EQ WIWill“NW)!NWWHIWIIHWWW

   

 

 

 

 

 

 

 

 

lullllIlllullIllllullllfll‘lwl

31293 01691

This is to certify that the
thesis entitled

Childbearing Health Practices as Described
by Old Order Amish Women

presented by
Nancy L. Mi11er
has been accepted towards fulfillment

of the requirements for

Master's degree in Nursinq

Z5 is raga . (in 4 4

am professor

Date 4W¢W/J: / q 47

0463‘.) MS U is an Affirmative Action/Equal Opportunity Institution

 

 

 

LIBRARY

Michigan State

University

 

 

PLACE IN RETURN BOX

to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

DATE DUE

MTE DUE

MTE DUE

 

Agfi 399055

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1m MAM“

CHILDBEARIN G HEALTH PRACTICES AS DESCRIBED BY
OLD ORDER AMISH WOMEN

By

Nancy Lynne Miller

A THESIS
Submitted to
Michigan State University
in partial fiilfillment of the requirements
for the degree of

MASTERS IN SCIENCE

Department of Nursing

1997

ABSTRACT

CHILDBEARING HEALTH PRACTICES AS DESCRIBED
BY OLD ORDER AMISH WOMEN

By

Nancy Lynne Miller

The Old Order Amish culture influences the health practices of its people. Large
families and home births are common practices among the Old Order Amish. Often Amish
women lack or receive little prenatal care; the influencing factors are often unknown to the
health care professionals. Thus, the dilemma of providing culturally congruent care to this
population is presented to the health care professionals. This study described the
childbearing health practices as described by Old Order Amish women which can be
utilized to provide culturally congruent nursing care to childbearing Amish women. This
qualitative descriptive study used a focus group with Old Order Amish women of
childbearing age. Leininger’s Cultural Care Diversity and Universality theory with the
Sunrise Model provided the conceptual framework. The results revealed that faith
motivated these Amish women to bear children; childbearing was a private matter and
home births are preferred; and formal knowledge of childbearing was limited but support

reinforced their childbearing health practices. Traditional professional health care was

sought only with a perceived complication during pregnancy or labor.

Copyright by
NANCY LYNNE MILLER
1997

iii

Dedicated to the memory of
Elizabeth Miller
(1953-1995)

An Amish Friend

iv

ACKNOWLEDGMENTS

Without the dedication of my daughter, Rachel M. Miller, I would have not been
able to complete this thesis. Her computer skills were invaluable, but most of all her
encouragement and support were greatly appreciated.

Also special recognition to the thesis committee Mildred Omar, RNC, Ph.D., Thesis

Chairperson, Mary Jo Amdt, RN, Ph.D., and Joan Wood, RN, PhD.

TABLE OF CONTENTS

LIST OF
TABLES ................................................................................................................................. viii
LIST OF
FIGURES ................................................................................................................................. ix
INTRODUCTION .................................................................................................................... 1
Background of the Problem ......................................................................................... 1
Statement of the Problem ............................................................................................. 5
Research Question ........................................................................................................ 5
Importance of the Study ............................................................................................... 5
CONCEPTUAL FRAMEWORK ............................................................................................ 7
Conceptual Definition of Childbearing Health Practices ............................................ 8
Theoretical Model ........................................................................................................ 9
Review of the Literature ............................................................................................ 14
General Health Beliefs And Practices Of Amish ................................................. 14
Childbearing Health Practices As Described By
Amish Women ................................................................................................. 16
Critique of the Literature ........................................................................................... 18
METHODS ............................................................................................................................. 19
Design ......................................................................................................................... 19
Sample ........................................................................................................................ 20
Instrumentation ........................................................................................................... 20
Procedure .................................................................................................................... 21
Recruitment of Subjects ................................................................................ 21
Setting for Focus Group Interview ............................................................... 21
Conduction of the Focus Group .................................................................... 22
Data Analysis ............................................................................................................. 23
Protection of Human Subjects ................................................................................... 24
Assumptions and Limitations .................................................................................. 24
RESULTS ................................................................................................................................ 25
Demographics ............................................................................................................. 25
Results Related To The Research Question ............................................................. 27

vi

DISCUSSION ......................................................................................................................... 55
Interpretation of the Findings .................................................................................... 55
Theoretical Model In Relation To Childbearing

Health Practices As Described By Amish Women of the Marlette

Amish Community Sanilac County, MI ................................................................ 58
Implications for Advance Practice Nurses ................................................................ 6O
Implications for Research ........................................................................................... 64
Summary ..................................................................................................................... 65

APPENDICES ....................................................................................................................... 66
REFERENCES ........................................................................................................................ 74

LIST OF TABLES

Table l-Range, Means and Standard Deviations

of Demographic Characteristics ................................................................................ 26

Table 2- Pattern of Themes Related to the
Focus Group Questions ........................................................................................... 28
Table 3- Analysis of Focus Group Question 1 ....................................................................... 29
Table 4- Analysis of Focus Group Question 2 ...................................................................... 33
Table 5- Analysis of Focus Group Question 3 ...................................................................... 34
Table 6- Analysis of Focus Group Question 4 ...................................................................... 35
Table 7- Analysis of Focus Group Question 5 ...................................................................... 36
Table 8- Analysis of Focus Group Question 6 ...................................................................... 39
Table 9- Analysis of Focus Group Question 7 ....................................................................... 40
Table 10- Analysis of Focus Group Question 8 ..................................................................... 42
Table 11- Analysis of Focus Group Question 9 ..................................................................... 48
Table 12- Analysis of Focus Group Question 10 ................................................................... 49
Table 13- Analysis of Focus Group Question 11 ................................................................... 50
Table 14- Analysis of Focus Group Question 12 ................................................................... 51
Table 15- Analysis of Focus Group Question 13 ................................................................... 54

viii

LIST OF FIGURES

Figure 1- Sunrise Model ...................................................................................................... 11
Figure 2- Modified Sunrise Model of Culture Care .............................................................. 12
Figure 3- Modified Sunrise Model of Study Findings .......................................................... 59

ix

Introduction

Background of the Problem

The United States is a nation with a wide cultural diversity. Culture reflects the
background and experiences of a specific group of individuals (Henkle & Kennerly,
1990). Culture is characterized by a pattern of values, beliefs, and behaviors manifested
by a particular group and is greatly influenced by traditions and customs learned
throughout life (Henkle & Kennerly, 1990). Thorne (1993) states health beliefs are often
considered to be those peculiar ideas held by individuals which affect decision making
and behavior. Clients can be labeled noncompliant when their choices of care do not
coincide with the professional's recommendations and/or when the professional has a lack
of cultural awareness (Charonko, 1992). Leininger (1993) defines culture as "the learned.
shared, and transmitted values, beliefs, norms, and lifeways of a particular group that
guides its thinking, decision, and actions in patterned ways" (p. 19). Culture plays a role
in childbearing beliefs and practices in America since many Americans have an
immigration background in which folkways and "old wives tales" are passed from
generation to generation (Stam, 1991).

A unique culture in the United States that has a fast growing population is the Old
Order Amish. The Old Order Amish culture influences the health beliefs and practices of
its people. Health care professionals are presented with the dilemma of providing
culturally congruent care to this population. Large families and home births are common
practices among the Older Order Amish. This study focused on the childbearing health
practices as described by Old Order Amish women which could increase health care
professionals’ understanding and promote culturally congruent perinatal care with this
population.

The Old Order Amish is a religious group formed after the Reformation in
Europe. For further reference, the Old Order Amish will be referred to as Amish. They

became what are known as Anabaptist, opposing infant baptismal. Jacob Ammann

brought his people, who were named Amish afier him, to the United States in the 1700's
to escape religious persecution. The Amish are Protestant with a religious basis in the
belief that they are to be in harmony with the earth and themselves (Naylor, 1974). The
Amish accept death as a process of life that leads to the entrance to a better life (Brewer
& Bonalumi, 1995). Their religion dictates that they maintain a simple way of life. They
believe in keeping the "old ways" and avoid modern trends (L. Troyer, personal
communications, March 20, 1992). This places them in a rural setting where farming,
food preservation, and raising a large Amish family is their priority. Amish believe it is
very important to keep and hand-down the Amish traditions (N aylor, 1974). The
"Ordnung" either written or unwritten, are the strict rules that regulate church members'
lives by dictating style of dress and hair, style of home furnishings, and style of farming
methods (Wiggins, 1983).

The Amish believe in separation of church and state. They do not accept
governmental social support such as welfare. They are exempt from paying social
security taxes as determined by the Federal Supreme Court. They do not believe in
formal insurance plans; instead an Amish community will share the burden of cost if a
hospitalization is required for one of its members.

Some of the traditions are speaking German as the primary language; this creates
an unique language barrier since children do not learn English until they begin to attend
school at age six (Brewer & Bonalumi, 1995; Naylor, 1974). The Amish are formally
educated by Amish, in Amish schools through the eighth grade. Further education
continues at home which includes learning the skills to manage a home and farm (N aylor,
1974)

The Amish maintain a holistic health practice (Henderson, 1981). Before seeking
entry into the professional health care system, the Amish rely on their own home
remedies and midwifery (Brewer & Bonalumi, 1995; Finn, 1995). Wenger (1995) lists

three factors the Amish consider when seeking health care whether folk, alternative, or

professional care as: "1) type of health care problem; 2) accessibility of health services;
and 3) perceived cost of health care services" (p. 12).

Amish women often have home births. A study by Palmer (1992) found that the
Amish prefer home births and that children are viewed as a blessing from God;
contraception is not a practice. If available "midwives or family physicians may attend
the home births and if not, the birth takes place in a hospital" (Palmer, 1992, p. 118).
Some health care providers will only provide care when the Amish woman agrees to
comply with prenatal and postnatal care (McGinn, 1996). A birthing center in one Amish
community has been established with the collaboration of the Amish and local health care
providers to increase perinatal care, improve prenatal outcomes, and reduce costs of
childbirth while allowing the Amish to maintain their cultural values and beliefs
(Acheson, 1994).

Patterns of health behavior reflect characteristics of the Amish culture and may be
responsible for certain mortality rates among the Amish population (Fuchs, Levinson,
Stoddard, Mullet, & Jones, 1990). It is reported that men tend to outlive their wives and
it is speculated that high fertility and the stresses of childbearing may have an adverse
effect on female longevity (Cross, 1976).

Amish record keeping is usually accurate for live births and stillboms; premature
fetal deaths and miscarriages are often not recorded (Acheson, 1994). Even though birth
certificates are filed, it is impossible to differentiate Amish births from the general
population so as to study infant mortality and morbidity (Acheson, 1994).

Perinatal risk factors prevalent among the Amish which adversely

affect perinatal outcomes, include short birth intervals and more

births to older women; grand multiparity; a high degree of

consanguinity; a very high rate of twinning; a high-fat, high-sugar

diet; obesity; psychological stresses related to temptations of

modern technology; lack of medical insurance; late entry to prenatal

care; few prenatal visits; and a substantial proportion of births

attended by lay midwives (Acheson, 1994, p. 173).

Positive health practices which enhance more positive outcomes, however, are also
reported. Amish women "do not smoke, consume alcohol, or use recreational drugs; their
roles as wife and mother are highly valued; with an extensive psychosocial support
system of family and community; and excessive financial burdens of a family are
assumed by the community" (Acheson, 1994, p. 17 3).

The following exemplar serves as an example of Amish women's childbearing
health practices can be described. An Amish woman, having delivered a premature infant
(third pregnancy) per Cesarean section after an appendectomy, sought advise from this
researcher about her fourth pregnancy. The woman was referred to and received care
from an obstetrician who delivered her infant vaginally in a birthing room in a hospital;
she was discharged 12 hours afier delivery without incidence. With her fifth pregnancy,
she consulted a lay midwife who did home deliveries. This pregnancy ended at 32 weeks
gestation with a precipitous delivery of a stillborn with anomalies. The Amish woman
believed she did not need a physician with her fifth pregnancy since she was "cure " with
the previous vaginal delivery.

The Amish culture is reflected in the childbearing health practices among Amish
women. There are certain lifestyles that promote healthy pregnancy outcomes, but there
are also other factors that contribute to poor outcomes. The practices of not starting
prenatal care until the sixth month of pregnancy or not receiving any prenatal care at all,
home deliveries attended by lay midwives, grand multiparity, and lack of insurance
contribute to poor pregnancy outcomes. It is not always clear as to what cultural factors
influence Amish women in these childbearing health practices. An understanding from
the Amish woman's perspective could give insight into these childbearing health practices
so professional health care providers can implement care that would be culturally

acceptable and promote positive pregnancy outcomes to this population.

