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The Old Order Amish in Lancaster County: The effects of culture on prenatal care

Carol Pugh

Critical Inquiry II
Carol Pugh
Institute of Midwifery, Women & Health, 1998
Philadelphia University, Master of Science with Concentration in Midwifery, May 2000

Abstract
The term Old Order Amish refers to the most conservative and distinctive division of a Protestant group of individuals who are direct descendants of the Swiss Brethren (Anabaptists). The total Amish population in the United States is estimated at 145,000, but estimates vary and only adults are counted as full church members. In Lancaster County, Pennsylvania there are approximately 16-18,000 members of the Old Order Amish faith. Health care providers need to understand their ways of knowing; the patterns of thinking, feeling and acting, that are valued in the Old Order Amish culture in order for therapeutic care to evolve. Knowledge of communication patterns and traditional health beliefs of the people of this culture assures optimal care. There are many relevant sociocultural factors which have an influence on Amish health care practices. Beliefs and values such as respect for authority, obedience to parents, group responsibility, and individual humility bind the Amish people in their culture. These beliefs and values also relate to the health care practices in the family and community. Cultural beliefs and practices tend to separate the Amish from the conventional American (“English”) culture in ways that sometimes make it difficult for midwives and other health care providers to understand this unique population. Of particular interest are the choices Amish women make with regard to childbearing care. The birth of a child enhances the standing of the parents in the community, and since children are wanted, an Amish couple may expect to have several, if not many, children. The number of pregnancies per Amish woman in Lancaster County is an average of 7, with 10 or 11 live births being not uncommon. Using Leininger’s Sunrise Model of Health Care as the theoretical perspective, information about the Old Order Amish culture is presented that will assist midwives and other health care providers to promote and provide culturally congruent prenatal care.


Introduction

An important cultural group in the Lancaster County, Pennsylvania area is the approximately 16-18,000 members of The Old Order Amish faith. Old Order Amish refers to the most conservative and distinctive division of a Protestant group of individuals who are direct descendants of the Swiss Brethren (Anabaptists). Midwives and other health care providers need to understand the patterns of thinking, feeling and acting, that are valued in the Old Order Amish culture in order for therapeutic care to evolve. Knowledge of communication patterns and traditional health beliefs of the people of this culture assures optimal prenatal care. Midwifery care includes the independent management of women’s health care focusing on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women. It also includes those assistive, facilitative, or enabling acts by a midwife that reflect ways to adapt or adjust health care services in order to be culturally congruent with the health care needs of the Amish client.(Leininger, 1988) In order to provide culturally congruent prenatal care to women of the Old Order Amish Faith, it is important for the midwife to be aware of the services that can be adapted or adjusted to fit the needs of the client. Using Leininger’s Sunrise Model of Health Care as the theoretical perspective, this article will examine the influence of culture on the prenatal health care practices of the Old Order Amish women in Lancaster County, Pennsylvania.

Review of Literature

A search of bibliographic databases revealed a core of six monographs and a handful of journal articles which contained significant information on pregnancy and childbirth, culture specific care, pregnancy outcomes among Amish and non-Amish women, and health care beliefs and practices among the Amish. For Internet resources on information about the Old Order Amish see Table 1.
TABLE 1
INTERNET RESOURCES
Bibliographic database -- First Search<http://fscat.oclc.org>
Pennsylvania Dutch Country Welcome Center --general information on the Amish, Mennonites, Brethren and other “Plain People of the Pennsylvania Dutch Country<http://www.800padutch.com/amish.html
University of Michigan<http://www.personal.umich.edu/~bpl.menno.html
Religious Tolerance.org<http://www.religioustolerance.org/amish.htm>
University of Virginia<http://cti.itc.virginia.edu/~jkh8x/soc257/nrms/amish.html>

The Old Order Amish

The Amish and Mennonites were both part of the early Anabaptist movement in Europe, which took place at the time of the Reformation. Religious reformers during this time preached that believers should separate themselves from all secular activities. The Anabaptists were one of the radical movements of the 16th Century that insisted that only adult baptism was valid and held that true Christians should not bear arms, use force, or hold government office. In 1536, a Catholic priest from Holland named Menno Simons joined the Anabaptist movement. Through his powerful writings and leadership he united many of the Anabaptist groups who were then called "Mennonites."

