ANTEPARTUM HAEMORRHAGE: THE ARGUMENTS AND ITS IMPLICATION TO MUSLIM PARTURIENT

Pregnancy and bleeding during pregnancy are the two entities that cannot be separated. The implication of this issue leads to differences in thought, understanding and interpretation of the Islamic law, and has implications for the consequences of ibadah, referred to the worship of God. Although there are many sources that dealing with this issue, the understanding among Muslim parturient is considered inconclusive. Therefore, this article will discuss the condition of antepartum haemorrhage as bleeding during pregnancy, the arguments as well as the implications of it to Muslim parturient. This study uses a qualitative research methodology by analysing primary and secondary documents such as the classical books as well as academic writings in the journals. The result of the study suggests that there are differences or arguments regarding the issue of bleeding in pregnancy. In addition, this article has also found out that there are implications on the ibadah of Muslim parturient if the issues are not resolved due to differences of arguments. Therefore, this article proposes to improve some of the knowledge and understanding regarding the issue of antepartum haemorrhage to ensure the consistency in worship towards God.


INTRODUCTION
Bleeding per vagina is the common presentations during pregnancy. In a prospective study of 3531 women seeking prenatal care in New York City, the incidence of vaginal bleeding during pregnancy was 22% (Barbara Strobino et al. 1989) while another study found an incidence of 9% (E.W. Harville et al. 2003). It is either mild or severe as obstetric haemorrhage is the leading causes of maternal mortality in the world (Lolonde A et al. 2006) and antepartum haemorrhage is one of them. Muslim generally have to perform their obligations daily as per Islamic Jurisprudence. In Islam, there are five main duties for every Muslim. These are also commonly referred to as the Five Pillars of Islam and consist of the Shahadah (declaration of faith), Salah which must be performed five times a day, Zakat which is the giving of a portion of one's profitable wealth to charity, Fasting during the holy month of Ramadan, and finally Hajj which translates to pilgrimage which is an annual event in Islam where Muslims of all ethnic groups come together and circumambulate the Holy Ka'aba in assembly as part of the holy pilgrimage. These are the five basic principles required of a baligh (mature or adult) Muslim. These ibadah are an obligation and are no exception, including Muslim parturient, that referred to a woman about to give birth or in labour.
According to Royal College of Obstetricians and Gynaecologists (RCOG) United Kingdom, antepartum haemorrhage (APH) is defined as bleeding from or into the genital tract, occurring from 24+0 weeks of gestattion and before the birth of the baby. It is the cause of up to 50% of the estimated 500 000 maternal deaths that occur each year worldwide (RCOG UK. 2011). Another definition defined APH as any vaginal bleeding from the female genital tract that occurs during pregnancy from the time of potential foetal viability until delivery (K. Morgan et al. 2003). Intrauterine foetal death was the most important foetal complication, and the most important maternal complications were postpartum haemorrhage and anaemia with consequent high rate of blood transfusion (Idris Usman Takai et al. 2017). The suggested measure to reduce morbidity and mortality in pregnancies complicated with APH are by early diagnosis, appropriate pregnancy planning and termination of pregnancy in a well-equipped tertiary health centre (Sunil Kumar Samal et al. 2017). Both abruptio placenta (defined as the premature detachment of the placenta from the uterus) and placenta previa (occurs when a baby's placenta partially or completely covers the mother's cervix, which is the exit for the uterus) are the leading causes, although these are not the most common (RCOG UK. 2011).
Placental abruption appears to be multifactorial and its aetiology is not fully understood. The most predictive risk factors for abruptio placenta is an abruption in a previous pregnancy. A prospective observational study from Norway reported 19-24% of women who have had two previous pregnancies complicated by abruption (S Rasmussen et al. 2009). A retrospective cohort study from Denmark found that the risk of placental abruption increased from 1.0% to 1.4%. First-trimester haemorrhage in the first pregnancy increased the risk of recurrence in placental abruption from 0.9% to 1.0% in the second pregnancy (Lykke JA et al. 2010). Other risk factors for placental abruption include: pre-eclampsia, foetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparity, low body mass index (BMI), pregnancy after assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and from domestic violence), smoking and drug abuse (cocaine and amphetamines) during pregnancy (RCOG UK. 2011). Immunological, inflammatory, or vascular factors appear to explain a large proportion of the aetiology of placental abruption (Minna Tikkanen. 2010).
A number of risk factors have been described for placenta praevia including previous placenta praevia, previous caesarean sections, previous abortion, multiparity, advanced maternal age (>40 years), multiple pregnancy, smoking, deficient endometrium due to presence or history of: uterine scar, endometritis, manual removal of placenta, curettage, submucous fibroid and assisted conception (RCOG UK. 2011). The study by Juan Yang et al. 2004 included 2,829 women whose pregnancies began between January 1995 and August 2000, showed an association between vaginal bleeding and preterm birth. First trimester bleeding was associated only with earlier preterm delivery (≤34 weeks' gestation) and preterm delivery due to preterm premature rupture of the membranes (PPROM). In contrast, bleeding in the second trimester only, of a single episode, on a single day, and with less total blood loss were not associated with any category of preterm birth.
SM Axelsen et al. 1995 reported for 8714 singleton pregnancies, that the overall incidence of bleeding was 19%. The median week of first occurrence was 8 weeks' gestational. The median duration of bleeding was 2 days, and the median number of episodes was one. This suggests that there is a higher incidence of vaginal bleeding during pregnancy associated with anxiety and worries that persists beyond the bleeding episode. Other causes of antepartum haemorrhage from the lower genital tract include cervical erosion, cervical polyp, cervical cancer, vaginal moniliasis and vaginal varicose veins (G Chamberlain. 1991).