Statement of the Problem

There are over 100,000 Amish in 21 states (Adams & Leverland, 1986). It is
estimated that an Amish community can double its population approximately every 23
years (Cross, 1976). A community in Marlette, Michigan, had a population count of 380
in 1995 (Budget, 1996). The Marlette Amish community had 12 live births in 1996 (E.
Petersheirn, personal communication, December 8, 1996). Record keeping consists of
each family maintaining a list of births in the community with parents' and infants' names
and the dates of birth. No birth weights or gestational ages are included. There is no
record of stillboms or miscarriages; births are registered at the county court house before
the first birthday. The Marlette Amish community's growing population is increasing its
presence in the health care delivery system.

An understanding from the Amish perspective could provide insight into the
Amish's childbearing health practices. An understanding is required by the Advanced
Practice Nurse (APN) before attempting to implement interventions such as education
relating to childbearing, perinatal health promotion and prevention and accessing
culturally congruent professional health care. The care must be culturally acceptable or it
will not be followed by the Amish since their childbearing health practices are defined by
the Amish culture. If the Amish ways are not followed there are severe consequences of
being shunned (Wiggins, 1983).

Research Question

This descriptive study examined the following question: What are the
childbearing health practices as described by Old Order Amish women of the Marlette
Amish community of Sanilac County, Michigan?

Importance of the Study
This study adds to the body of knowledge about childbearing health practices

among this population of Amish women. It provides insight and understanding of the

practices as described by a group of Amish women from an emic perspective. There is
minimal information available on this topic.

When obstetric emergencies arise such as fetal distress or breech presentation
during attempted home deliveries, the Amish women are taken by car to a hospital over
25 miles away. Hospital personnel lack any knowledge regarding the pregnancy or health
care status of the Amish women. Few Amish women seek early or continuous prenatal
care unless a known risk/medical emergency occurs during the pregnancy. Opportunities
are lost during the prenatal and postnatal periods for health promotion, especially in the
form of the newborn screening for potential disease (e. g., hypothyroidism) and
immunizations. Further knowledge is needed to understand the childbearing health
practices from the Amish perspective so that culturally congruent care interventions can
be implemented to promote positive pregnancy outcomes for Amish women.

Additional knowledge will enable the APN, who may care for this unique group
of people, to provide cultural congruent care. Trust in the APN by the Amish is an
essential first step towards establishing a therapeutic relationship (Palmer, 1992; Wenger,
1991). The APN needs to possess patience and an understanding and respect for the
Amish health practices since the Amish will reject a health practice that the church
discipline finds unacceptable, such as contraception (Adams & Leverland, 1986; Brewer
& Bonalumi, 1995).

Wiggins (1983) reports the best role of the APN is "caregiver” and “educator" (p.
28). The role of caregiver promotes health maintenance and prevention. The APN as
educator provides information about health promotion and prevention. Since the Amish
have limited formal education, by increasing the Amish's knowledge level about health, it
is anticipated that their health practices will improve (Wiggins, 1983). Caring behavior
characteristics of health care professionals are described by the Amish as: "takes time,

listens, knowledgeable and provides information, allows for choices of treatment and

respects the choices, includes the family, and doesn't ask for money first" (Wenger, 1995,
p. 11).

Health promotion teaching about childbearing is an important component to
assure successful outcomes (Fuchs et al., 1990; Kemp & Hatmaker, 1992; Kogan,
Alexander, Kotelchuchk, & Nagey, 1994; Lewallen, I988; Tiedje, Kingry, & Stommel,
1992). An assessment of the nature of the health behavior needs to be considered when
beginning the interventions related to childbearing health practice (Tiedje et al., 1992).
The APN who shows respect for cultural influences is better able to overcome the barriers
to health teaching (Scott & Stern, 1985). Combining the "generic folk care with
professional care provides culturally congruent care" (Leininger, 1991, p. 37). These
concepts provide the direction of the APN's role when offering professional services to
the Amish women of childbearing age. The specific roles of the APN are: a trusted
primary care provider whose care is culturally congruent; an educator of health promotion
and prevention; an advocate when the choices of the Amish woman may not coincide
with the routine protocol; and a collaborator with other health care professionals involved
with the Amish.

Conceptual Framework

The Cultural Care Diversity and Universality theory (Leininger, 1991) includes
several assumptions which explain the phenomenon of care within the context of culture.
The theory's assumptive premise that provides the guidance for this study states:

"cultural care values, beliefs, and practices are influenced by and tend to be embedded in
world view, language, religion (or spiritual), kinship (social), politics (or legal),
education, economic, technology, ethno-history, and environmental context" (Leininger,
1991, p. 45). The conceptual definition of childbearing health practices is theoretically

defined using the literature and Leininger’s theoretical perspective.

Conceptual Definition of Childbearing Health Practices

There is limited literature that specifically defines childbearing health practices.
Related literature was examined which defined health practices among various
childbearing populations. Kemp and Hatrnaker (1992) studied health practices and
anxiety related to low and high risk, low-income pregnant women. These authors defrned
health practices as "the perception of threat if the pregnancy was at risk which increased
anxiety levels and health-protective and health-promoting behaviors" (Kemp &
Hatmaker, 1992, p. 266). Lewallen (1989) defined health practices of pregnant women in
the conceptual framework of loci of control where the pregnant woman perceives control
over her own health. Positive health promoting practices were defined by a high belief
that the women's "own actions control their health" (Lewallen, 1989, p. 245). The
childbearing health practices of black women were studied by Scott and Stern (1985)
within the context of the "meaning of menstruation, bathing during menstruation and
postpartum, pregnancy, diet during pregnancy and postpartum care along with the care of
the infan " (p. 48). Negative pregnancy health practices were defined as "inadequate
prenatal care, poor nutrition, smoking, and the use of alcohol" in a study by Tiedje et a1.
(1992, p. 482). Marshall (1991) defined maternal health practices as "weight control,
exercise, smoking, alcohol consumption, sleep patterns, and eating habits" (p. 169).
Davis et a1. (1991) provide a global definition of health practices as the person's
"singularity (demographic characteristics, social influence, previous health-care
experiences, and environmental resources, along with expression of motivation, cognitive
appraisal of the health-care concern, and the affective response to that concern)" (p. 12).

In summary, the literature defines childbearing health practices as the woman's
perception of risk or threat and self-control over her own health (Davis et al., 1992; Kemp
& Hatmaker, 1992; Lewallen, 1989; Tiedje et al., 1992). Action or lack of action for
childbearing health practices are influenced by the environmental context, specific

cultural beliefs, and life experiences (Davis et al., 1992; Kemp & Hatmaker, 1992;

Marshall, 1991). This provides a general conceptual definition of childbearing health
practices, but further definition is required in the context of the Amish culture.

The Cultural Care Diversity and Universality theory does not explicitly define
health practices but does define "generic care" which can be considered health practices,
as "an essential behavior for human growth, health, and survival which includes the home
remedies and folk care used by families" (Reynolds & Leininger, 1993, p. 25). Health
practices of the Amish can be derived from the literature as practices that enable one to
function in the work role one occupies (Wiggins, 1983). Wenger (1991) defines the
Amish's health practices as "the maintenance of the culture dictating health care, resulting
in rituals" (p. 100). "Hard work, clean living, and a well-balanced diet contribute to good
health which is believed to be a gift from God" (Brewer & Bonalumi, 1995, p. 495). For
the purpose of this study childbearing health practices are defined as those behaviors,
actions, or habits which are influenced by cultural values, beliefs, traditions, ideas, or
rituals women related to the pre-conceptual, antepartum, and postpartum stages of
pregnancy as identified by Amish women of childbearing age.

Theoretical Model

The Culture Care Diversity and Universality theory and the Sunrise Model by
Leininger (1991) provide the theoretical guidance to discover childbearing health
practices as described by Amish women. The theory postulates "that in all cultures,
human care exists but remains undiscovered; with knowledge of culture the nursing
profession could provide transcultural care" (Leininger, 1991, p. 36). The theory
"interrelates culture and care" through a qualitative induction theory construction
(Leininger, 1991, pp. 20-24). Care is based on a "generic (emic) and professional (ethic)
level of care knowledge" (Leininger, 1991, pp. 41-42). An emic knowledge of care is the
insider's (person who belongs to the cultural group) perception of care with its "specific
meaning, experiences, symbols or processes within the cultural context of its people"

(Leininger, 1991, p. 79). The theory supports exploration of unknown childbearing

10

health practices as described by Amish women from the emic perspective. Leininger’s
assumption: "cultural care values, beliefs and practices are influenced by and tend to be
embedded in world view, language, religion (or spiritual), kinship (social), politics (or
legal), education, economic, technology, ethno-history, and environmental context of a
particular culture (Leininger, 1991 , p. 45), provides the guidance for this study.

The Sunrise Model provides the conceptual map of all the components of the
theory (Figure 1). The nurse uses the model to assess all aspects of the care systems to
develop culturally congruent care (Leininger, 1991). The sunrise effect depicts culture
and care interrelated with influences flowing in either direction. The assumptive premise
selected to guide this study is displayed in the upper portion of the model as the seven
fanned sections under the Cultural and Social Structure Dimensions.

The Modified Sunrise Model (Figure 2) displays examples of specific influences
on care patterns and expressions of childbearing health practices as described by Amish
women. Beginning from left to right, the influential technological factors are "keeping
the old ways" (L. Troyer, personal communication, March 20, 1992). Modern technology
such as electricity, telephones, and automobiles are prohibited. Reluctance to access
perinatal care may be attributed to the distance to travel or the need to hire a driver.

Religious and philosophical factors of the Amish culture are based on the doctrine
of Christianity and adult baptismal (Anabaptist) (Wiggens, 1983). Children are perceived
as a blessing from God which provides the guidance for large families (Palmer, 1992).

Kinship and social factors of a strong sense of family and community supplies the
social support to the Amish woman during the childbearing years (Acheson, 1994). The
Amish live together in closely connected settlements which provide the needed support

for their culture.

1 1
ULTURE CAR
C WORLD VIEW E

AL —_STRUCTUH
Low 5°“ so,”
deflv/‘if— 5' 5” ”3’03
\
6° \
\

Commence I] ”a;
llleways [eye/2,,
/ \ W9 ‘\
/ 6b \ 39>: envlro “’7”ch

\x
47,,” j//
«N
e
\l/o\\’:O/fi‘//" I ficfi \
Influences

     
     
       
   
 

Individuals, families. roups and Institutions

Diverse health systems

J.— |
Folk I Professional
\ systems I) Nursing ‘1 systems i

T

Nurstng care decisions and actions
Cultural core preservation I maintenance
Cultural care accommodation I negotiation
Cultural care matternlng I restructuring

Culture congruent care
LEGEND:
--— IOMMB
— WM“

Figure l Lemmger 3 Sunrise Model depicts dimensions of Cultural Care Diversity and

Universality (From Leininger, M. (1992). Culture C are Diversity & Universality A theory of nursrng
(p. 43). New York: National League for Nursing. Used with permission )

.332 8:55

as: .2 cases. see 8.2.2.5 2.835 38¢. Ea 32.6 .26 22.5% .35: 8E5 8532 «an

     

 

    
 

anfl< 502° 3°
II I I I I I I I I I I I I I J I I I I I I I I I I I I I I q I I I I I I I I I I J

. 25:95: \vvlv 89:99... 9.8 33.8.. -

_ :63 he onto—>35. he so: .58: not-2.330 8 868. v8.53.

. 8:- ... t . £958....
. .a 8.8. 323259 .elneeh e e v I o 6.3 .86.... oz -
— e e e [\Nn l n e a .

Q - Ilfl‘ '
—— o e o e I I ~
G \ ‘ Q ll.
‘ ~ ~
9 e 85.3.5 .862... 02 e nut-ant: .3...qu 00 a: “.30 ”:8.— s
a aim in... . o .53 a. Gm: ~
.I 3!:— . £53.33». o. S. 3 <s
e .
I e . a o 0 ss
. . . . no» ”5:335 . .
I e a 5:5 0
2 I o . a 283» . e \
1 I . . : 38m o s
I e 858:5 . . bisllou \
. e .6552.— o>=¢wo= . a no 83m 88
I now—82.93: - a \
I I .5 $.38 38. . €2.23...qu . s
I al— ..o 89' .2. on . 89.: 5a..— . \
I a \
a: seam \

 

 

I,

n32.053— 9.32:5
zoom v..- 1.5.1.0

   

 

“

 

"|‘

    
     

9.6 .555

  

  
  

 
 

13

The cultural values and lifeways are respected and followed; those who do not
subscribe are shunned by the Amish community (Wiggins, 1983). The simple lifestyle
and plain dress with the beliefs of large families (grand multiparity); a balanced diet, and
the avoidance of tobacco and alcohol are major influencers (Acheson, 1994).
Contraception is not an acceptable practice (Palmer, 1992).

Political and legal factors influence the Amish culture through their strong belief
of separation of church and state. This is demonstrated by not voting, and the limited use
of the judicial system to establish Amish schools and to be exempt fiom paying social
security tax (N aylor, 1974). Negative influences are demonstrated as failure to report
stillboms and communicable diseases, a high degree of consanguinity, and failure to
receive state required immunizations and neonatal screening tests (Acheson, 1994;
Brewer and Bonalumi, 1995).

