmin, who immigrated to the United States from Bangladesh in 1999 and works as a research scientist at the Center for Behavioral Epidemiology and Community Health in San Diego, completed her MBBS degree (Bachelor of Medicine and Bachelor of Surgery) in Bangladesh, where she specialized in obstetrics and gynecology.

Many patients find they are further limited by insurance plans and other factors. "For the first two, I didn’t really have a choice. We were students, and the hospital assigned a doctor to us," said Linda Jitmoud, a mother of six and author of the Echoes series of Muslim novels, which she writes under the pen-name Jamilah Kolocotronis. "With the fourth, we couldn’t afford conventional treatment, so I went to a local hospital which provided health care for the poor, where we received a substantial discount. I had no choice in doctors. The doctors were young and used to working with lower income – and often unmarried – women. I don’t know if they were rude to everyone, or if Islam had something to do with it. I didn’t feel respected." she said.

"At Kaiser, there was really no choice – you were delivered by whoever was on duty," said Nancy O’Barr, a San Diego resident who embraced Islam in 1982 and a mother of three girls.

Kaiser Permanente, in Anaheim Hills, Calif., was where O’Barr gave birth to her first child.

With her second and third births, O’Barr switched to the university midwife program at UCSD, which she says was, at that time, "very receptive" to working with Muslim women.

"The American woman I saw for my checkups had worked for a number of years in a hospital in Saudi Arabia and was very familiar with all religious issues and customs," O’Barr said. "She also trained the other midwives so they were all familiar with working with Muslim women."

Because the hospital at UCSD is a teaching hospital, however, O’Barr found she was the object of unwanted interest when it was discovered her second daughter, Nasreen, was positioned hand-first.

"There was some concern about the safety of the delivery and whether a C-section should be performed," O’Barr said. "A male doctor was brought in, to my husband’s dismay. Word got out, and a number of students kept popping in to ‘see.’ The midwife sent them all away, but it was not the most desirable situation. I was mainly upset because my husband kept getting upset."

According to Rose Khalifah, RN, BSN, the best time to start raising concerns about privacy and other issues is during routine prenatal care visits.

Khalifah, who is also president of the National American Arab Nurses Association in Dearborn Heights, Mich., and a national trainer for Network Omni’s Caring with CLAS (Cultural and Linguistic Appropriate Services), also suggests discussing any special requests with the hospital during this period.

"Any patient, man or woman, has the right to voice their preference, concern and requests of their health care providers," Khalifah said.

But, she warned, health care settings do not always have "the luxury of having male or female providers on call 24 hours a day, seven days a week, to accommodate such requests, especially in labor and delivery units."

Khalifah, who is herself a Muslim, says she has seen many women request female providers in labor and delivery settings and actually leave against medical advice if requests were not fuflfilled, "only to return in worse medical crisis."

This, she says, leaves the non-Muslim medical community with a "poor take on our religion," especially if they are given "the impression that Islam is so strict that the mother’s life and unborn child could be risked as a measure of ensuring modesty." She also feels the situation can be exacerbated by patients who "have had very minimal, if any, prenatal care and often are uninsured or under-insured," yet make "multiple demands of the health care providers."

Lallia Allali, an Algerian who came to the United States in 2002 and lives in San Diego with her husband Taha, an imam, and their three children, expressed impatience with Muslims who fit this particular stereotype.

In one case she knows of, a Muslim couple deliberately did not seek insurance, because, as the husband put it, "We don’t need insurance, because the hospital (must) take care of a pregnant woman – this is the rule."

"I think it’s very important to educate our community," Allali said. "If we want people to respect us, we need to respect ourselves."

"Patients have the right of respect and nondiscrimination," said Hoda Shawky, RN, MSN, PNP, a pediatric nurse practitioner who works at both South Bay Family Healthcare Center in Redondo Beach, Calif., and the UCLA Medical Center in Los Angeles, referring to what is known as the Patients’ Bill of Rights.

"There is a big move in health care to provide culturally/religiously appropriate care to patients, because it leads to better health outcomes in the end. For that reason, a woman’s provider is encouraged to work with the female patient to come up with a plan of care that most suits her personal, religious and linguistic needs."

"Muslim women are not the only patients who would prefer to be seen by female providers," she said. "At work, I frequently come across both male and female patients who are not Muslim requesting to be seen by a provider of the same sex because they feel more comfortable that way, and their request is honored. The only exception to this is when staffing does not allow it."

Shawky strongly advises patients to devise a birth plan during pregnancy.

Like Khalifah, she says prenatal visits are the ideal time to discuss one’s special needs.

"If the woman has reasonable requests that the provider refuses to try to accommodate, or simply the woman is not comfortable with her provider, she has the right at any time to select a different provider," she said.

Aisha Brown*, an American of European heritage who embraced Islam in 1995, discussed religious issues with her providers during each of her three pregnancies.

"I always stated that I would not accept any men in the room unless there was an emergency situation," Brown said. "They were generally OK with that, but would always say that an emergency would override any of my personal preferences."

Brown, who gave birth in America but now lives in Amman, Jordan, always prepared detailed birth plans, but points out that doctors and midwives tend not to spend much time with you during delivery.

"I usually would have to inform the (hospital) nursing staff of my requests, and these would always be in my birth plan, of which they would have a copy," she said.

Because it is not always possible or practical to maintain hijab during labor, delivery and recovery, most women recommend getting a private room whenever possible. "The private room was very important to me as a Muslim, as a shared room meant that I would not have privacy from men visiting other patients," Benlafquih said.
"Surprisingly, sometimes men deliver the meals to the maternity ward. This happened even in Morocco. What a shock. And there is the likelihood that the on-staff pediatrician or person who brings social security and birth certificate paperwork is a man."