In 1693, a Swiss bishop named Jacob Amman, left the Mennonite church. His followers were called the "Amish." The division from the Anabaptists was based on differences about conforming to certain norms, not on differences in fundamental beliefs. The main controversy between the Amish and the Anabaptists involved shunning or excommunicating (Meidung). The Anabaptist believes that only the pure should be involved in religion and if that member falls into sinful actions, he/she should be excommunicated and shunned. Jacob Amman’s interpretation and practice of Meidung also included those members who left the Amish church and those who married an outsider. Members of the Amish community are not permitted to buy from, or sell to, the excommunicated individual. The spouse of a person under the ban is not permitted to sleep or eat with that person until he/she repents and changes the offending behavior or beliefs. These strict traditions have been passed down from generation to generation, and have kept the Amish lifestyle stable. (Hostetler, 1980) The two groups have split many times but still share the same beliefs concerning baptism, non-resistance, and basic Bible doctrines. "They differ in matters of dress, technology, language, form of worship, and interpretation of the bible”(Pennsylvania Dutch Country Welcome Center, 1999, p.1).

The Amish settled in Pennsylvania as part of William Penn's "holy experiment" of religious tolerance. The first group of Amish arrived in Lancaster county between 1714 - 1730. Today the total Amish population in the United States is estimated at 145,000, but estimates vary and only adults are counted as full church members. Amish settlements can be found in 22 states in the United States. Seventy-five percent of the Amish population can be found in Ohio, Indiana, and Pennsylvania. The oldest group of Old Order Amish, approximately 16-18,000 members, live in Lancaster County, Pennsylvania.

In his book Amish Society, Hostetler (1980) states that the Old Order Amish still believe in the original tenets of the Swiss Brethren. They believe in the separation of the church and state, and their members are baptized as adult believers upon confession of their faith. They practice separation from the world through group solidarity and caring for their own. They dress in the manner of sixteenth century European peasants, speak Deitsch, a German dialect, and travel by horse and buggy. Church services are held in homes, farming is the principal occupation, and they repudiate such worldly conveniences as electricity, telephones, central heating and automobiles.

Amish live in close geographical areas called settlements which are divided into church districts that are composed of 30-40 families. They do not live in communes, and non-Amish families and towns are interspersed. “The church district and the friendschaft (the three generational family unit) are major sociocultural structures within Amish society that encourage family and community caring.” (Wenger, 1991, p. 80) The three -generational family unit is composed of grandparents, parents, siblings and their spouses. The limited size of the church district encourages personal interaction, where people learn to know each other and respond to the care needs of one another. The family and the larger community thereby promote both intergenerational knowledge and interaction. Amish life plays itself out in the security of the church; birth, growing up, baptism, weddings and death, with a wide spectrum of psychological, pedagogical, biological, and mutual assistance. The church district is the primary social unit within the settlement, and the leadership of the bishops, ministers and deacons within each church district provide the structure for this boundary maintenance. In Amish culture, the Ordnung (unwritten rules maintained by the local church district) is powerful in daily reinforcing the Amish way and maintaining traditional and accepted behavior in each community ( Hostetler, 1980).

A central belief of the Amish is the rejection of worldliness and materialism. In order to avoid any pretext of vanity, their style of dress is uniform and plain. Amish men in Lancaster County, wear button-front trousers and suspenders, wide-brimmed straw hats in the summer and black felt hats in the winter. Men shave until they marry; they then grow a beard. The upper lip is always clean-shaven because a mustache is forbidden by the church. Women wear dresses of solid colors of blue, green, gray, purple, or wine for everyday wear and black dresses are worn for special occasions. A white organdy head covering, is worn at all times; a black bonnet is added for outdoor wear. The female members of the family make most articles of clothing worn by the Amish. (Hostetler, 1980; Brewer, 1995)

Social roles are well defined within the Amish family. Family organization is strictly monogamous and patriarchal. Authority tends to belong to the father, but with varying degrees of practice in specific families. There is no provision for divorce. The wife follows her husband's leadership and example, but it is felt that the wife has an immortal soul and is an individual in her own right. The wife is often consulted when family problems arise, and exercises her powers in rearing the children, but her husband's decisions are considered as final in domestic matters. "She is her husband's helper but not his equal" (Hostetler, 1980, p.153). An Amish woman's attitude is one of willing submission.