Economic factors are influential since most Amish prefer to be farmers, or if only
necessary, work in other areas such as carpentry (Wiggins, 1983). In seeking farms to
support the large families, there is frequent migration among the Amish (Wiggins, 1983).
The Amish do not use commercial health insurance with the cost of health care a factor in
seeking medical treatment (Brewer & Bonalumi, 1995). Low incomes and large families
limit the Amish's economic resources.

Education is the final factor. Amish children attend Amish schools taught by
untrained Amish teachers only through the eighth grade (L. Troyer, personal
communication, March 20, 1992). The curriculum is basic and weak in the sciences,
leaving out knowledge of human anatomy and physiology (Adams & Leverland, 1986).
This contributes to the lack of formal education regarding the process of pregnancy, labor
and delivery, and the postpartum period. It is unknown what additional knowledge is

gathered from other sources about childbearing health practices.

14

These seven factors are in the context of German as the primary language and
living in a rural setting. All these factors influence the care patterns and expression of the
childbearing health practices as described by Old Order Amish women.

Review of the Literature

The current literature provides limited information about Amish health beliefs and
practices with even less known about childbearing health practices. The literature
reviewed examines health care practices from a general epidemiology perspective to an
extensive qualitative description of the Amish culture. The literature acknowledges the
Amish culture as unique to study because strong values and beliefs influence their health
care practices. Review of the literature of general health beliefs and practices of the
Amish will precede the review of the childbearing health practices of Amish women.

General Health Beliefs and Practices of the Amish, Some of the literature
describes with accuracy the lifestyle, health beliefs and practices generally associated
with the Amish culture (Acheson, 1994; Adams & Leverland, 1986; Brewer & Bonalurrri,
1995; Lucas, O'Shea, Zielezny, Fruedenheirn, & Wild, 1991; McGinn, 1996; Palmer,
1992; Wenger, 1991; Wiggins, 1983). The Amish have no religious proscriptions against
medical doctors, drugs, or hospitals (Brewer & Bonalumi, 1995; Fuchs et al., 1990;
Wiggins, 1983). Lack of higher education prevents an Amish from becoming a physician
but there is mention of the Amish "Brauche", a form of healing involving ritual acts and
quiet recitation of verses which is often referred to as "pow-wowing" and handed down
from person to person (Adams & Leverland, 1986; Brewer & Bonalumi, 1996; Palmer,
1992; Wiggins, 1983). Some Amish deny the practice but others are convinced by
hearsay that it provides a cure (Palmer, 1992). The BLdggt, the national Amish
newspaper, often supports cure-alls with its advertisements (Palmer, 1992). Home
remedies are often used prior to seeking professional health care (Brewer & Bonalumi,
1995). In general, the Amish children receive few, if any, immunizations (Brewer &

Bonalumi, 1995; Fuchs et al., 1990). The Amish consider a healthy person as having a

15

good appetite, able to do hard work and looking well (Adams & Leverland, 1986).
"Good health is considered a gift from God" (Brewer & Bonalumi, 1995, p. 495).

An extensive qualitative study of the Amish culture by Wenger (1991) provides a
wealth of information and promotes further investigation to discover the health practices
of the Amish. The purpose of the study was to discover and explicate the nature,
meanings and expressions of health care practices among the Amish (Wenger, 1991).
Using Leininger's Cultural Care Diversity and Universality theory and Hall's concept of
culture context, the analysis showed four Amish cultural themes. These themes relate to
the general health beliefs and practices of the Amish: 1) "an emic concept of care" as
"being Amish" which means care is vital to survival of the social structure; 2)
"anticipatory care" which means keeping the community together and helping others; 3)
"active participation in care situations" which means the promotion of individual, family,
and community well being on a daily basis; and 4) "principled pragmatism is culture
care" which refers to a wide range of health care options, a high value in seeking counsel
from each other, a focus on day to day consequences, and following the accepted mles of
behavior (Wenger, 1991, pp. 161-169).

In a more recent article, Wenger (1995) discusses the Amish culture relating
cultural context, health, and health care decision making. Folk, alternative, and
professional care services are described along with the Amish's rationale for choosing a
particular care service. The folk or "Braucher" is used "to keep cost down, for small
children, to avoid drugs, or to get there easier/not as far" (Wenger, 1995, p. 7). The
Amish use professional care for "high fever, need surgery or stitches, if you need
medicine, or if you need to go to a hospital" (Wenger, 1995, p. 7). Chiropractic care
described as alternative health care, was the most ofien sought alternative care (Wenger,
1995)

A more recent article also supported these findings of Amish health care beliefs

and practices. It discussed the importance of providing transcultural nursing care in a

16

hospital emergency department to the Amish (Brewer & Bonalumi, 1995). The health
care professionals lacked knowledge about this unique culture and found that providing
appropriate, acceptable health care was difficult. Study findings revealed that Amish
prefer home births; a language barrier exists with small children; cost is a contributing
factor in delaying health care; a reluctance to use preventive professional health care
exists; immunizations are often lacking; and home remedies are used as the first course of
treatment (Brewer & Bonalumi, 1995). Health care professionals need to understand
these factors in order to provide culturally congruent care. These descriptions of Amish
care lack details relating to specific childbearing health practices as described by Amish
women.

Childbearing Health Practices As Described By Amish Women. Scant literature was
found describing childbearing health practices as described by Amish women from their
perspective. The literature available related to Amish childbearing health practices
discussed pregnancy outcomes or delivery practices. In one Amish community home
births have been reported as the delivery choice preferred by the Amish with a midwife or
physician in attendance or when a professional is not available for delivery, then the
Amish baby is born in the hospital (Palmer, 1992). Acheson (1994) and Lucas et al.
(1991) studied pregnancy outcomes among the Amish and non-Amish women. Both
studies found little difference in infant mortality between the two groups, and suggested
that error existed in reporting of stillboms or neonatal deaths by the Amish. A study of
social support in the rural setting during pregnancy which compared Amish women and
women of the general population found social support as an equivalent factor in
pregnancy outcomes for both groups (Lucas et al., 1991).

The Amish population has been the focus for only a few epidemiological studies,
studying infant mortality and morbidity since the Amish are a homogeneous group
(Cross, 1976; Fuchs et al., 1990; Khoury & Cohen, 1987; Resseguie, 1974; Stevenson,

Everson, & Crawford, 1989). Even though genetic factors were the focus, the studies

17

were consistent with some of the childbearing health practices among Amish women.
Consanguinity was described as high; stillboms were underreported, grand multiparity
with pregnancies occurred until the age of mid-forty, and life expectancy was shorter for
Amish women than men.

Literature revealed the Amish culture, in relationship to pregnancy, was
significantly different from the general population. Lucas et a1. (1991) statistically
quantified the comparison of births of Amish and non-Amish using the variables of
lifestyle, particularly the prohibitions against smoking and alcohol use by the Amish, and
thus formulated the hypothesis that the Amish would have shorter labors. Labors were
significantly shorter for the Amish than the non-Amish by three hours, but bias may have
been introduced with lack of data from the non-Amish (Lucas et al., 1991). A statistically
significant finding was reported between smoking and alcohol use with Amish not using
them; however, the small sample size (n=3 9) for Amish compared to the non-Amish (n
=145) may have obscured important differences between the two groups along with a bias
of missing values due to lack of information.

A study using Leininger's (1991) Theory of Culture Care and Sunrise Model
researched a subculture of a non-Amish communal group living in Tennessee referred to
as "The Farm" (F inn, 1995). The Farm had created their own culture with the practice of
home births attended by their own-trained lay midwives. It was discovered that the
neighboring Amish community sought the services of The Farm's midwives, resulting in
these midwives training selected Amish women as midwives (Firm, 1995). This Amish
community chose to rely on the folk care system using the professional health care
system as a last resort (Firm, 1995).

McGinn (1996) described cultural, practice, and family issues that a family nurse
practitioner experienced working with the Amish and Mennonite families living in
Lancaster County, Pennsylvania. The family nurse practitioner found an understanding

of the Amish culture was needed when providing health care that would be accepted and

18

followed by her clients. "Clinic appointments were often missed on Tuesdays or
Thursdays since these are days wedding occur, but wedding plans are not discussed prior
so that planning cannot occur; negotiation became an art to provide care on a mutual
agreement; and careful history taking is essential to determine previous home care
received” (McGinn, 1996, pp. 56-57).

Critique of the Literature. The literature available is limited about Amish
childbearing health beliefs and practices. The available literature supports the need for
further study of the Amish culture in order for health care professionals to implement
culturally congruent care. Limitations of the literature are: the methodology limits the
findings due to small sample size, the lack of control groups, and lack of generalizability.
Some of the studies occurred over ten years ago, and the few epidemiological studies lack
accuracy due to under reporting of data or lack of records by the Amish (Acheson, 1994;
Cross, 1976; Fuchs et al., 1990; Khoury et al., 1987; Resseguie, 1974; Stevenson et al.,
1989). The epidemiological studies used data ranging fiom the late 1890's through the
1970's. Consanguinity relating to genetic risk factors which resulted with pregnancy
outcomes of intrauterine growth retardation, prematurity and fetal death was the focus of
these studies. Khoury et a1. (1997) found prematurity related to consanguinity and
inbreeding of the offspring related to intrauterine growth retardation and congenital
anomalies. Prospective studies need to be done using methods of collecting accurate data.
Acheson (1994) suggests further studies which described the social supports and informal
care systems of Amish women to be conducted. Past studies have failed to inform health
care professionals of the emic perspective of the Amish such as their values, beliefs and
health care practices.

More recent literature indicates the need to study the Amish culture which
consistently reflects the general lifestyle and the influences behind seeking alternative
care before professional health care. This need is based on having only a few credible

sources of anthropological and epidemiological studies available (Acheson, 1994;

Wenger, 1991). Wenger's (1991) study was conducted over a three-year period. It
provides a qualitative description of the Amish's nature, meanings and expressions of
care. It is quite detailed about the Amish yet true disclosure may not have been given by
the Amish if there was perceived lack of trust (Wenger, 1991).

Even though the study by F inn (1995) focused on the non-Amish, it did discuss
the Amish and the practice of home deliveries. Training Amish women to be midwives
by non-Amish cannot be generalized since this was only one community. Each Amish
community makes its own decisions about specific practices with the "Ordnung",
therefore, it cannot be assumed this is a practice in every Amish community.

Recent literature (Brewer & Bonalumi, 1995; McGinn, 1996) described the role of
nursing in providing transcultural nursing care to the Amish. This supports the need for
the APN to understand the unique Amish culture since an understanding is needed to
provide culturally congruent care. In order to provide appropriate health care to Amish
women, the APN found it necessary to negotiate for acceptable professional health care.

In summary, the studies are limited and provide minimal information about
childbearing health practices directly from the Amish perspective. Lack of information
indicates the need for qualitative studies of the meaning of childbearing health practices
as described by Amish women so that health care professionals can provide culturally
congruent care. This study addressed the concept of childbearing health practices as
described by Amish women. The conceptual definition provides for the Amish women to
describe their childbearing health practices and thus supports the emic perspective.

Methods
26.81211

This was a qualitative descriptive study. The purpose of the study was to describe
childbearing health practices as described by Amish women of the Marlette Amish
community of Sanilac County, Michigan. Leininger's qualitative ethno-nursing research

method provided the philosophical guidance for the design. This method was designed to

19

20

study nursing phenomena in a "naturalistic and emic open inquiry discovery process"
(Leininger, 1991, p. 75). The nurse-researcher coaxes care patterns and expressions from
people in an open-ended inquiring method in a trusting and relaxed atmosphere. A focus
group was conducted on July 16, 1997, for the purpose of gathering emic information
about childbearing health practices as described by Amish women of the Marlette
community of Sanilac County, Michigan.
Seraph

The convenient, homogeneous sample consisted of five Amish women of the
Marlette Amish community of Sanilac County, Michigan. The ideal focus group is
composed of 7 to 10 people with similar backgrounds (Krueger, 1988, p. 91). Women
who had experienced four to six pregnancies with more pregnancies anticipated were
included in the study. Since the average Amish family size in this area was ten, with a
range of five to thirteen, these women were in the middle of their childbearing years so
recall of their experiences was more reliable.
Instrumentation

The sernistructured interview guide for the study was a set of carefully worded,
focused questions (Appendix A) which were prefaced by a brief statement about the
context. The questions were derived from the seven influencing factors of the modified
conceptual framework of Leininger (1992). Open ended questions beginning with an
introduction or warm-up question, and progressing from general to specific questions was
the format. The sequence of the questions progressed from non-threatening to the more
threatening questions allowed for expression of the more difficult answers (Kingry,
Tiedje, & Friedman, 1990).