Problem statement
Queries about bleeding during pregnancy and related fatwa or hukum are not well addressed. It seems that scholars interpret differently in different approaches and perspectives. This multivariance of thought is probably due to the fact that different sources are used for direct or indirect discussion on this issue. Therefore, this article aims to discuss antepartum haemorrhage as a general understanding, the argument regarding the fatwa or hukum and its implication for Islamic law as it relates to daily practices as a Muslim.

Selected Definition
The author prefers the selected definition mentioned by K. Morgan et al, 2003. The article mentions that APH is defined as any vaginal bleeding from the female genital tract that occurs during pregnancy from the time of potential foetal viability until delivery. Therefore, we agree that any bleeding from vagina during pregnancy, at any time throughout pregnancy is considered as antepartum haemorrhage (APH). This also means that any kind of bleeding, whether mild or severe, in any trimester of pregnancy, throughout the period of pregnancy, the fatwa or hukum will circulate with it as antepartum haemorrhage.
However, this scope does not apply to postpartum conditions, including miscarriage or stillbirth. According to U.S. National Library of Medicine, a miscarriage is defined as spontaneous loss of a foetus before 20 weeks gestation (pregnancy losses after the 20 weeks are called stillbirths). Miscarriage is a natural occurrance, as opposed to medical or surgical abortions. These include complete abortion (all the products or tissues of conception leave the body), incomplete abortion (only some of the products of conception leave the body), inevitable abortion (symptoms cannot be stopped and a miscarriage occurs), infected (septic) abortion (the lining of the womb or uterus and any remaining products of conception become infected) and missed abortion, when the pregnancy is lost and the products of conception do not leave the body. All these conditions have been discussed in a different scope in Islamic Jurisprudence, where wiladah or nifas is referred to as the blood which is discharged from a woman's womb after childbirth (MR Hehsan. 2014).