The Amish community requires their children to complete eight years of "Amish schooling", and some children will opt for one more year of "technical" study. The teacher is most often a young Amish woman who has completed her eight to nine years of education. People who continue their education to the high school level and beyond, may change and not fit with being Amish. "The function of the school is to teach the children the three R's in an environment where they can learn discipline, basic values, and how to get along with others" (Hostetler, 1980, p.177). "Pennsylvania Dutch" is spoken in the home, and Amish children do not learn the English language until they begin school. It is expected that they will master the English language in school and learn the skills that will enable them to transact business with outsiders. In Pennsylvania there are no Old Order Amish involved in professional medical, nursing, or allied health care practices. (Hostetler, 1980; Palmer, 1992)) Since the Amish in Lancaster County do not have members of their own culture practicing as physicians or other health care providers, they must seek medical technology and professional care from outsiders.

The Amish do not reject modern medical treatments but will use folk remedies in addition to physician/midwifery care. An extensive folk health care system exists within the Amish culture. They use a wide variety of providers, including reflexologists, herbalists, chiropractors, midwives, and brauche or pow-wow practitioners. Brauche is a practice of physical manipulation similar to therapeutic touch in which the person with the gift of healing places his or her hands near the patient's head or abdomen to draw illness from the body. (Brewer & Bonalumi, 1995) Pow-wowing is an old-world brand of faith healing in which words, charms, amulets and physical manipulations are used to cure both man and beast.( Adams & Leverland, 1986; Hostetler, 1980; Wenger, 1995) The practice of brauche and pow-wowing are rarely discussed with "outsiders". When pressed for an explanation about these practices, a member of the Amish community will explain that they don't really know of any people who utilize these services anymore. Several Amish communities have experienced much strife over the controversial pow-wowing because of its association with black magic or hexing. (Hostetler, 1980)

In the Amish family, it is the father who decides when medical treatment is needed. Families vary greatly in their attitudes toward preventative care and health practices. Some Amish do not see the importance of being immunized against the diseases that are outside the scope of their knowledge or experience. They will do what is deemed necessary when outbreaks occur, but to take preventive measures against all types of diseases that might occur in the future is to rely too much on worldly knowledge.(Hostetler, 1980) Most Amish children are not immunized against diphtheria, tetanus, polio, measles, or mumps. Although there is no Ordnung, or "rule" forbidding vaccination, many parents still object. In these cases Amish families will present waivers in place of immunization certificates for children starting school. (Brewer & Bonalumi, 1995)

The Amish are exempt from paying into the Social Security system. They also do not buy commercial health insurance. This means that in times of illness they must pay all medical expenses, and they cannot collect Social Security benefits. Families pay for their health care expenses in cash, but alternative providers may be paid with food or other goods from the farm. Communities form their own insurance fund, with each family contributing an initial amount and contributing again when someone is in need. (Adams & Leverland, 1986; Hostetler, 1980; Brewer & Bonalumi, 1995)

The Amish are one of the best-defined inbred groups in the United States. They are a closed population with extensive genealogical records. They have large families that tend to reside in one place. Therefore observations can be made on many relatives in a restricted geographic area. "The Amish population is not, however, a single genetically closed population. Within it are separate inbreeding communities or demes." (Hostetler, 1980, p.320) The separateness of these groups is found in the history of the immigration into each area, and defined by the uniqueness of the family names in each community, by the distribution of blood groups, and by the different hereditary diseases that occur in each of these groups. (See Table 2)
TABLE 2 -- LANCASTER COUNTY AMISH
In each of the three largest Amish settlements, different family names prevail.The name Stoltzfus accounts for 25% of the Amish people in Lancaster County. Yet among the immigrant founders, there was only one male by the name of Stoltzfus. Nicholas Stoltzfus appears to have contributed disproportionately to the present Lancaster Amish gene pool.
The frequency of blood types A, B, O varies among the Amish communities.In Lancaster County, Pennsylvania about 3/4 of the individuals have type A blood. O is unusually low. This phenomenon is attributed to the founder effect, a type of genetic drift.
The hereditary diseases that occur in the different settlements (demes) are indicators of the distinctness of the groups.Ellis-van Creveld syndrome (EVD) or dwarfism is extremely high among the Lancaster County Amish.
In no other community of Amish has this type of syndrome occurred. All the affected sibships have been traced to Samuel King and his wife, immigrants of 1767.
A second type of dwarfism, named cartilage-hair hypoplasia (CHH) is also seen.
A rare blood-cell disease (pyruvate kinase deficiency anemia) is unusually frequent in central Pennsylvania.Affected children are often jaundiced and anemic at birth and require blood transfusions. This disease has been traced to Jacob Yoder, an immigrant of 1742.
Families with the name Glick and FisherGlutaric aciduria type 1
This is an electron transport dehydrogenase deficiency.
Children are born looking healthy, but can experience permanent neurological damage when a mild illness strikes.
There is no effective therapy at this time.
Males with the name of Beilertend to have the chromosomal variant short Y.
Families with the name of Eshtend to have a higher incidence of microcephaly and spina bifida.
HypertensionRare among the Lancaster County Amish.
(Hostetler, 1980, p. 319-322)