A pilot test of the questions, using the same procedure as used for the actual focus
group, was conducted on June 23, 1997, with an Amish woman who was not a candidate
for the study. The pilot test indicated the questions were understandable to the Amish

woman with information freely given over a two-hour period. The pilot study was not

21

tape recorded since the purpose was to verify clarity of the questions and not to gather
data. There were no alterations of the questions for the study.
Procedure

Recruitment of Subjects. Recruitment of the sample population began with
gathering a list of 10 names of eligible women who met the eligibility criteria, with
assistance of an Amish woman who did not meet the eligibility criteria and was not a
potential participant. The eligibility criteria was any Amish woman who experienced
four to six pregnancies with more pregnancies anticipated. To these potential women, a
letter (Appendix B) was sent on June 24, 1997, providing an explanation of the study and
requesting their participation. A self-addressed, stamped postcard was enclosed for each
participant to return with an affirrnation or decline of her intent to participate in the focus
group. After receiving only 3 postcards (2 affirmations and 1 requesting more
information), this researcher traveled to Marlette to meet with the remaining candidates.
The researcher being familiar with the participants asked if the recruitment letter was
received and if the return postcard was sent. All had received the letter but reported they
were too busy to return the postcard. A verbal response was given at the time. Of the 8
candidates visited, 2 refused, 2 were soon to deliver babies, 1 accepted but declined due
to a previous commitment, and 3 agreed to participate. In total, five Amish women
agreed to participate in the focus group. During this time, a mutually agreed upon date
was determined for the focus group session. A postcard reminder was sent to all the
women who agreed to participate in the study a few days prior to the meeting. An
incentive of free transportation to shop at Sam's Club was offered to those who
participated in the focus group.

Mg for Focu_s Group Interview. Since an Amish home was not conducive for
the focus group interview due to lack of electricity and privacy, a setting that provided
these plus being free of interruptions yet large enough and comfortable was needed.

After assessing possible sites, this researcher's home was selected. A large table with

22

comfortable chairs was used to allow for positioning of audio-taping equipment. Since
there was a matter of traveling approximately 15 miles one way, this researcher provided
the transportation to and fiom the focus group session for all the women.

Cflduction of the Focu_s Group. A. The focus group was held in Mayville,
Michigan, in the researcher's home. The women were seated around a large table. All
women agreeing to participate were requested to read and to sign an informed consent
form (Appendix C). Questions relating to their identity in the study were answered by
explaining that after the completion of the study, the audio tapes would be destroyed.
There would be no direct identification of the participants in the transcription. All five
women signed the consent forms.

B. After written consent was obtained, a demographic information sheet
(Appendix D) was given to the women to complete. The purpose was to obtain a profile
of the group and to stimulate the women to think about their pregnancies.

C. An explanation of the purpose of the focus group was given which was to have
the Amish women describe childbearing health practices as described by each of them, so
that health care professionals could learn from the Amish through their experiences.
Questions were asked only to guide and to keep the discussion focused on the topic of
childbearing health practices. It was requested that only one person speak at a time so
that a clear recording could be obtained.

D. The focus group discussion was stimulated with open-ended questions
(Appendix A). The focus group questions began with a general individual introduction to
give all women a chance to speak. Questions progressed from general questions to the
more critical specific questions (Krueger, 1988). The women needed much coaxing to
begin the discussion; it appeared there was a reluctance to be the first to speak. There
were long pauses of silence. One participant spoke very little and when she did, she
placed her hand over her mouth speaking softly. Two of the five women usually initiated

the discussion.

23

E. The focus group was conducted by this researcher. A time frame of one and
one half-hours was allowed. To gather precise data, tape recorders were used with prior
signed consent given by the participants. The researcher took notes to serve as reminders
to clarify a participant's comment at the end of each question.

F. One tape recorder malfunctioned and the dialogue at times was unintelligible.
Precise transcription of the audio-tapes was not possible. The researcher verified the
accuracy of the transcript by comparing the transcript to the audio-tapes.

G. Refreshments were served.

H. At the completion of the focus group, the women were given the opportunity
to set up a time for their free transportation to Sam's Club.

Data Analysis

The audio-tapes were transcribed by a paid typist almost verbatim with some
dialogue being unintelligible. The participants' confidentiality was protected by coding
the information without names and deleting all identifying information from the
transcripts of the focus group. The audio-tapes will be destroyed upon completion of the
study.

The data was managed manually. Content analysis of the transcripts was done by
the researcher to match the themes used in Leininger’s Sunrise Model as a method to
organize the childbearing health practices as described by the five Amish women. There
was no verification of the themes by other researchers. Analysis of the data was done to
draw meaningful conclusions about the women’s childbearing health practices. The
demographic data was organized to demonstrate the group's profile. The demographic

information obtained from the group was displayed in a frequency table.

24

Protection of Human Subjects

Approval of the study was obtained from the University Committee on Research
Involving Human Subjects (U CRIHS) at Michigan State University (Appendix E).
Guidelines established by the committee regarding confidentiality were adhered to by
deleting all identifying information about the participants from the transcripts of the focus
group. The audio-tapes will be destroyed upon completion of the study. A follow-up
letter was sent to UCRIHS informing the committee of a slight change in the recruitment
of the subjects, such that a personal contact was made after two weeks whether or not a
return postcard was sent (Appendix F). A written response from UCRIHS was received
(Appendix G). Only aggregate data was used with no individual's name used for any
presentations or writings. A consent form from each participant was obtained prior to the
interview (Appendix C). There were no known psychological, social, physical,
economical, or legal risks anticipated for the subjects who participated in this study.
Assumptions and Limitations

Assumptions were:

A. The participants were truthful about childbearing health practices and
answered the questions honestly.

B. Amish women's childbearing health practices were identified by the
conduction of the focus group.

Limitations were:

A. There was a chance of bias in analysis of the focus group transcript.
Conclusions were drawn directly from the dialogue being careful not to change the
content in relation to the context.

B. Respondents' answers may have be given so to be socially acceptable and self
selected within the group, due to sharing of intimate feelings.

C. Validation of analysis of classifications was not completed by the thesis

committee.

Results
Demographics

The five subjects were all married, Amish women living in the Marlette Amish
community of Sanilac County, Michigan. All had at least five pregnancies with more
pregnancies anticipated.

Table 1 describes the demographic characteristics. The mean age was 35 years
with the mean number of pregnancies, 7. The mean age of marriage was 20.6 years.
There was a total of 37 pregnancies between the five Amish women. Most pregnancies
reported were viable and term (live births at 38-42 weeks gestation). One woman .
experienced one early birth (< 38 weeks gestation) and a miscarriage. Another woman
experienced a miscarriage and a stillborn. A third woman experienced one early birth and
one late birth (> 42 weeks gestation). Only four births of the 37 occurred in the hospital;
there were more home deliveries reported assisted by the family members (husband,
mother and/or mother-in-law). The average interval between pregnancies was 20.5
months when the two extreme births occurring at 44 and 54 months interval were not
included. It can be assumed that these women were either pregnant or breast feeding
during the majority of this interval. The mean birth weight was 7.75 pounds with the

range between 5 to 10 pounds.

25

26

Table 1
Range, Means and Standard Deviations of Demogr_aphic Characteristics (N=5)

 

 

Characteristics M SD 31113;
Age (years) 35 8.37 31-42
Number of pregnancies/women 7 2 5-10
Number of viable births/woman 7 4 5-10
Number of term pregnancies (38- 6 2 5-10
40 weeks
Age @ time of 1"' period (years) 11 1 10-12
Age @ time of marriage (years) 21 1 19-22
Age @ time of 1" birth (years) 22 1 20-23

Infant birth weight (pounds) 7.75 1.04 5-10

 

27

Results Related to the Research Question

 

The research results are presented by answering the original research question;
What are the childbearing health practices as described by Amish women of the Marlette
Amish commtmity of Sanilac County, Michigan? The results of the focus group
responses are listed by the categories of the focus group questions with text examples
grouped according to the seven factors of cultural and social structure dimensions.
The themes that emerged were easily categorized into the seven influencing factors of the
Modified Sunrise Model (Figure 2): 1) Technological Factors (rely on neighbors’
telephones and cars and keeping the “old fashioned ways”); 2) Religious and
Philosophical Factors (childbearing is the Lord’s Will); 3) Kinship and Social Factors
(childbearing is kept secret and family offers a strong support system); 4) Cultural Values
and Lifeways (prefer home births, use home remedies and herbs); 5) Political and Legal
Factors (church elders assist in decision making when there is a poor pregnancy outcome)
6) Economic Factors (family and community assist with excessive health care costs); 7)
Educational Factors (experience and mother, sisters, and/or grandmothers provide the
education about childbearing). Table 2 displays the distribution of the themes as related
to each focus group question. The results are presented in the sequence of the focus
group questions (Table 3-Table 15) so the context is maintained. Descriptive narrative of

the contents are in the first column with categorized excerpts of the dialogue given in the

second column.

28

688m
3:33:3—

338m 988m Bung
30:22.3 v5 Eugen

395:4

v5 mos—“5
Bea—=0

998m 38m
as ease.

690$

32.3822; 992$
an 829.3. nemesis:

m;
N;
:n
c;
on
an
S“
on
ma.
3,
mm.
m»

I“

acumen—O

 

 

N 033.

Table 3

Analysis of Focu_s Group Question 1. The sign of passage from agirI to womanhood is

the first period. Deacribe your feeling and expariences with your first period.

 

Narrative Discussion

All expressed being scared at the sight
of the first blood and felt it would be with
them the rest of their lives. Activities were
limited at the time of menstruation (e.g., no
running or strenuous playing, lifting heavy
objects, and hoeing in the garden). It was
expressed that the body was weaker and
needed to be protected for childbearing.
By doing her chores, sisters would be

supportive during another sister's period.

Dialogue Excerpts with Themes
Kinship and Social Factors

"1 was scared, but I was sleeping with
grandmother and I used her potty. She seen
it so she told Mother. Mother knew right
away."

"I learned that all my sisters had it too.
That helped, too."

"Mom explained about it...a sign of
womanhood. I just thought it was terrible
to have to put up...the rest of my life."

"My older sisters told me...I wasn't
scared, but I thought it was such a bother."

"...if there was some heavy work that
had to be done and we noticed this certain
sister that's having her flow, we'd be there
so she wouldn't have to go out {to do

chores} .

 

(Table 3 continued)

Table 3 continued

30

 

Narrative Discussion

Dialogue Excerpts with Themes

 

The boys would ask why the girls could
not work, but a diversionary answer would

always be given.

Two of the women described having
clothing become bloody at school where
upon they were very embarrassed. A
teacher (female) or older sister would give
discrete assistance. They felt it was due to

the use of rags for sanitary pads.

We get there and do it for her so it
wouldn’t be noticeable.”
Cultural Values aid Lifewaya

"That you gotta' take care, not run
around, jump, and play like we normally
do."

"My mother was old fashioned...my
older sisters and I used rags."

"It was supposed to be a personal
private deal among the girls and not talked
to other children that aren't old enough to
understand."

"...she always told it not be shared with
the boys."

"If the boys caught on, they never talked
about it."

Economical Factors

"1 used rags, we didn't have expensive
pads."

"My mother always saved the long-john
rags."

"Anything that was worn out that you

could tear up as rags and be absorbed,

 

(Table 3 continued)

Table 3 continued

31

 

Narrative Discussion

Dialogue Excerpts with Themes

 

Only one of the five women stated she
had had previous instruction on
menstruation before the event. The other
four did not learn about menstruation until
the first occurrence of menses; a mother, a
grandmother, or an older sister gave an
explanation. One woman experienced an
extreme "belly ache" from her first period
resulting in being taken to the hospital
where the cause was discovered. It was
through the nurses that she learned about
menstruation and the related purpose to
childbearing. The other four women did
not have the understanding of the

relationship of menstruation to childbearing

worked. I guess I got 21 or whatever, I quit
using rags."

"I go back to rags the first few days after
a baby."
Educational Factors

"...will it be the rest of my life?"

"She (mother) explained how it would

be."

"...take care of yourself."

"...important to keep yourself clean."

"...not talked to other children that aren't
old enough to understan ."

"...she explained it to me...a way of
growing up."

{First connected menstruation to
childbearing}: "When I started working at a
place were they had little babies. Like
helping take care of the mother and baby."

"That's where I learned most of mine,

when I helped take care of them."

 

(Table 3 continued)

32

Table 3 continued

 

Narrative Discussion

until they were older when caring for older
sisters after childbirth; one woman gathered
observations while being with her mother
who was a midwife. All expressed they
were instructed not to share this
information with their younger sisters and

never to discuss it with any of the boys.

Dialogue Excerpts with Themes

 

33

Table 4

Analysis of Focus Group Question 2. What was your understanding of childbearing at
the time of your wedding?

 

Narrative Discussion Dialogue Excerpts with Themes

 

It was the general consensus that all had Kinship and Social Factors
received some information about the "Once they get up to years close to
wedding night but no one would share the marriage, usually all mothers would
details of the information. Two women felt explain it (wedding night) or they would
comfortable in approaching their mothers find out for themselves from their sisters or

with questions but the other three did not. whatever."

