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The religious and cultural beliefs of the Amish culture have led to variations in health care practices that are different from main stream American culture. The Amish have a health care belief system that includes traditional remedies passed from one generation to the next. Amish families are without health insurance and though concerned about paying medical expenses, most of the time the extended family, friends, and the church help pay for the expenses. For example if a female infant of the Amish family is in the hospital for an extended period of time the biological and extended family visit frequently and bring in their own food in bags. The grandmother and neighbors would gather the children in the hospital waiting room to feed and entertain them while the mother would visit her baby daughter in the neonatal care unit. The father would most likely visit on weekends. The family would speak Pennsylvania Dutch among themselves but use English in speaking with the health care providers. The children in the family are dressed like undersized replicas of their parents. They are in distinctive clothing that is subdued and devoid of any designs of flowers, figures or animals on the material. The little girls wear long dresses and head coverings, while the little boys wear trousers with suspenders. Some of the older boys wear broad-brimmed hats. All are very polite and well mannered. This Amish family appears to come from another time, another place. In an instant the Amish family came into another world, the world of high tech health care. One may well surmise the "cultural - shock" of this encounter.
The Amish are a conservative Protestant group who emerged after 1693 as a descendent of the Anabaptist movement that originated from Switzerland and spread to neighboring Germany. The Amish parted ways with the larger Anabaptist group, now known as the Mennonites, over a doctrinal dispute, (Hostetler 1993) and immigrated to America in the 17th & 18th century after experiencing religious persecution in Europe.
The diverse subgroups of the Amish Culture have distinctive beliefs, values, and behaviors). Today the Amish stand somewhere between the parent body, the Mennonites, and the four groups of Amish: Swartzentruber (ultra conservative), Andy Weaver (conservative), Old Order (conservative), and the New Order (less conservative). The New Order leads a more progressive path that diverged from the Old Order in 1968 (Blair & Hurst 1997). The New Order of Amish attempts to balance distinctive rituals and practices against accommodations. Over time the Amish have adapted to some change but at their own pace.
In various rural regions of the United States, especially in Indiana, Ohio, and Pennsylvania, there are large settlements or communities of Amish families. About 75% of the estimated Amish total population of over 130,000 is concentrated in Indiana, Ohio, and Pennsylvania. In these areas good farmland can be purchased reasonably as agriculture is the main stay of their economy. Holmes County in Millersburg, Ohio has the largest population of Amish in the United States as compared to the more widely known areas of Amish settlements in Lancaster, Pennsylvania or Elkart, Indiana. The population in Holmes county is 38, 943 and about 18,000 of that are of Amish descent (Holmes County Chamber of Commerce 2002).
Amish Mutual Network
The Amish community has a very strong network of mutual support and assistance for its families. Amish "barn raising" is one example where several hundred men from many church districts gather to build a new barn. The Amish women plan and prepare the meals for the workers and take the food to the site. Smaller networks with projects called "frolics" occur when several neighbors and extended families and friends gather to help build a small building such as a shed or corn crib. Another example of Amish mutual aid is the harvesting of crops.
A serious illness or accident brings an immediate response of both emotional and financial support from their community. In Holmes County, Ohio, for example, a cooperative effort by both Amish and non-Amish people resulted in the formation of the Rainbow of Hope Foundation. This foundation assists all families in the area with health care costs affecting infants and children. Bake sales, benefit auctions, and private donations assist in raising the needed funds. There is a genuine ritualistic response to human troubles in the Amish close knit family environment.
The Amish father is responsible for providing for his family through farm work or by employment in the local community. Many Amish men are working away from the farm with the declining availability of farmland. Many Amish men work as carpenters, masons or laborers in factories. Some have home based businesses such as furniture making, harness repair or the shoeing of horses. Amish culture teaches girls to serve and please others such as their parents, husbands and relatives. An Amish wife is identified by using her husband's name, eg. Eli Katie means Eli's wife, Katie. The social life for an Amish woman is centered around church, funerals, quilting bees, baking, barn raising and frolics. Amish families usually have many children. Amish women raise on average seven children. On the family farm, parents and older siblings model work roles for the younger siblings. Children are an economic asset to the family as they assist with farm chores, gardening, mowing of lawns, housework or work in a small family business. These activities involving children serve to strengthen family ties and promote survival of the Amish life-style.