Inbreeding does not necessarily result in hereditary defects, but among the Amish, inbreeding has this tendency. Because the gene pool of this group of people contains certain recessive tendencies, the probability that a child will be born with a birth defect is greater when the members intermarry and the gene is carried by both father and mother. This is why the Amish have certain birth defects and why these defects occur in certain areas more than others.

The ceremony associated with birth is barely visible (Hostetler, 1980, p.190). Birth is not marked by sacred or kinship ceremonies. The birth of a child enhances the standing of the parents in the community, and since children are wanted, an Amish couple may expect to have several, if not many, children. The number of pregnancies per Amish woman in Lancaster County is an average of 7, with 10 or 11 live births being not uncommon. Birth control and abortion are forbidden by church doctrine. Some Amish women will use Natural Family Planning, diaphragms, and on some rare occasions Depo Provera as forms of birth control.

Adams and Leverland (1986) state that the Amish view a healthy person as "one who has a good appetite, looks physically well and finds satisfaction in a good day's work (p. 63)". Illness is seen as a failure to function in the work role. Many Amish have a belief that their sins cause illness, suffering and death. Therefore, the belief is that no amount of prevention or immunization will prevent illness. It is also noted that Amish men outlive the women, possibly due to the physical stress of early and frequent childbearing. (Adams & Leverland, 1986)

Culture and Childbearing

Although there are numerous articles that address cultural/religious childbearing practices based on observations by health professionals, research findings are limited on the sociocultural/spiritual meaning of birth to the childbearing woman. Callister (1995) identified childbirth as both physiological and time limited, yet much more than a transient physical experience. She states that "culture is among the most significant variables that influence a woman's perception of the childbearing experience" (Callister, 1995, p. 327). "Sociocultural/spiritual beliefs and values lend perspective to the meaning of childbirth, for it is within the context of the rich sociocultural/spiritual setting that a woman gives birth" (Callister, 1995, p.328). Becoming knowledgeable about the meaning of childbirth in different cultures and recognizing cultural coping patterns, facilitates the health care provider's ability to identify and understand the childbearing woman's attitudes, behaviors, values, and needs. "Culturally sensitive care should be given during pregnancy, childbirth, and beyond, thus increasing positive outcomes, including the promotion of feelings of self-actualization in the woman, maternal role attainment, the fostering of a positive relationship with the woman's significant other, and enrichment of the family perspective" (Callister, 1995, p. 329).

Prenatal Care

Gaining an understanding of and appreciation for the cultural and spiritual meanings of childbirth to the woman has important implications for midwifery practice. The midwife needs to develop a cultural assessment that will aid in identifying and understanding the childbearing woman's (in this case the Amish woman's) attitudes, behaviors, values and needs.
Callister (1995) suggests nine questions that should be considered when making such an assessment.
1. How is childbearing valued?
2. What does the childbearing experience mean to the woman?
3. Is childbearing viewed as a normal physiologic process, a wellness experience, a time of vulnerability and risk, or a state of illness?
4. Are there dietary, nutritional, pharmacological and activity prescribed practices?
5. Is birth a private intimate experience or a societal event?
6. How is childbirth pain managed, and what maternal/patenal behavior is appropriate?
7. What support is given during pregnancy, childbirth, and beyond, and who appropriately gives that support?
8. How is the newborn viewed, and what are the patterns regarding care of the infant and relationships within the nuclear and extended families?
9. What maternal precautions or restrictions are necessary during childbearing? (p329)

Where babies are born, who will deliver them, and how the family will pay the costs, are of great importance to the Amish community. Pregnancy and childbirth are important events in the life of Amish adults, and many Amish parents prefer to have their children born at home. The availability of qualified physicians and/or midwives to assist in home deliveries are factors to be considered, as is the cost of a hospital delivery and stay. (Huntington, 1993) "Amish self determination is directed and circumscribed by their church. Because individual responsibility is so closely tied to social responsibility, the Amish are amenable to programs that protect the health of others. They ask, however, to maintain the right of personal choice and to remain ' "a peculiar people, separated from the world." ' (Huntington, 1993, p. 189)