The woman who had received Educational Factors
information about menstruation from a "I never did {have an understanding of
professional also received information the wedding night} till after I was married."
concerning the relationship of menstruation "I don't think I would have cared to."
and childbearing. {prior knowledge}.

"I wasn't ready for it."
"If I had any questions or anything like
that she {mother who was a midwife}

explained things to us."

 

34

Table 5

Analysis of Focu_s Group Oue§tion 3. What made you realize you were pregpant?

 

Narrative Discussion

The women all agreed the first
indication of pregnancy was a missed
period followed by morning sickness. One
woman particularly experienced severe
morning sickness which prompted the
group to discuss remedies for morning
sickness. Even though the first indication
of a pregnancy was a missed period, no one
kept a formal record of the date of the last

period.

Dialogue Excerpts with Themes

Educational Factors

"I'm not sure who it was that told me,
but said there's signs, so you know what's
going on."

"I thought it's when you missed your
period."

"I just figured it was part of married
life...I skipped my period then I got

morning sickness. OH!"

 

35

Table 6
Analysis of Focus Group Question 4. How does your faith gtp'de you during pregwcy?

 

Narrative Discussion Dialogue Excerpts with Themes

 

All the participants were in agreement Religious and Philosophical Factors
that their faith provided the fundamental "The scripture tells us bearing children,
belief that a woman's purpose in life is to we will have more hopes of entering
bear children. It also provided acceptance kingdom, Heaven."
when a woman could not bear children or "Eve sinned."
when a pregnancy results in a poor "All of us have inherited that (sin) and
outcome. Their own words describe it best. women can still..."
"...have hopes and keep steadfast and
bear children..."
"It's almost as if He is forgiving us our
sins."
"If we patiently bear children, we can
feel that we're trying to live the will of
God."
"My oldest sister doesn't have any
children...it's the Lord's will."
“I had one complication that l
thought...all we could do was to

trust...hope,1 guess."

 

Table 7

Analysis of Focua Group Question 5. What are the things you do that are spacifically for

you and the baby before, during, and after the pregancy?

 

Narrative Discussion

Many different home remedies (herbs:
i.e., ginger, collage of herbs, red raspberry
leaf tea, emu leaf, and comfrey) were
discussed to ease nausea. Vitamin and
mineral supplements may be taken. The
pregnancy is kept a secret as part of the
Amish women’s culture. Efforts are made
to attend church when not feeling well so
that others do not suspect. The children are
never told about the pregnancy with the
exception of an older daughter who may be
told when the pregnancy becomes
noticeable, but details were not explained.
Normal everyday activities continue
throughout the pregnancy except for
overhead stretching and straining or heavy

lifting. Baby clothes are prepared secretly

Dialogue Excerpts with Themes
Kinship and Social Factors

"My sister told me not to give up during
morning sickness...keep going."

"I remember my mom told me calcium
was important."

"I found out from another lady that she
drinks three cups red raspberry leaf tea...I
didn't have any kind of pain {during
labor} ...makes me a true believer."

"...too sick to be able to attend
{church}, it wouldn't be a bad thing."

"...if you had a lot of morning
sickness...you might want to stay home
from church, so people wouldn't think you
were pregnant."

"Just try to put up a good front."

 

(Table 7 continued)

37

Table 7 continued

 

Narrative Discussion

Dialogue Excerpts with Themes

 

at least two weeks before the expected
delivery.

Seeking medical attention varied. One
woman would see a physician before the
last two months of pregnancy just for a
check up without follow-visits. A midwife
may be consulted a couple of months
before to inform the woman of the expected
date of confinement. Some women never
saw a physician. A woman who knows she
is Rh negative seeks professional care for
the Rho-Gam injection, yet others are not
aware of their blood types. All agreed a
sense of well being indicates the pregnancy
is progressing without complications. The
first step if not feeling well, would be to
ask another Amish woman who had either
experienced the same problems or who had
many children. The purpose of the visit to

the professional would be to determine the

"I'd brace up and try to put on a good
face and go to church."
W

"I always aim to go {to a physician}
sometime in the last month to have the
examination to make sure the baby's turned
right and everything's OK, blood pressure
and everything for home delivery. I
usually ask my doctor if it's OK for a home
delivery or ask him if he thinks there is a
reason why there may be complications.
Other than that if I feel well, I don't see a
doctor."

"I think it's from experience
{recognizing complications} ...you've been
through so many pregnancies...you know
what to expect. If it's something very
unusual, I would probably ask another
experienced mother if she experienced such

a thing or what she knows about it."

 

(Table 7 continued)

Table 7 continued

38

 

Narrative Discussion

baby's position, blood pressure, test the
urine and serum iron and to hear the baby’s
heart beat. One participant delivered in the
hospital with the first pregnancy being
unsure how labor would progress. All
agreed they preferred home deliveries but
would not hesitate going to the hospital if

there were complications.

Dialogue Excerpts with Themes
"1 ask an older lady that has had a batch
of children or someone before I go and get
an opinion from a doctor."
"We just try to help each other out, I

guess."

 

39

Table 8
Analysis of Focus Group Question 6. Mo you do to prepare for the birth? Wha_ti_s

the role of your husband and other famin members?

 

Narrative Discussion Dialogue Excerpts with Themes

 

The women all agreed that in the early Kinship and Social Factors
stages of labor, they continue with the "Well as long as our children are old
usual daily activities. When delivery is enough, like the girls to take the others
eminent during the day, the children are outdoors or whatever, we take them to a
sent to stay with relatives and if at night the sister or a relatives. They stay there until
children are sleeping in their beds. the baby was born."
Husbands are present for the delivery along "Only my husband would be there."

with a mother or mother-in-law to assist. A Cultural Values and Lifeways

brother-in-law may be sent to call the {Early stages of labor} "Send them
midwife or physician. Baby clothing is (children) outdoors to do chores or
ready, a pair of scissors and fabric or whatever."

shoelace is available to tie and cut the cord. "1 never lay down until I have to."

There was no mention of any other

necessary equipment.

 

40

Table 9

Analysis of Focu_s Group (mestion 7. What is your understanding of the birth process?

 

Narrative Discussion

Dialogue Excerpts with Themes

 

The education that the Amish women
received was only from the experience of
childbirth. Anecdotes described either a
physician or a midwife teaching during the
birth process. Those that had neither a
physician nor a midwife, gathered
information about the birth process by the
experience. Medical terminology was very
limited during the discussion. The primary
understanding of the birth process included
walking during the early stages, breaking of
the water, and bearing down pains. The
woman who had experienced ten
pregnancies used appropriate medical
terminology and described specific
procedures she used during the birth
process, which were taught to her by a

physician or midwife.

Educational Factors

"...mother told me you should have your
first one at the hospital, but we didn't get
there in time...I guess we didn't realize...my
mom always told to expect the first one to
take quite a long while, so...I guess it
didn't."

"See that's what I can't understand. I
had a breech too, but it was feet first, that
one. But I didn't have as much pain and as
hard of delivery with that one as I had with
some of the others. I can't understand
that."

"Usually when the bag of water broke,
there wasn't that much space between that
and when the baby was born. And if there
is plenty of moisture it wasn't nearly as

hard."

 

(Table 9 continued)

Table 9 continued

41

 

Narrative Discussion

Dialogue Excerpts with Themes

 

She prefaced a comment while describing
breathing patterns that helped. She did not
want to be dishonest in not telling what she
understood, but ‘she also thought others
may look down on her for doing something
that may not be the Amish way. One
woman had experienced two pregnancies
where the amniotic fluid had been ruptured
for over 24 hours without labor. She
expressed no understanding that this may
be a complication. Two of the women
experienced breech deliveries: one
delivered vaginally at home, and one
delivered by Cesarean section in the
hospital, but expressed no understanding
that this may be a birth complication. Dry
births were considered difficult because it

took more effort to push the baby out.

"My midwife...told me that it's
important that once the head had broken
through, pant like a dog. To slow the labor
down so it doesn't rush out and tear...But I
think that not everyone does this, but I just
didn't want to be dishonest, my midwife
prefers it. I was at home for all ten."

"...but what I didn't realize until the last
baby was that it helped to dilate, to help
labor, to throw up. Did you know that?"

"I guess I also learned with the babies. I
never really lmew with the first one."

"...my mother....said...if you weren't
dilated or labor was slow...to sit on a pan of
warm steaming water...the last midwife I
had...used a towel with hot water...that also

helps, it feels good."

 

Table 10

Analysis of Focus Group Question 8. Describe vour childbirth exmriences.

 

Narrative Discussion

Dialogue Excerpts with Themes

 

One woman gave two relatively lengthy
anecdotes about unusual occurrences: a
birth that resulted in a Cesarean-section

from a breech presentation and a stillborn.

Educational Factors

{Anecdote} "I guess I never went into
labor, my water broke...till it went on long
enough {one full day} that we thought we
should check to see what's...I guess I did
notice a greenish discharge so we decided it
was time to go {hospital}. The baby was
breech. I ended up with a C-section
because I couldn't deliver the baby...They
had to do a C-section to save the baby."

{same woman} "The next was another
C-Section...There again my water broke
and I never labored. It just didn't start...We
called her {midwife} and I guess she
figured because I wasn't in labor there was
no hurry to come...We would have liked it
if she would have came to check me to see

if everything was OK. And then she

 

(Table 10 continued)

Table 10 continued

43

 

Narrative Discussion

Dialogue Excerpts with Themes

 

did come, she said the baby wasn't down
like it should be and I had a fever, and that
again was a little over 24 hours. We were
getting a little bit uneasy but still waited for
her to come. We called her a couple of
times...one time I think she wasn't there or
she went to check another lady before she
came to our house, because she figured as
long as I wasn't in labor there was no hurry.
But when she came she took us in...the
nurses checked and felt the cord first. So
they done a C-section because the
prolapsed cord...I might have an infection."
Cultural Values and Lifeways

{same woman} "The next one I had a
midwife. I guess she was certified midwife
or whatever...The one lady works for
family service. She's got a lot of

experience. I know she's good.

 

(Table 10 continued)

Table 10 continued

 

Narrative Discussion

Dialogue Excerpts with Themes

 

(Another lady came with the midwife
whom was assumed to be New Order
Amish).
Educational Factors

"1 think she's real good. Learned. I
guess we were at the point where we didn't
know what to do, we didn't want to go to
the hospital. One of the doctors said you
should go with a C-section every time afier
that, but {name of midwife} gave us a lot
of hope, she said she doesn't think it's
necessary, just because you had one or two
you know...doctors might tell you shouldn't
try to have it naturally. But she doesn't feel
that it's always necessary to go with a C-
section. The other lady she's got a lot of
herbs and vitamins that she gives and she
feels it helps a lot. So we're glad to know

her."

 

(Table 10 continued)

Table 10 continued

45

 

Narrative Discussion

The remaining women described
excerpts of various childbirth experiences.
One woman told in detail how her midwife
took a long strip of cloth, (like from a bed
sheet) and knotted it at the end. She pulled
the strip of cloth through the foot of the bed
frame and gave the knotted ends to the
woman to hold while pushing. Other
women felt the bed was too sofi and would
deliver laying on table leaves or on the

floor.

Dialogue Excerpts with Themes

{Anecdote another woman} "I had one
complication that I thought was a
complication. But I learned it was OK...I
got to a spot I couldn't get anywhere else.
When {name} was born, we lived out in
Missouri...we had a midwife that had a lot
of experience, an Amish midwife...she said
it wasn't the head she was seeing. She sees
something else. She's not willing to be
alone...at the time we had a doctor that
would come fiom house to house to deliver
if we called him...she {midwife} didn't
want {husband} to go that far to phone to
leave her alone...So he quickly went to my
brother-in-law's house and asked him to
call...the doctor's in surgery, he can't come.
So there weren't much choice to be had.
And I was progressing pretty good...here

she came breech...everything worked out

 

(Table 10 continued)

Table 10 continued

46

 

Narrative Discussion

Dialogue Excerpts with Themes

 

great. No complications at all."
Kinship and Social Factors

{Anecdote} "Our second was stillborn.
My mother was there...the baby went a
little early, so {husband} wasn't home, his
sister was there with me at the time...she
went to call {husband} home. He got there
just after the baby was born.
Educational Factors

"...just a little bit before the delivery...I
had laid down to take a rest at noon, and
when I got up, a real had pain came and my
water broke. I never can recall that I felt
any movement of the baby afier that. I
went into labor, it was the shortest that I
ever had. Then the baby was born, it was
limp and blue looking and it just didn't
breathe at all. The cord was limp and

white...that part of the cord looked

 

(Table 10 continued)

47

Table 10 continued

 

Narrative Discussion Dialogue Excerpts with Themes

 

pinched or whatever. There was no blood

going, circulating through there."

 

Table 11

Analysis of Focu_s Group Question 9. The Amish do not possess modern conveniences

such as cars, telephones. or electricity. Describe how this may influence your

childbearing health practice?