DISCUSSION
The argument of antepartum hemorrhage is that it can either be classified as normal menstrual blood or not. Menstrual blood is the blood that comes out from a woman's vagina due to the uterine wall collapsing and absent of fertilization. Menstrual blood loss varied significantly by age at menarche, marital status, and parity, with older, married, and parous women more likely to report heavier bleeding. Bleeding patterns and anovulation (in which ovulation does not occur) women bled for a median of 5 days (Sonya S. Dasharathy et al. 2012). Fertilization is the fusion of the male and female gamete or reproductive cells. The process involves the fusion of an oocyte with a sperm, resulting in a single diploid cell, the zygote, which will develop into a new individual organism. Any defect in any part of fertilization will cause the problem in the molecular mechanisms of cell-cell interactions and the pathological defects later (Katerina Georgadaki et al. 2016).
When fertilization occurs, the uterine wall thicken in preparation for the attachment of the ovum to the uterine wall. This thickening of the uterine wall occurs with the help of the hormone estrogen. After the ovulation process occurs, the hormone progesterone acts to maintain the thickness of the uterine wall (Katerina Georgadaki et al. 2016). Therefore, based on these findings, it is unlikely to classify antepartum hemorrhage as normal menstrual blood.
The classical jurists differ on the issue of bleeding during pregnancy. In short, we can divide their argument into two opinions (Mohammad Naqib Hamdan et al. 2015).

First opinion:
It is istihadah blood. The istihadah blood refers to abnormal uterine bleeding, not menstrual blood although it comes out at the same time and period as the menstrual cycle. This is the opinion of the Hanafi school (Al-Kasani, 1990; Al-Sarakhsi, no date), Hanbali (Ibn Qudamah, 1997;Dawayan, 1982) and Zahiri (Ibn Hazm, 1352H). Jumhur Fuqaha and Tabi'een also agreed that there is no menstrual blood during pregnancy. Some of them mentioned as Dammul Fasad the same as abnormal uterine bleeding. Among them are Sa'id Bin Musaiab, Atha, Hassan, Jabir Bin Yazid, Ikrimah, Muhammad Bin Munkadir, Assya'abi, Makhul, Azzahari, Hamad, Atthauri, Auza'ie and others. It is also mentioned by Imam As-Syafie in his old opinion (Muhammad Naim, 2010).

Second opinion:
It is haid or menstrual blood when it comes out at the same time, period and condition as when she is not pregnant. The haid or menstrual blood is the opinion of the Maliki, Shafi'i sects and a narration of Ahmad (Al-Qarafi, 1994; Al-Nafrawi, 1997; Al-Dusuqi, no date; Al-Mawardi, 1994; Al-Juwayni, 2007; An-Nawawi, no date; Al-Maqdisi; no date). This is the new opinion of Imam As-Syafi'e and Ibnu Wahab narrated it from Az-Zahari, Rabi'ah, Yahya Bin Sa'ied. Ibnu Abi Salamah and Aisyah RA (Muhammad Naim, 2010).

First Argument.
The argument used by the first opinion is based on the Quranic verse.

ِ َ
"As for those of your women who have reached menopause, if you have any doubts, their term shall be three months-and also for those who have not menstruated. As for those who are pregnant, their term shall be until they have delivered. Whoever fears God-He will make things easy for him." (Surah al-Talak: 4).
They also use the argument from the hadith narrated by Abi Sa'id Al-Khudri RA that the Prophet SAW said: Do not have intercourse with a pregnant woman (wife) until she gives birth, and (do not have intercourse) a woman (wife) who is not pregnant until she finishes her period. (Abu Dawud, no date, hadith no. 2157; Ahmad, 1420H, hadith no 16997).
In the above Quranic verse, Allah SWT has mentioned the 'iddah of a pregnant woman, which is meant by three holy times periods (or menstruation), that is, free from menstruation. This situation is a proof that pregnant women are not among the group who experience menstruation because the period of their 'iddah is mentioned in separately. The same situation can also be explained in the hadith (Al-Sarakhsi, no date, Ibn Al-Mundhir, 1405H).
In an athar narrated from 'Aishah RA, she said: The pregnant woman will not experience menstruation (if she bleed), she only needs to clean it and then pray (Al-Bayhaqi. 2003, hadith no. 15432;Al-Daruqutni. 2004, hadith no. 849). According to them, this matter cannot be known except by literature alone.
Aishah RA says this as if she heard it from the Prophet SAW (Al-Kasani, 1990; Al-Sarakhsi, no date). In fact, menstruation is the blood that comes out from womb. The blood that comes out of a pregnant woman is not from the uterus because the uterus is already closed (Al-Kasani, 1990). This emphasize that the vaginal bleeding during pregnancy is not considered as menstrual bleeding.