The popular sector; individual, family, social network and community beliefs and activities is very powerful within the Amish community. Amish women will use herbs during pregnancy as a means of maintaining good health. These "herbs are commonly taken on the advice of other Amish women although they may be prescribed in the folk/alternative sector" (Campanella et al., 1993, p.335). Most often popular sector advice outweighs the professional sector advice. (See Appendix A for Commonly used herbal remedies)

Primiparous Amish women who perceive no problems with their pregnancy begin prenatal care at about four months gestation. Multiparous Amish women are noted to initially seek prenatal care in the third trimester. (Campanella et al, 1993) The Amish view pregnancy as a private but normal biological function, and unless there is a problem or concern they will not seek prenatal care until later in their pregnancies. Amish women do not automatically reject medical technology that could be of assistance, but like Amish in other situations, selectively determine what would best meet their individual and cultural needs (Campanella et all, 1993).
Perceived barriers to professional prenatal care are difficulty obtaining child care, long waits at the physician's office, difficulty scheduling appointments, transportation, cost of prenatal care, and physician gender. (Campanella et al, 1993) The most powerful impediment to seeking prenatal care is that of transportation, because if the woman can not drive the team to the appointment, she has to hire a driver at a considerable expense. The factors cited here can serve to encourage practitioners involved in Amish prenatal care to search for more cues to increase cultural understanding of the Amish.


Conceptual Framework

Leininger's Theory of Culture Care Diversity and Universality and her Sunrise Model provide a useful framework for understanding the childbearing practices of the Amish population. A key concept in Leininger's theory is "cultural care congruence". Culture congruence is defined as the “fit or agreement with the values and beliefs of a particular cultural group” (Leininger, 1988, p. 30). The major components of the Sunrise Model; 1)social structure, 2)world view, 3)cultural values, and 4)lifeways, are used to investigate care phenomena. Important social structure factors such as technological factors, religious and philosophical factors, kinship and social factors, political and legal factors, economic factors, and educational factors are a framework for cultural assessment that is helpful in examining information for culture-congruent prenatal care. Three principles for client therapy goals are presented: 1)cultural care preservation or maintenance -- "those assistive, facilitative, or enabling acts that preserve cultural values and lifeways viewed as beneficial to the care recipients" (Leininger, 1988, p. 50), 2) cultural care negotiation or accommodation -- "those assistive, facilitative, or enabling acts that reflect ways to adapt or adjust health care services to fit clients' needs" (Leininger, 1988, p. 51), and 3) cultural care repatterning or restructuring-- " those altered designs to help clients change health or life patterns that are meaningful to them" (Leininger, 1988, p. 52).

Application of the Sunrise Model of Health Care to the Old Order Amish

The following are selected Amish cultural patterns related to health care that may influence prenatal care, health and well-being:

1. Technological Factors -- The Amish do not have easy access to professional health care/prenatal services. They do not have telephones in the home; nor do they own cars. The Amish form of transportation is the horse and buggy, so it is not unusual for a woman to spend most of her day traveling to and from a clinical visit. At times post cards or letters may be the only way to communicate, which may delay necessary prenatal care. These factors encourage the use of traditional health modalities unless acute medical care is needed. (Hostetler, 1980; Wenger, 1991) The use of high technology health care will be considered after carefully weighing the benefits against any detrimental effect on their chosen way of life.(Huntington, 1993) It is important for the midwife to understand what forms of technology are acceptable and what forms are not; e.g., electronic fetal monitoring and alpha-fetoprotein testing.
2. Religious and philosophical factors -- Because the body is viewed as the temple of God, personal and family health are highly valued. An Amish woman’s nutritional status may be a cause for concern because the typical Amish diet is high in starches and high fat meats. Fruits and vegetables are typically only eaten seasonally. Many Amish women have iron deficiency anemia during pregnancy due to their eating habits.

3. Kinship and social factors -- "The three-generational family concept promotes a family culture whereby health beliefs are communicated and maintained within the extended family context." (Wenger, 1991, p.81) Some families use more alternative and folk care remedies than do other families. During the prenatal assessment it is important to elicit what alternative therapies/remedies the woman may use, because some herbal remedies are not safe during pregnancy. The midwife must accept those beliefs that are not harmful, and educate the client for those that are.