 

Narrative Discussion

The women did not find the lack of
modern conveniences to be a problem.
However, throughout the discussion
specific times were necessary to use the
neighbor's phone or to have transportation
to the hospital. The women simply felt
adjustments had to be made for every

situation.

Dialogue Excerpts with Themes

Technological Factors
"We had a hard time getting a driver, the

neighbors weren't home. By the time the
driver was there, the baby was there, too."

"I wouldn't consider it as a hardship, but
I see it as a part of life. If we know ahead
of time, we'll just try to adjust to it, and
make arrangements ahead.”

"There's always neighbors that are
willing to help."

"I guess if you would have been used to

it, it would be more of a problem."

 

49

Table 12

Analysis of Focu_s Group Question 10. Sometimes a pregnancy ends early with a

miscarriage or stillborn. Describe what is done if this should hapfin.

 

 

Narrative Discussion Dialogue Excerpts with Themes
The woman who experienced both a Political and Legal Factors
miscarriage and a stillborn shared her "They came out and took the baby. It
experiences. She was unsure of the was in the aftemoon maybe. And she

gestational age of the miscarriage, possibly brought it back again that night. It was

4 V2 to 5 months gestation, but the baby quite the experience."

was simply buried. She reported the baby Religious and Philosophical Factors

could be named or not, but she did not say {Did you have a funeral?} "Not what
what was done. In the case of the stillborn, would you say, maybe a grave side service,
she vaguely recalled the details, but the and not a real funeral."

bishop encouraged an autopsy. She and her

husband took his advice. A lady took the

baby, but she did not know her or what

agency was involved. The cause of death

was from a prolapsed cord.

 

Table 13

50

Analysis of Focg Group Ou_e_stion 11. If a pregnancy should result in excessive costs

such as a large hospital bill, describe how the additional cost is managed.

 

Narrative Discussion

Dialogue Excerpts with Themes

 

All the women agreed that the cost of
the hospital would not be considered if
there were complications during labor. If
the birth resulted in a normal birth, then
each family assumes the cost. An early
discharge would be requested along with
monthly payments. However, if a lengthy
hospitalization resulted due to
complications, the church and family

would give financial assistance.

Economical Factors

“Well, if it's just a normal baby case in
the hospital, we try to pay it ourselves."

{Would the cost of the hospital be a
decision in whether to go to the hospital or
not?}

"Not for me, I just don't prefer to go to

such a public place and be uncomfortable."

 

Table 14

_;A_n_alvsi§ of Focuis Group Question 12. Describe the care of the baby afier birth.

 

Narrative Discussion

The care of the cord was described in
detail. Items used to cut and tie the cord
were primitive. The salvage edge of the
white gauze fabric used to make bonnets is
used after running it through the flame of a
kerosene lamp to sterilize it. Sometimes
both ends may be tied and sometimes not.
Care of the cord varied with some home
remedies from alcohol to cotton bands
around the abdomen to nutmeg sprinkled to
enhance drying. The babies are bathed and
dressed. Breast-feeding occurs if the baby
is interested in eating. An anecdote of a
cord coming untied was given. Male
infants are not circumcised or the foreskin

retracted.

Dialogue Excerpts with Themes

Educational Factors

{Cord care} "...before they do anything
with the cord or bathe, they have a bowl of
Lysol water to wash the hands...tie the cord
and do the clipping..."

"We always soak a...put a little cotton
band around it, the belly, the tummy of the
baby. Then we try to keep that cotton wet
with alcohol every time we change the
baby."

"They say it's harder to keep it from
getting smelly or something. If you keep it
open, it's had."

"We had one scare...the midwife had left
and I decided that I wanted to take the baby
before I fell asleep for the night...his

blanket was blood stained...he

 

(Table 14 continued)

Table 14 continued

52

 

Narrative Discussion

Dialogue Excerpts with Themes

 

One woman described how her first
baby could not breast feed due to being
tongue-tied; formula was bought but it was
too expensive, so a goat was bought. Her
mother gave her a recipe for homemade

formula from cow's milk.

Introduction of the new baby to the

family lead to many descriptions of telling

was bleeding...an experienced mother came
and helped us tie it again so it was done
safely...he probably would have been gone
by morning."

Economical Factors

" We were buying formula but switched
to cow's milk...didn't agree with him...had
him on soybean...we bought a goat...my
mom gave me a recipe that you use cow's
milk...I don't know some flour and cooked
it and added some Karo...he did real good
afier that."

{Humor} "When you travel you
couldn't take your goat with you, if you
bought formula at the store, it was high
priced."

Religious and Philosophical Factors

"I think breast feeding keeps you

 

(Table 14 continued)

Table 14 continued

53

 

Narrative Discussion

the children of where the baby comes from.

This was managed based on the Amish
faith and descriptions revealed the Amish

sense of humor.

Dialogue Excerpts with Themes

close to the child."
{Introducing the baby to the children}
"We just tell them the Lord gave it to
us."

"...He's got a way to do it. It's not hard
for him to give them to us the ones who
want to have babies. And usually the little
ones are pretty satisfied with that. We tell
them that God has a way to do it, He knows

how. They understand that and don't ask as

many questions."

 

54

Table 15

Analysis of Focu_s Group Question 13. How is it decided when the next child will be

conceived?

 

Narrative Discussion Dialogue Excerpts with Themes

 

This topic was lead into by discussing Religious and Philosophical Factors
breast-feeding. Weaning occurred when "We just leave it to the power of the
the child is "too old" which was "when they Lord."
come and ask". The women felt breast-
feeding helps to prevent future pregnancies
for some. The next child is planned for

"afier we know it's coming."

 

Discussion
Inteppretation of the Findings

The participant comments were selected to give the emic perspective of
childbearing health practices as described by Amish women of the Marlette community
of Sanilac County, Michigan. Tables 3-15 provide a glimpse of the style of speech and
the individual understanding of each participant’s childbearing health practices. A
contrast of perception was presented with the sense of control over the labor while at
home, e.g. by the detailed sharing of methods used, as compared to the perception that
hospitals are "public and uncomfortable." Home births were still preferred even afier
women had experienced Cesarean-section births and a stillborn birth. The descriptions
given were consistent with the Amish culture with one woman even venturing to describe
a childbearing health practice Gareathing pattern during labor) that may not be within the
culture. The secrecy of the pregnancy, the use of home remedies, having a strong support
system of family and community were consistently described. The only clear difference
in the descriptions was the level of knowledge of childbearing of each Amish woman due
to various life experiences.

The birth intervals of approximately 20 months suggests that women were either
pregnant or breast feeding during this time period. Considering the grand-multiparity,
this indicates that a woman’s body is experiencing constant physical stress. Cross (1976)
speculated the stresses of childbearing may have an adverse efl'ect on female longevity.

The childbearing health practices as described by the sample supported the
literature of other studies of Amish women (Acheson, 1994; Brewer & Bonalumi, 1995;
Firm, 1995; McGinn, 1996; Palmer, 1992). Multiparity, late entry into prenatal care, few
prenatal visits and births attended by midwives were comparable to the Amish in Ohio
(Acheson, 1994) as were the value placed on motherhood, the supports system of family

and community, and the excessive health costs assumed by family and community.

55

56

Home births were preferred which was similar to the Amish in Pennsylvania (Palmer,
1992); the Amish faith provided the acceptance for life circumstances.

The pattern of themes are demonstrated in Table 2 by each focus group question
showing which themes emerged. Educational Factors appeared most frequently. The
results indicated initial primary knowledge was received from other Amish women
(mothers and sisters). Home remedies and the advice of the other experienced Amish
women were sought before professional health care. This is consistent with the literature
(Brewer & Bonalumi, 1995; F inn, 1995). The three factors that influence using folk or
professional health care found by Wenger (1995) are evident in this Amish population:
(a) type of problem (folk care for home births and professional care for complications of
pregnancy); (b) accessibility of health services (midwife comes to the home whereas a
driver is required to access professional health care); and (c) perceived cost (hospitals are
used for complications of pregnancy with excessive cost assumed by the community).

Lack of basic knowledge of human anatomy and physiology was substantiated by
the specific details describing the Amish women’s experiences; very few medical terms
were used. The Amish women demonstrated a lack of curiosity about menses and the
relationship of pregnancy and the desire not to inquire about details concerning the
wedding night. Amish women's understanding of childbearing was based on their own
experiences or learned from other Amish women's experiences. Examples of lack of
formal knowledge were: (a) failure to keep an accurate record of the first day of
menstruation accounting for not knowing exact gestational dates; (b) failure of
recognizing prolonged rupture of membranes as a complication; and (c) lack of
knowledge about proper cord care or that cow's milk cannot be digested by newborns.
There was no mention of a newborn examination or immunizations. The fact that the
pregnancy was kept a secret or not discussed openly limits the opportunity for exchange
of information. None of the women gave full detailed explanations of menstruation, such

as a 28-day cycle, ovulation, or the relationship of menstruation and pregnancy.

57

The next theme that emerged most frequently was Kinship and Social Factors.
This reflected the strong support system among the Amish women, assuring maintenance
of the Amish culture. Mothers and husbands were present for the births with extended
family assisting in care of the other children. The sisters of an Amish girl menstruating
will complete her work. The Amish women concealed their pregnancy from others as
much as possible, such as attending church when not feeling well during the early stages
of pregnancy.

Religious and Philosophical Factors and Cultural Values and Lifeways occurred
with equal frequency. Religious and Philosophical Factors provide the understanding of
the Amish’s childbearing health practices of multiparity. It is the “Lord’s will” to bear
children which gives the purpose in life for these Amish women. Cultural Values and
Lifeways are demonstrated in the day to day living experiences of the Amish culture; the
strong desire for home births and seeking professional health care when perceived
complications occurred.

Economical Factors occurred infrequently and included the use of rags for
sanitary pads during menstruation, the cost of hospitalization, and the cost of infant
formula. Providing sanitary pads for several daughters could be a considerable cost.
Standard manufactured infant formula for one month is estimated to cost $80.00. These
Amish women breast fed their infants, but on occasion when the breast milk ceased,
whole cow’s milk was substituted to avoid the cost of formula. Hospitalization costs
were not covered by insurance and the family and/or the Amish community assumed the
cost.

Technological Factors and Political and Legal Factors were reported only once.
These two themes appear to have minimal importance to the participants; women stated
that lack of modern conveniences was not a “hardship”. The bishops or elders make the

political and legal decisions within the Amish community so this was not relevant for the

58

women (e.g., the woman who experienced the stillborn birth did not question the
authority of the outsiders).

What the data does not demonstrate is the critical thinking of the participants.
One participant who ventured to describe the breathing patterns she learned, questioned
the consent form as to how confidentiality would be managed, and would not sign the
consent form until all her questions were answered to her satisfaction. In addition, the
woman asked if someone else could obtain the data and print it in the newspaper. The
woman was reassured that her name and any identifying information would not be
included in any written form.

Following the formal focus group discussion, while serving the refreshments, the
participants continued the discussion about home remedies and various herbs. They
asked each other for clarification of the preparation, amount, and frequency of use of the
herbs. Half of the time the group spoke in German. This sharing of information
continued during the ride home with the comments made of how much each one learned
which again support the two main themes: Educational Factors and Kinship and Social
Factors of knowledge being gained from other Amish women and the strong support
system of maintaining the Amish culture. Only a few direct questions were asked of the
researcher (e.g., should both ends of the cord be tied, and at what age cow’s milk can be
give to the infant). The researcher gave each participant the recipe and the materials to
make baby wipes out of paper towels.

Theoretical Model in Relation to Childbearing Health Practices as Described by Amish
Women of the Marlette Amish Communig of Sanilac County. Migmgg

The Sunrise Model as it was modified provided an excellent conceptual
framework for this study. However, given the findings, modifications could still be made
(Figure 3). The Amish faith, culture and lifestyle are all strongly interconnected. Figure
3 displays the cultural and social structure dimensions connecting the seven influential

factors to the findings of this study. The technological factor was the need to rely on

59

as: s. .2553 52.. Sfioga 222:5 .38 a... 33.5 .26 2238.. .08: 3:3 BEE: ”dim

-
- 5:838 035:. n 305255..
.. 33 83. .852: 6 85:25.

a .

' ‘

. \ a :39 23 5.3.. e
a 3.38..» .23 33- e
o bis—5:3 Q bila— o
. :80...— SIenoon. e .. «g 3.5..

 

 

 

 

3:65.. £3: a... 8 3.3 .822 833m

.353 .3: 5.5 so

tutu-nunuquunouuu-nua

I ' ' - ' ' J ....
83.8...

‘

 

‘

as 28.. t\\r. 5.8: 3.83.6

‘ \ V ‘~0 0
:22: 1.3.8.3. . v I\\/ .
Q
Q

3333 ale—sue
Q

Q
—

hud-

ffii {3.32 8 23. .
238.. .5383; .-

I
I
I

l
0!
ll —

~
I
EB: s

. 9932333335 s
o esatszsesa...