When she opted to have an epidural, Benlafquih said the anesthesiologist was respectful of her privacy. "He involved my husband with positioning me, and opened the back of my hospital gown only enough to reveal the area of my back that he needed to work with. My husband was careful to keep my lower half covered."

Brown made signs with "No Men Allowed" written on them and taped them to the doors of her room, while O’Barr was careful to keep the curtains around her cubicle closed.

Brown, who went into labor with her third child on Sept. 11, 2001 and delivered him the next day at Kaiser Permanente said there was a nurse who made "snide" comments about her hijab.

"I am not sure if this was her usual stance or if the circumstances of (9/11) had something to do with (it)," said Brown. "I was so exhausted that I let it go."

In another instance, Brown says she told the nurse she wanted to accompany her when she took the baby out of the room for photos and would need some time to cover her head.

"She did not wait for me to get dressed, and I had to leap out of the bed, in pain with stitches, and throw on my hijab and coat and chase her down the hall to the nursery. When I confronted her on this, she gave me an odd look and told me the photos were mandatory, which did not answer the issue at hand."

Skimpy hospital gowns are a thorn in the sides of many Muslims and even the doctors who treat them.

In Portland, Maine, which is home to a large and growing community of Somali-born immigrants, the Maine Medical Center took steps to design a modest hospital gown when it was discovered that as many as 30 percent of female Muslim patients were missing appointments because of having to wear the flimsy "Johnny" gowns that reach down to mid-thigh and open in the back, sometimes exposing a patient’s rear.

According to a report by MSNBC, Muslim patients felt humiliated having to wait in the hallway for x-rays and other procedures while wearing these gowns.

Other hospitals in America, Canada, and the United Kingdom have followed suit, offering long, flowing gowns with special openings to access the chest and back, roll-down sleeves with elastic wrists, snap-away pants to wear under the gowns – and even burka-style coverage for women who cover the face.

Muslims are not the only ones benefiting from such gowns, however.

Numerous companies have stepped up to fulfill a demand among patients who feel that modest gowns protect their dignity during a hospital stay.

One company (Spirited Sisters, Inc.) was formed by three sisters, two of whom had cancer, who agreed that "the most odious and visible sign of cancer or illness was the dreaded hospital gown."

Together, they design a collection of modest, stylish hospital gowns they called the Original Healing Threads.

"This gives the patient back their dignity, modesty and empowerment," states the company’s Web site (www.spirited-sisters.com). "It allows people to feel more like themselves and less like a defective person in prisoner’s garb."

Although Original Healing Threads are pricy ($80-$90 for a complete set purchased online, including the "Grace" line designed with Muslim and Hassidic Jewish women in mind), it is evident from customer testimonials that many patients find them well worth the cost.

"Bless you for preserving the dignity of women undergoing treatments, and for enabling them to look as good as they can in the face of something so terrible," wrote one woman, speaking of her mother-in-law’s experience with breast cancer several years ago, a time when modest gowns were not widely available.

In the absence of such options, some women will simply choose to wear a long nightgown from home.

Ben, who preferred to stay covered during the birth of her fourth child, purchased some cotton scarfs so she could sleep comfortably, and said the midwife in this instance was "extremely respectful of Islam and the family during such a vulnerable time" and even confided to her that she was looking into having an experienced Muslim midwife join her practice.

Brown also cites a positive experience she had when the staff in a Long Island, N.Y., hospital asked her if she would like them to put a sign in the baby’s bassinet which read: Please do not praise child without parents present.

"I was very surprised with this and very pleased," said Brown, referring to the commonly held belief that children can be harmed by hasad (jealousy) or the "evil eye" if the name of Allah is not mentioned when offering compliments.

"Every time the baby left to the nursery, I felt better knowing that they were aware of our religious beliefs and that my child was protected," she said.

"Health care institutions should have speakers who come in and provide training on the health care beliefs and practices of Arab and Muslim patients," Khalifah said. "It is critical for hospitals to provide training, which will help to ensure that the services provided are culturally and linguistically appropriate."

Several programs of this nature exist in metropolitan areas of the United States and are growing in popularity.

At the University of Michigan Medical Center in Ann Arbor, Mich., an area of the country having one of the heaviest concentrations of Arab Americans, a Muslim Patient Care Committee (MPCC) was established in 2000 to help meet the special needs of Muslim patients.

To date, the committee has achieved milestones like the use of a "Knock - Await response" door sign in the Ob/Gyn department, standarizing procedures for the care of deceased Muslims and establishing a room for Friday prayers.

The group provides training sessions for non-Muslim staff and has also developed a voluteer program for interested Muslims.

Yasmin believes questionnaires presented to patients upon arrival at the hospital could also be of help to hospital staff unfamiliar with Muslim beliefs. "I believe the more we practice, the more people around us know about us," she said. "At least, that is what I experience in my workplace."

"Be pleasant yet firm with a positive attitude when you make your requests known to a health care team member," Khalifah suggested.

"State that you understand that they may not be able to honor your request, and hope that they can hear you out. Do not come off as if you are making a demand and expect that they will be able to honor. This is not realistic and may cause a person to not work as hard to seek alternatives for you."

"Our sisters should not forget the power of dua (prayer) and a positive attitude," added Shawky, saying that health care providers are human and can only do so much. "Remember that the miracle of bringing a new human being into this world is something so grand that only Allah has control over (it). Thus, after making the appropriate plans before birth, the next step is to put complete and utter trust in Allah and enjoy the anticipation of meeting (your) new Muslim child, in sha Allah."

* Name changed per request of anonymity.