4. Cultural Values and Lifeways --The popular sector that includes individual, family, social network and community beliefs is very powerful within the Amish community. This is due to the strength of the Amish family and preference for self-care. Amish women do not practice birth control. In fact, they are encouraged to have as many children as possible. These values cannot be changed, but with education, it may help them to understand the health consequences of such reproductive decisions. Abortion is not permitted. "What ever happens, happens. It is the will of God" (Finn, 1995, p. 33). All children are accepted as a gift from God. It is important for the midwife to recognize this, and not offer abortion as an alternative to having a handicapped child. After trust has been established with the physician or midwife, the Amish "tend to follow directions unquestioningly because of their values regarding authority, except when prescribed interventions conflict with their deeply held religious values" (Wenger,1991, p.83).

5. Political and Legal Factors -- The Amish tend to be distrustful of governmental health care regulations. Most women of the Amish lifestyle have not been immunized against childhood diseases or tetanus. It is vitally important for the midwife to be aware of the woman's immunity status. It is difficult to convince the Amish woman that the tetanus inoculation is warranted even though the farming life-style causes an increased risk of Trismus (lock jaw).

6. Economic Factors -- Since Amish families do not have health insurance plans, hospitalizations are very costly for them. They may try to reduce hospitalization time, or refuse costly treatments because of the expense. In order to provide adequate health care to this population, the midwife must be conscious of costs. The midwife must take longer to explain the need for testing or hospitalization so the family can understand that they are not spending money unnecessarily. Having a child every year is expensive for the Amish family. Midwives caring for this population should emphasize to the women that a single fee for prenatal care and delivery is charged, regardless of the number of prenatal visits. It may be necessary to stress that if prenatal care is begun early in pregnancy, appointments will be scheduled for 6-8 weeks instead of 4 weeks unless problems arise.
7. Educational Factors -- Amish attend school through the eighth grade. There are no Amish who are professionally educated as physicians or nurses. Children speak only Deitsch in the home and do not learn English until they begin school. Because educational levels are lower and more restrictive, prenatal classes are conducted according to the educational level of the clients, and procedures are demonstrated. And still the midwife's recommendations and prenatal/health teaching may have little or no effect. The assumption cannot be made that because these clients speak English, they understand everything that is being discussed. Amish women function on a very naive level, and what we take for granted regarding our bodies and health concepts, they most often do not understand. (Finn, 1995; Wenger,1995)

Implications for midwifery practice

In order to provide optimal prenatal care, the midwife should be aware of those genetic disorders prevalent in the Amish population she serves, particularly those carried by members with certain surnames or peculiar to certain communities.

Home birth practices that serve the Amish communities should offer prenatal home visits beginning at the woman’s thirty-sixth week gestation, in order to break down the transportation and isolation barriers to prenatal care. Alternative therapies should be offered along with conventional medical therapies whenever possible, since many Amish women prefer to use alternative therapies during the course of their daily lives. Nutritional counseling should be provided and proper nutrition should be encouraged at each prenatal visit.

Although there are social implications that child care is women’s work, Amish fathers should understand that they too have a stake in the health and well-being of their children. During education sessions at childbirth classes midwives can encourage these husbands to believe that it is good and acceptable to participate in the care and nurture of their children.

MY EDITORIAL COMMENT: it may not be possible to convince husbands that they should help their wives (wives are supposed to help their husbands), but it might just work to appeal to fathers to help their children. After all, “the birth of a child enhances the standing of the parents in the community.” Might it not also be that the birth (and nurture) of a HEALTHY child also enhances the parents -- both parents.

Conclusion

The Amish are often perceived as unchanging, yet their responses to modern medicine often show a steady acceptance of medical interventions and prevention. Awareness of cultural issues in the clinical encounter can greatly facilitate adherence to prescribed care. Patience, an unhurried and caring manner, and understanding and respect for the beliefs that shape the health care practices of the Amish will enable midwives and other health care practitioners to provide their Amish clients with necessary and appropriate care.

References

Leininger M. Care - discovery and uses in clinical and community nursing. Wayne State University Press; 1988.

Hostetler, J.A. Amish Society (3rd ed.). Baltimore: Johns Hopkins University Press; 1980.