O
O

dis-.3. ~

      
 
    

Q
. 2:83;

      
  
      

e 3.88.. 5552.. .
Boa-32055:! .. . 938.. s
3...... 858.. s . ...33 a £15. s
38. 9820 £820 . . s
:30...— . 3.2. d 862:2 use: a \ \
. I :53 a .852... . 3.. .53 2.3.. 52.. . s
I . . . \
I I . gI’Uh: .\ \
I I . a 8:12:33 . \
I I ' ‘ ‘
' a ' ' ’ ‘
afiauoflgfi 9.32:5
imam in. 7.5250

9:0 3.3.50

 
 

  

 

   
   

60

neighbors' telephones and cars for communication and transportation. The religious
factor was the strong faith that their life was guided by the Lord's Will. Kinship and
social factors related to strong support family and community systems and the pregnancy
was kept a secret. Cultural Values and Lifeways Factors were indicated by the preference
of home births and home remedies and herbs. The political and legal factors incorporated
the church elders making decisions with a poor pregnancy outcome occurred (stillborn).
Economical factors were evident when the family and community assisting with
excessive health care costs. Educational factors were the lacking of formal education
about childbearing with experience and female family members providing the education.
Implications for Advanced Practice Nurses

In order to provide culturally congruent care, the APN must become
knowledgeable of the Amish culture. Knowledge can be gained through formal
education, through informed learning by reading about the Amish culture in professional
journals or the few books available that depict the authentic culture, and through research
and practice. This researcher gained knowledge about the Amish culture through
research with the Marlette Amish community of Sanilac County, Michigan. The Amish
are willing to share information about their culture if approached in a respectful, polite
manner; intrusive behavior is simply ignored by the Amish, with no information
provided.

The APN is most likely to encounter the Amish in a clinical setting. Amish
communities are expanding, increasing the possibility of encounter with the professional
health care system. Currently, it is unlikely that the APN within the professional health
care system would be consulted for preventive care. However, the APN is more likely to

be consulted after the folk care system has not produced positive results (Wenger, 1995).

61

The role of the APN is to establish a trust relationship with the Amish as a
primary health care provider and to provide culturally congruent care. The Amish have
respect for professional health care providers, but their trust is earned through
incorporation of the Amish culture into the professional health care provider’s plan of
care. The APN needs to creatively combine folk and professional health care to this
population seeking health care services receive culturally congruent care (Leininger,
1991). This researcher can attest to this through her own professional health care
experiences with the Amish. If an intervention is decided by the APN, but is not
culturally congruent with the Amish beliefs, the Amish will politely agree but will not
comply. If the APN consistently practices in this manner, the Amish will not seek out
this individual provider’s care again. Trust in the APN by the Amish is an essential first
step towards establishing a therapeutic relationship (Palmer, 1992; Wenger, 1991).

In the process of assessing the Amish client, patience is required in history taking,
since answers may be vague and incomplete. Persistence is a quality also needed to
secure accurate answers concerning current use of home remedies and herbs, which are
used prior to seeking professional health care. It is advantageous if the APN has prior
knowledge of herbal therapy as to know what may be safely incorporated into the plan of
care.

Cost of care needs to be a consideration when negotiating for a mutually
acceptable plan of care since the Amish do not have health insurance. The Amish are not
reluctant to pay for necessary professional health services, but are appreciative when
appropriate care is also cost contained. In some Amish communities, any commtmity
service, such as the Women, Infants, and Children (WIC) Supplemental Food Program,
that requires the signature of the beneficiary, is not be an acceptable practice. Thus,
Amish women miss out on the opportunity to receive certain community resources which
might benefit their health during the childbearing years. Taking all of these financial

factors into consideration promotes trust of the APN.

62

This study found the sample of Amish women lacking basic scientific knowledge
of childbearing health practices. An assessment of each individual’s understanding needs
to be discovered before education is initiated. Offering formal childbirth education
classes to a group of Amish women most likely would not be successfiil since
pregnancies are kept secret or not openly discussed in public. However, the Amish
woman is open to learning, but care must be taken to teach at her level of understanding.
Education with every encounter with the individual Amish woman is an important
component to assure successful outcomes (F uch et al., 1990; Kemp & Hatmaker, 1992;
Kogan et al., 1994; Lewallen, 1989; Tiedje et al., 1992). Negotiation with the between
the APN and the Amish of the planned intervention is needed so that it is both mutual and
acceptable (McGinn, 1996). This may take much creativity on the part of the APN to
adapt the appropriate intervention so as to assure engagement and adherence. The
following exemplar illustrates this.

This researcher currently has an established independent nursing practice with the
Marlette Amish community. Two years ago, a participant of this study who was Rh-
negative needed assistance from this researcher to locate obstetrical care with her fifth
pregnancy. She was almost six months pregnant and knew she soon needed a Rho-Gam
injection. Arrangements were made with a female obstetrician, who was understanding
of the Amish cultural practices and complied with the Amish woman’s request. The
Amish woman “felt well” and refused the initial pelvic examination and opted for only
the essential blood work, a complete blood count, and blood type. The woman was
scheduled for a Rho-Gam injection which she received, but she refused to comply with
the routine antepartum appointments because she “felt well”. This researcher felt a
professional obligation to both the Amish woman and the obstetrician to ensure
appropriate health care during her pregnancy. Therefore, it was mutually negotiated and
agreed upon that home visits for the antepartum care would be done by this researcher.

During the home visits, it was necessary to assure privacy since the children were

63

unaware of the pregnancy. Because a fetal ultrasound doppler was being used, the
children were sent outside so that they would not hear the sound of the fetal heart beat
from the ultrasound since this would surely have generated many questions.

This Amish woman’s pregnancy ended with a positive home birth, with the
delivery of a term female infant; the woman was assisted by her husband and her mother.
The next morning, the husband using the neighbor’s telephone, contacted this researcher
to obtain the Rho-Gam injection. After a home visit to assess the mother and infant, the
Amish couple were persistent in receiving the Rho-garn injection rather than testing the
baby for her blood type. The Amish parents felt it was “too cruel” to subject the infant to
such a procedure. The next day, the obstetrician approved and allowed the Rho-Gam to
be given at home.

The Amish couple commented on their appreciation for all that was done to
comply with their cultural practices. However, the infant never received the state
mandated Hepatitis B vaccine nor the neonate screening for possible disease (e. g.,
hypothyroidism). The Amish woman never received a postpartum examination. Often
this may lead to feelings of fi'ustration with noncompliance of “professional” health
promotion and maintenance practices. This is an area where creativity, patience, and
persistence are necessary characteristics in order to gain a trustful therapeutic
relationship. Reprimanding for noncompliance will not accomplish this. By openly
combining the Amish folk care with professional health care, there will be increased
willingness for continued care so that “health can be maintained and health education
provid ”(Adams & Leverland, 1986, p.67).

For the Amish women in the Marlette community who seek out lay midwives, the
APN could assure quality professional care by collaborating with obstetricians at the
hospital where an Amish woman may appear suddenly unannounced with a complication
of labor. The APN could meet with the current lay midwives involved with the Amish

community to gain an understanding of their education and practices. A Certified Nurse

64

Midwife may have an interest in providing services in these communities. Establishment
of a local Amish birth center such as described in Ohio (Acheson, 1994) would not be
feasible in some communities where the birth rate is small. This is true for the Amish
living in the Marlette community, where only 12 births were reported for 1996.

Changing of childbearing health practices by an outsider would be met with
resistance (Adams & Leverland, 1986; Brewer & Bonalumi, 1995). The Amish culture
influences are strong; acceptance of change is a slow process. A general knowledge base
of the Amish culture is needed as well as an awareness of the individual Amish
community's practices. The APN faces the challenge of becoming a trusted primary
health care provider. This can only occur by direct individual interactions with respect
for the Amish culture. Through education, mutual respect, and negotiation, the APN can
begin to give culturally congruent care (Wenger, 1995; Wiggins, 1983).
Implications for Research

There are many areas in the Amish culture that could be researched such as
immrurizations and safety, as well as more information about childbearing health
practices. A study may be attempted among the Amish women in the Marlette Amish
community using a similar design but with an one-on-one interview methodology being
used in place of a focus group. Without the group’s influence, it could be anticipated that
more detailed, intimate information could be obtained fiom a single subject for deeper
insight of Amish childbearing health practices. A larger sample including older,
experienced Amish women could be interviewed to compare and contrast childbearing
health practices from one generation to the next. By examining changes in the folk care
system an understanding of the process of change among the Amish could give insight

into implementation of new childbearing health practices.

65

m

This study described childbearing health practices of five Amish women. The Amish
women were influenced to bear children by their faith. Their faith supports acceptance of
life circumstances such as a poor pregnancy outcome (miscarriage or stillborn). These
Amish women preferred home births. It was a practice to keep the pregnancy a secret and
discussion of childbearing health practices a private matter. The support-network of
these Amish women reinforced the practice to use home remedies and recommendations
from other Amish women before seeking professional health care. It was discovered that
these Amish women had limited formal knowledge of the childbearing process.
Education of childbearing was from experience or from other Amish women.
Professional health care was sought only when these Amish women perceived a
complication during the pregnancy or labor.

The APN who encounters the Amish in a clinical setting needs to have knowledge
and respect of the Amish culture to face the challenge of becoming a trusted primary
health care provider. Through education, mutual respect, and negotiation, the APN can
begin to give culturally congruent care. Future research could examine Amish
childbearing health practices from one generation to the next to gain insight into the

process of change to implement new childbearing health practices.

APPENDIX A

WW
Introduction

You have previous knowledge the purpose of this gathering is for you to describe
your childbearing health practices which will be of a very personal nature. Questions will
be asked to guide the discussion and to keep focused on the topic of childbearing health
practices so that an understanding of your ways is gained to help health care professionals
be able to provide care that would be acceptable to the Amish. All that is said is strictly
confidential with privacy maintained during the discussion. It is hoped that you give
open and honest answers. The content of the questions range from your first period, your
understanding of childbirth, the role of the family with childbearing to planning the next
child. It is hoped that each woman will participate and share her unique feelings and
experiences. It will take approximately one and one half-hours. Are there any question
before we begin?
Warm up

We will begin the focus group session by going around the table with each of you
telling us your first name (last initial if two first names the same), the number of children
you have, and what you like about being a mother.
Cultural values and lifeways

The sign of passage from a girl to womanhood is the first period. Describe‘your
feelings and experiences with your first period an include any preparation or
understanding you may have received.
Kinship and social factors

What was your understanding of childbearing atthe time of your wedding?
Educational

What made you realize you were pregnant?
Religious and philosophical

How does your faith guide you during your childbearing years?

66

67

Cultural values and lifeways

What are the things you do that are specifically for you and the baby before,
during, and after the pregnancy?
Kinship and social factors

What do you do to prepare for the birth? What is the role of your husband and
other family members?
Educational

What is your understanding of the birth process?
Religious and philosophical

Describe your childbirth experiences.
Technological

The Amish do not possess modern conveniences such as cars, telephones, or
electricity. Describe how this may influence your childbearing health practices.
Political and legal

Sometimes a pregnancy ends early with a miscarriage or stillbirth. Describe what

is done if this should happen.
Economical
If a pregnancy should result in excessive costs such as a large hospital bill,
describe how the additional cost is managed.
Cultural values apcflifem
Describe the care of the baby after birth.

Religious and philosophical

How is it decided when the next child will be conceived?

APPENDIX B

W

(Date)

Dear (NAME),

As a woman of the Old Order Amish culture, you are requested to participate in a nursing

research study conducted by Nancy L. Miller, R.N., B.S.N., from the College of Nursing,
Michigan State University.

The purpose of the study is to describe childbearing health practices as described by Old
Order Amish Women so that further understanding can be gained to provide professional
health care that would be acceptable to the Old Order Amish. Information will be
gathered from completion of an informational demographic questionnaire and

participating in a focus group discussion with about five to seven other Amish women.
All information received will be confidential.

The focus group discussion will take place at my home: 569 Saginaw Road, Mayville,
MI, so that privacy can be maintained. It will take approximately ten minutes to
complete the questionnaire and the focus group discussion will last one and one half-
hours. Transportation to and from the focus group will be provided. The time will be
mutually decided by participants in the group.

For your participation, free transportation to shop at Sam's Club will be provided at a
mutually decided time.

Enclosed is a self-addressed postcard to be completed indicating your decision. If you
are undecided and want more information please indicate so on the postcard. After

receiving the postcards, personal contact will be made to establish a time and to answer
any further questions.

Thank you for your consideration to participate. I will be looking forward to hearing
from you soon.

Sincerely,

Nancy L. Miller, R.N., B.S.N.
569 Saginaw Road

Mayville, MI 48744

(517) 843-6179

68

APPENDIX C

lnfonned Consent Form

Nancy L. Miller, R.N., B.S.N., from the College of Nursing, Michigan State University, requests
your consent to participate in the study "Childbearing Health Practices As Described By Old Order Amish
Women" of Sanilac County, Michigan.