Second Argument
The argument of the second opinion is based on Quranic verse: And they ask you about menstruation. Say, "It is harm, so keep away from wives during menstruation. And do not approach them until they are pure. And when they have purified themselves, then come to them from where Allah has ordained for you. Indeed, Allah loves those who are constantly repentant and loves those who purify themselves." (Al-Baqarah: 222).
In fact, the Prophet SAW said: If it is menstrual blood, then the color is black and smelly, then do not pray. But if otherwise, then take ablution and prayer. Indeed, it is the blood of sweat (istihadah) (Ahmad, 1420H; Abu Dawud, no date, 304).
Accordingly, Allah SWT and the Prophet SAW have mentioned the condition of menstruating women in general without attaching it to any condition, whether the woman is pregnant or not. Thus, there is a probability that pregnant women may also experience menstruation based on the general verses and hadiths above (Al-Shirbini, 1997;Qalyubi and 'Umayrah, 1956). If blood comes out during pregnancy, there are two possibilities. It can be either umbilical cord blood or istihadah blood. The original condition for a person is normal in a good health. Thus, it is menstrual blood based on the method of istishab, an Islamic term used in jurisprudence to denote the principle of presumption of continuity (Al-Sharbini;1997).
Implication antepartum haemorrhage to Muslim Parturient 1. The effect on the ibadah and deeds connected with worship towards God. The effect of opinion diversity has lead to disagreement among the jurists on several issues of fiqh regarding antepartum haemorrhage. From these arguments, we can conclude that there are two major opinions regarding the issue of antepartum hemorrhage. Those who say that a pregnant woman may experience menstruation as per the opinion of the Maliki, Shafi'i sects and a narration from Ahmad, she should abandon prayers and fasting, should not have sex with her husband, should not hold mushaf and circumambulate (tawaf) around the Kaaba. However, it should not be used as a standard for 'iddah because the' iddah for a pregnant woman is to give birth to her child based on the word (firman) of Allah in Surah At-Talaq, verse 4 (Ibn Rushd, 1995; Al-Jassas, 1335H). This statement is only applicable to talaq casses. The other opinion was who think and consider it as blood of istihadah. Therefore, she is obligted to pray as usual, can fast in month of Ramadhan, can have sex with her husband, circumambulate (tawaf) around Kaabah and iktikaf just like a holy woman (Ibn Rushd et al, 1995;Al-Jassas, 1335H). In case of talaq that referred to granting of divorce by the husband, it is not counted as talaq bid'i according to these two opinions (Ibn Qudamah, 1997;Al-Jawziyyah, 1399H;al-Shirbini, 1997). Talaq bid'i is a divorce that violates the commandments of Allah and the sunnah of the Prophet SAW, such as when the husband divorces his wife while the wife is menstruating or pregnant.

2.
The effect on understanding and the psychological distraction among parturient that causes the dilemma. After comparing these juristical views, some Muslim parturient may get confused as to what would be the best if they themselves were face the same situation and dilemma. Some may adopt the first opinion, others the second, and it seems inconclusive when there is difficulty. This dilemma will further affect their ibadah towards God and may affect the parturient emotionally. Moreover, pregnancy is a crucial condition that can potentially cause emotional stress (Jenny McLeish et al. 2017). Therefore, any disturbance in area of confusion and critical thinking especially in relation to ibadah, could significantly affect the mental health of the woman giving birth, especially as a Muslim woman.

CONCLUSION
As a conclusion, the author prefers the opinion that stated pregnant women cannot menstruate is stronger and reasonable with the support of the latest scientific or medical evidence. Without a conclusive fatwa or hukum regarding vaginal bleeding during pregnancy or antepartum hemorrhage, there are possible implications on the ibadah of Muslim childbearing women and may disrupt their daily practice as Muslims. Therefore, this article proposes to improve some of knowledge and understanding regarding the issue of antepartum haemorrhage to ensure consistency of worship towards God. It is hoped that this discrepancy can be addressed and further clarified with the help of laboratory studies or medical findings.