Pennsylvania Dutch Country Welcome Center (1999, November 1) The Amish, The Mennonites, and "the plain people [article posted on web site 800padutch]. Retrieved November 2, 1999 from the World Wide Web: http://www.800padutch.com/amish.html

Wenger, A.F.Z.. Culture-specific care and the old order Amish. NSNA/Imprint, April/May, 1991; 80-87.

Brewer, J., Bonalumi, N. Cultural diversity in the emergency department. J Emergency Nursing, 1995; 21: 494-497.

Palmer, V. The health beliefs and practices of an Old Order Amish family. J American Academy of Nurse Practitioners 1992; 4: 117-122.

Adams, C.E., Leverland, M.B. The effects of religious beliefs on the health care practices of the Amish. Nurse Practitioner 1986; 11: 58-67.

Wenger, A.F.Z.. Cultural context, health and health care decision making. Journal of Transcultural Nursing 1995; 7: 3-13.

Callister, L.C. Cultural Meanings of childbirth. JOGNN 1995; 24: 327-331.

Huntington, G.E. Health care. In: D.B. Kraybill (Ed.), The Amish and the State. Baltimore: Johns Hopkins University Press: 1993.

Campanella, K., Korbin, J.E., & Acheson, L. Pregnancy and childbirth among the Amish. Social Science Medicine. 1993; 36: 333-342.

Finn, J. Leininger's model for discoveries at the farm and midwifery services to the Amish. Journal of Transcultural Nursing 1995; 7: 28-35.

Wenger, A.F.Z., Wenger, M. Community and family care patterns of the old order Amish. In: M.M. Leininger (Ed.). Care - discovery and uses in clinical and community nursing Detroit: Wayne State University Press:1988

Pugh, C.T. Herbal remedies for discomforts of pregnancy. Millersville University. Unpublished manuscript and booklet copyright; 1995.
APPENDIX A

COMMONLY USED HERBAL REMEDIES

NAUSEA AND VOMITINGLemon Balm spearmint
peppermint Slippery elm
ginger Peppermint
cinnamon lavender
Chamomile meadowsweet
HEARTBURNChamomile Meadowsweet
Fennel Peppermint
Dandelion root Ginger
Lemon Balm Slippery Elm
Papaya
GASSlippery elm Cinnamon
Peppermint Lavendar
Chamomile Ginger
Peppermint
RUNNY NOSE -- COLDS, FLU OR ALLERGIESEchinacea/Chamomile tea
Cayenne pepper
Bee Propolis
Honey and Lemon tea
CONSTIPATION





Constipation --- baby
Colic (baby)
Slippery elm Lamb’s Quarter
Flax seed Aloe vera juice
Psyllium seeds slippery elm bark
Licorice root (if no blood pressure problems)
Chamomile
Dandelion root

dark molasses in water (bottle)
catnip and fennel drops
HEMORRHOIDS (PILES)


History of PROM

History of Elevated BP
Witch Hazel
Comfrey/St. John’s wort poultice
Papaya juice.

Zinc and Selenium tablets

Calcium & Magnesium tablets and/or licorice root
VARICOSE VEINS/ LEG ACHE/ LEG CRAMPS

witch hazel cayenne
Vitamin E Butcher’s broom
Rutin Raspberry leaf
yarrow Nettle infusions
shepherd’s purse calendula
Wild greens -- lambs quarters, mallow, shepherd’s purse, and dandelion leaves
BLADDER INFECTIONS






To “soften cervix”

To bring on labor

For bruises and muscle aches
unsweetened Cranberry juice.
barley water
corn silk Chamomile
Meadowsweet Lemon Balm
Raspberry leaves Lavendar
Echinacea root Dandelion leaf

Evening Primrose oil

Black and/or blue cohosh
B&B cohosh + red raspberry leaves - tea
Arnica Montana Bee Propolis
(Pugh, 1995)


APPENDIX B

Manuscript:

I will be submitting my manuscript to the Journal Of Nurse- Midwifery (soon to be the Journal of Midwifery and Women's Health). The JNM focuses on issues related to women's health, childbearing families, and midwifery. Submission criteria to JNM includes:
1. Two complete sets of the manuscript along with a signed copy of the Author Agreement and the Author Checklist to be sent to Mary Ann Shah, Editor-in-Chief, JNM, 67 Tarry Hill Road, Tarrytown, NY 10591.
2. Every manuscript that is submitted for consideration as a full length article is reviewed by a minimum of five members of the Editorial Board, three Peer Review Panelists, and when appropriate, by one to three Research Consultants.
3. Manuscripts are subject to modification and revisions to bring them into conformity with the fifth (1997) edition of the "Uniform Requirements for Manuscripts Submitted to Biomedical Journals as published in JNM, Volume 42, Number 3, May/June 1997:
a. Requirements for Submission of manuscripts:
1. Double space all parts of the manuscript
2. Begin each section or component on a new page
3. Review the sequence; title page, abstract, key words, text, acknowledgments, references, tables (each on separate page),
and legends.
4. Illustrations and unmounted prints, should be no larger than 203 X
254 mm (8 X 10 in).
5. Include permission to reproduce previously published material or
to use illustrations that may identify human subjects.
6. Enclose transfer of copyright and other forms
7. Submit required number of paper copies.
8. Keep copies of everything submitted


APPENDIX C

Query Letter

Carol T. Pugh, CNM
36 Clearview Road
Willow Street, PA 17584
January 21, 2000


Mary Ann Shah, CNM, MS, FACNM
Editor-in-Chief
Journal of Midwifery and Women’s Health
67 Tarry Hill Road
Tarrytown, NY 10591-6511


Dear Ms. Shah,

I have written a manuscript that I anticipate submitting to the Journal of Midwifery and Women Health for publishing. The current abstract follows:

An Ethnographic Study Of The Old Order Amish In Lancaster County, Pennsylvania -- The Effects of Culture on Prenatal Care

The term Old Order Amish refers to the most conservative and distinctive division of a Protestant group of individuals who are direct descendants of the Swiss Brethren (Anabaptists). The total Amish population in the United States is estimated at 145,000, but estimates vary and only adults are counted as full church members. In Lancaster County, Pennsylvania there are approximately 16-18,000 members of the Old Order Amish faith. Health care providers need to understand their ways of knowing; the patterns of thinking, feeling and acting, that are valued in the Old Order Amish culture in order for therapeutic care to evolve. Knowledge of communication patterns and traditional health beliefs of the people of this culture assures optimal care. There are many relevant sociocultural factors which have an influence on Amish health care practices. Beliefs and values such as respect for authority, obedience to parents, group responsibility, and individual humility bind the Amish people in their culture. These beliefs and values also relate to the health care practices in the family and community. Cultural beliefs and practices tend to separate the Amish from the conventional American (“English”) culture in ways that sometimes make it difficult for midwives and other health care providers to understand this unique population. Of particular interest are the choices Amish women make with regard to childbearing care. The birth of a child enhances the standing of the parents in the community, and since children are wanted, an Amish couple may expect to have several, if not many, children. The number of pregnancies per Amish woman in Lancaster County is a norm of 7, with 10 or 11 live births being not uncommon. Using Leininger’s Sunrise Model of Health Care as the theoretical perspective, information about the Old Order Amish culture is presented, that will assist midwives and other health care providers to promote and provide culture-congruent prenatal care.

This manuscript has been developed as the result of a proposed study in my clinical practice and my enrollment in the Master of Science in Midwifery graduate studies at Philadelphia University. I would like to add to the dialog of promoting cultural congruent prenatal care by presenting this study of a unique group of women to your readers. Presently, the manuscript is undergoing peer review and revisions.

My research course requires me to identify the Journal’s requirements regarding manuscript length, the manuscript acceptance/rejection rate for the Journal, and the submission deadlines for the Journal, Numbers 2 and 3 of Volume 45, Year 2000.

Thank you for your consideration at this time. I look forward to your reply and the opportunity to share my entire manuscript with you in the near future.
Sincerely,


Carol T. Pugh, RNC, CNM






APPENDIX D

EDITORIAL SUGGESTIONS

Suggestions from Pat Sonnenstuhl were gratefully received and acknowledged. Some suggestions I chose to use and some I did not. Thank you to Pat for her editorial help.
Unfortunately my computer will not allow me to copy and paste her paper here. I will send it under separate cover via e-mail.


Nancy Haninger’s suggestions were also gratefully recieved and acknowledged. The reference list was amended to fit the JNM style.

Dr.Farley’s suggestions --- noted -- gratefully recieved, and revised edition sent for grading.
The herbal list was compiled in 1995 from a previous study, I think I’ve referenced it correctly. For brevity, I only included SOME of the reasons for herbal use. Thank you.
. . . . . . .