The purpose of the study is to describe childbearing health practices as described by Old Order
Amish women so that further understanding can be gained to provide professional health care that would
be acceptable to the Old Order Amish. lnfonnation will be gathered from completion of an informational
demographic questionnaire and participating in a focus group discussion.

The informational demographic questionnaire will be completed prior to the discussion taking
about ten minutes. The focus group discussion will last one and one half-hours which will be taped
recorded. Your signature provides your consent to tape record the focus group discussion.

For your participation, you will receive free transportation to shop at Sam's Club at a mutually
decided time.

As a participant there will be no beneficial results guaranteed as a result of participating in this
study. You are free not to participate at all or to withdraw from participation at any time, and the decision
to withdraw will have no direct consequences to you. Concerns or requests of the results of the
questionnaire or discussion can be directed to Nancy L. Miller by letter at 569 Saginaw Road, Mayville, MI
48744 or by phone at (5l7) 843-6179.

The responses and comments made during the discussion are confidential. There will be no
identification of you on the questionnaire. The tape recordings will be transcribed without any
identification of you and the tapes will be destroyed after being reviewed. There will be no identifying
information in any written materials or in any presentation which may result from this study.

I certify that l have read the above consent and I voluntarily agree to participate.

 

(Date) (Signature of Participant)

 

(Date) (Signature of Witness)

69

APPENDIX D

Demographic Information of Parrticipa_r_rt_s

Age:
Number of Pregnancies: Children born

alive: ;

 

 

List gach date of Birth Wei t Spy On Time/Over/Early
birth

 

l.

 

 

 

 

 

 

 

 

09°89‘9wa

 

u—-
9

 

 

 

 

 

 

Stillbom: Miscarriages: Age of first period:

 

Age at time of Marriage:

 

Age at time of birth of first child:

 

Number of children born in a birthing center/hospital:

 

Number of children born at home with assistance of midwife:

 

Number of- children born at home with assistance of family:

 

70

APPENDIX E

 

 

(fflfiof
RESEARCH
AND
GRADUATE
STUDIES

IhhuflnCUIumuee
nunuunmeuhe
theuaaekes
answer
wmmeuNNan
RSknnmnuntean

anammeuuwpr
unudon

nunsvar
ansnnndnr

anaynQIUMUIV
nuanuueuauur
thinnekan

ASUsuahuhreUn
(nee-nmwmuuu

MICHIGAN STATE

UNIVERSITY

June 6. l997

TO- Mildred A. Omar
Aozro Life Scrences

RE. IRES: 97-388
TITLE: CHILDBEARING HEALTH PRACTICES AS LIVED 3? OLD
ORDER AHISH WOMEN
REVISION REQUESTED: N/A
CATEGORY: I‘C
APPROVAL DATE: 06/05/97

The University Committee on Research Involving Human Subjects'(UCRI85)
review of this project is complete:. I am pleased to advise that the
rights and welfare of the human suojects appear to be adequately
rotected and methods to obtain informed consent are appropriate.

gerefore. the UCRIHS approved this project and any revisions listed
a cve.

RENEWAL: UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be'ond one year must use the green renewal
form (enclosed with t.e original a proval letter or when a
project is renewed) to seek update certification. Ihere_is a
maximum or four such expedited renewals possible. Investigators
wishing to continue a proJect beyond that time need to submit it
again or complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects. rior to initiation o: the change. I! this is done at
the time o renewal. please use the green renewal term. to
revise an approved-protocol a: anv other time during the year,
send your written request to the_UC3IHS Chair. requesting revised
approval and rererencing the project's IRS s and title. Include
in your request a description o: the change and any revised
instruments. consent forms or advertisements that are applicable.

rnoatzns/
CHANGES: Should.either o: the follow . arise during the course of the
work. investigators must noti.y UCRIHS promptly: (l) roblems
(unexpected side effeCts, compiaints, etc.) involving uman
subjects or (2) changes in the research enVironment or new

information indicating greater risk to the human s::3ects than
existed when the protocol was previously reviewed approved.

I! we can be or any future help. lease do not hesitate to contact us
at (517)355-2100 or tax (SITIe 2- 171.

8 cerely.
32%. "right. Ph.D.
IRS Chair

DEH:bed

cc V‘ncy t... Miller

71

 

APPENDIX F

October 16, 1997

Office of Research and Graduate Studies

University Committee on Research Involving Human Subjects
(UCRIHS)

Michigan State University

246 Administration Building

East Lansing. MI 48824-1046

RE: IRB# 97-388

CHILDBEARING HEALTH PRACTICES AS LIVED BY OLD ORDER
AMISH WOMEN.

Dear UCRIHS,

This letter is to inform UCRIHS a slight revision in

the recruitment process from the original proposal. The
proposal stated that subjects would be contacted personally
after the investigator received postcards giving their
decision to participate. However. only 3 postcards were
received out of ten sent. After waiting two weeks this
investigator made personal contact with the remaining 7
potential subjects. Personal contact was necessary since the
Amish do not have telephones. The subjects were approached
by asking if they had received the recruitment letter and if
the postcard had been sent. All had received the letter. but
were too busy to sent the postcards. A verbal response to
the recruitment letter was given at that time. Of the ten
potential subjects. two refused to participate. two were
expecting to deliver soon. and one would like to but had
other obligations. or the ten, 5 women agreed to
participate. A date and time for the focus group interview
was agreed upon at this time as stated in the proposal.

With this slight change, there was no harm or injury to the
subjects and the subjects freely made their own decisions.

If the committee has any further questions please write or
call my home at (517) 843-6179. Thank you.

Sincerely:
77% KW

Nancy L. Miller

72

 

APPENDIX G

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

tleleersltv Committee ee
Research leeelelee
Itemse Seeleets
(UM)

' I‘ . Stae . ‘I
246 ministration Bum
East Lasing, Michigan
48824-1046

517055-21”
FAX: 517/432-II71

mwumsawm
mismuwm
damnation

macaw.
shimmer

  
 

15 December 1997

r. Mildred Omar and Ms. Nancy Miller

. David E. Wright. Chair. UCRIHS

ubject: [RB 397—388 “Childbearing Health Practices as Lived By old Order
Amish Women

UCRIHS reviewed each of your responses to a 18 November 1997 letter
requesting an explanation why a revision to the above mentioned protocol was
implemented prior to review and approval of the revision by UCRIHS. Dr.
Omar’s letter explains that due to her nine month appointment. she was not
available to advise Ms. Miller over the summer. Ms. Miller completed her field
work on her own. During that time Ms. Miller sent out postcards to Amish
women inviting them to participate in her research project. However. when she
did not receive postcards back from all of her potential subjects. she visited their
homes. Ms. Miller’s letter explains that she had intended to visit the Amish
women all along and therefore did not consider it a revision. Upon review of
the original application UCRIHS has determined that is clear that Ms. Miller
would have visited the homes of the women who did return postcards,
expressing an interest in the research project. However. it is not clear that a
home visit was intended as a second attempt to recruit potential subjects. Ms.
Miller and Dr. Omar explained that the Amish women were patients of Ms.
Miller and were known to her. Therefore, although University and federal
regulations require that any change in a protocol must be submitted to UCRIHS
for review and approval prior to initiating the change, it does not believe that
subjects were harmed or t at increased risk due to the implementation of this

revision. Therefore. U S will take no action to restrict Ms. Miller’s use of
the data in question.

73

References
Acheson, LS. (1994). Perinatal, infant, and child death rates among the Old
Order Amish. American Journal of Epidemiology, 139, 2, 173-183.
Adams, C., & Leverland, M. (1986). The effect of religious beliefs on the health

care practices of the Amish. Nurse Practitioner: American Journal of Prim_arv Hethh

Care 11 3,58, 63.

 

Brewer, J ., & Bonalumi, N. (1995). Cultural diversity in the emergency
department: Health care beliefs and practices among the Pennsylvania Amish. Journal of
Emergency Nursing, 21, 6, 494-497.

Bigggt. January 31, 1996. Sugarcreek, Ohio.

Charonko, C. (1992). Cultural influences in "noncompliant" behavior and
decision making. Holistic Nursing Practice, 6, 73-78.

Cross, H. (1976). Population studies and the Old Order Amish. Nature 262 17-

 

20.
Davis, D., Henderson, M., Boothe, A., Douglass, M., Faria, S., Kennedy, D.,

Kitchens, E., & Weaver, M. (1991). Health beliefs and practices of rural elders. Journal

 

of Gerontological Nursing, 17, 5, ll-l6.

Finn, J. (1995). Leininger's model for discoveries at The Farm and midwifery
services to the Amish. Journal of Transcultural Nursing, 7, 1, 28-35.

Fuchs, J., Levinson, R., Stoddard, R., Mullet, M., & Jones, D. (1990). Health risk
factors among the Amish: Results of a survey. Health Education Merly, 17, 197-211.

Henderson, G. (1981). Transcultural health care. Reading, MA:

Addison/Wesley.

74

75

Henkle, J., & Kennerly, S. (1990). Cultural diversity: A resource in planning and
implementing nursing care. Public Health Nursing, 7, 3, 145-149.

Kemp, V., & Hatmaker, D., (1992). Health practices and anxiety in low-income,
high- and low-risk pregnant women. Journal of Obstetric, Gmecologic, & Neonatal
Nursing, 22, 3, 266-272.

Khoury, M., & Cohen, B. (1987). Genetic heterogeneity of prematurity and
intrauterine growth retardation: Clues from the Old Order Amish. American Journal of
Obstetrics and Gmecology, 400—410.

Kingry, M., Tiedje, L., & Friedman, L. (1990). Focus groups: A research
technique for nursing. Nursing Researca 39, 2, 124-125.

Kogan, M., Alexander, G., Kotelchuck, M., & Nagey, D. (1994). Relation of the
content of prenatal care to the risk of low birth weight. Journal of American Medical
Association. 271. 17, 1340-1345.

Krueger, R. (1988). Focus ggoups: A practical gg'de for applied research.

Newbury Park, CA: Sage.

Leininger, M., (1991). Culture care diversity and universality: A theog of
Mg. New York: National League for Nursing Press.

Leininger, M., (1993). Quality of life fi'om a transcultural nursing perspective.

Nursing Science Quarterly, 7, 1, 22-28.

Lewallen, L. (1989). Health beliefs and health practices of pregnant women.

Journal of Obstetric, Gynecologic, & Neonatal Nursing, 245-246.

76

Lucas, C., O'Shea, R., Zielezny, M., Freudheim, J ., & Wild, J. (1991). Rural
medicine and the closed society: Pregnancy outcomes among Amish and non-Amish
women. New York State Journal of Medicin_e. 91. 2, 49—52.

Marshall, V. (1991). Maternal health practices and complications of term labor.
American College of Nurse-Midvvives, 36, 3, 168-173.

McGinn, K. (1996). Debbie LaBerge: Caring for Amish and Mennonite families.

Nurse Practitioner Forum 7 2, 56-57.

 

Naylor, P. (1974). An Amish family. Chicago: O'Hara.

Palmer, C. (1992). Health beliefs and practices of an Old Order Amish family.
Journal of the American Academy of Nurse Practitioners, 4, 3, 117-122.

Resseguie, L. (1974). Pregnancy wastage and age of mother among the Amish.
Human Biology, 46, 4, 633-639.

Reynolds, C. & Leininger, M. (1993). Madeleine Leininger: Cultural care
diversig and universalig theogy. Newbury Park, CA: Sage.

Scott, M., & Stern, P. (1985). The ethno-market theory: Factors influencing
childbearing health practices of northern Louisiana black women. Health Care for

Women International 6 45-60.

 

Starn, J. (1991). Cultural childbearing: Beliefs and practices. International

Journal of Childbirth Education 38, 38-39.

 

Stevenson, J ., Everson, P., & Crawford, M. (1989). Changes in completed family
size and reproductive span in Anabaptist populations. Human Biology, 61, 99-115.
Thorne, S. (1993). Health beliefs systems in perspective. Journal of Advapcp

Nursing, 18, 1931-1941.

77

Tiedje, L., Kingry, M., & Stommel, M. (1992). Patient attitudes concerning
health behavior during pregnancy: Initial development of a questionnaire. filth
Education Quarterly, 19, 4, 481-493.

Wenger, A. (1991). The cultural care theory and the Old Order Amish. In M.M.
Leininger (Ed.), Cultural care diversig and universalig: A theory of nursing. New
York: National League for Nursing.

Wenger, A. (1995). Cultural context, health and health care decision making.
Journ_al of Transcultural Nursing, 7, 1, Summer, 3-13.

Wiggins, L. (1983). Health and illness beliefs and practices among the Old Order

Amish. Health Values: Achieving High Level Wellness, 7, 6, 24-29.

"Illllllllillllllll“