Intermarriage among the Amish culture has resulted in the presence of a large number of recessive disorders, many of which are unrecognized outside of the Amish population. Consanguinity (relatives marrying relatives) accounts for the transmission of these various disorders. When a group of individuals mates only among themselves allele (alternate form of a gene) frequencies may change as a result of chance sampling from a small pocket of a population. This change of allele frequency is termed genetic drift. The founder effect is a common type of this genetic drift. A founder effect is when a community of people have descended from a few founders and have their own collection of inherited disorders that are rare in other areas (Lewis 2001). Amish couples are not deterred from having more children when they have a child with a hereditary defect. An abnormal child is referred to as a special child and is accepted as God's will (Julia 1996). http://dw.com.com/redir?tag=rbxira.2.a.10&destUrl=http://www.cnet.com/b.gif
CONCEPTION, PRENATAL CARE, AND BIRTH Babies are a welcomed gift in the Amish culture and are viewed as a gift from God. The Amish view fertility as a family and community gift. They nurture these children in preparation for eternal life (Purnell 1998). Most Amish couples do not use birth control to limit their family size, since it is believed that use of birth control would be interfering with God's will. Therapeutic abortions, amniocentesis and other invasive prenatal diagnostic testing are also not acceptable. Amish folk wisdom is an integral part of their prenatal practices, for example: walking under a clothesline will result in a stillbirth or crawling through a window or under a table will cause the umbilical cord to be wrapped around the baby's neck.
Lamaze classes are usually held in a church close to the Amish community to ease transportation barriers. Prenatal care is started in the first trimester for a first pregnancy and much later for subsequent pregnancies if the mother has no problems. The distance to the doctor and cost of care can influence the number of prenatal visits and how soon prenatal care is started.
Complications such as pregnancy induced hypertension and diabetes is low in the Amish culture most likely due to the well nourished state of the mother (Julia, 1996). Typically prenatal visits are scheduled every eight weeks, rather than every 4 weeks, during the first two trimesters to reduce the expenditures of money and time for prenatal care. Amish express their preference for prenatal care that promotes the use of nurse midwives, lay midwives, home deliveries, and limited use of high technology. The Amish desire culturally congruent and safe health care services.
In preparation for childbirth a five week formula (5-W) is sometimes used in the last five weeks of pregnancy. It is thought that the herbs in this formula tone and calm the uterus, quiet the nerves, ease pain, and help make labor easier and on time. In addition, it has been known to help with menstrual disorders, morning sickness and hot flashes. The herbs included in this formula are:
Red Rasberry Leaves: This herb has been used as an old friend to treat diarrhea, vomiting and the flu. It is used for similar purposes of relieving nausea and pain in labor. Red raspberry capsules and red raspberry teas are also used.
Butcher's Broom Root: This herb is used for hemorrhoids, varicose veins, and thrombosis. In addition, it is a diuretic, anti-inflammatory and improves circulation. This herb contains pseudo steroidal saponins which cause blood vessels to constrict and blood to thin. During the final months of pregnancy women may have circulatory problems such as varicose veins; therefore this herb is considered important.
Black Cohosh Root: This is a hormonal herb. It has an estrogenic effect because it contains compounds which mimic the effects of estrogen; therefore it is contraindicated in the early stages of pregnancy as it could bring on premature labor. This herb has a nervine effect which relieves spastic muscles, dilates peripheral blood vessels and helps reduce blood pressure. These actions aid the uterus and other muscles during labor. The anti-cramping effect of black cohosh is thought to help reduce pain during delivery. Black cohosh is also used to treat menopausal and PMS symptoms and menstrual cramps. Because black cohosh may minimic the action of estrogen, anyone who has had a cancer that's estrogen sensitive, such as breast, endometrial or ovarian, should avoid using it. Since this root contains a blood-thinner, it should not be taken with bloodthinning medications (such as coumadin or heparin).
Dong Quai Root: The anti-inflammatory and diuretic effect of this herb is used for treating swelling prior to labor. During labor it eases smooth muscle contractions and gives a general sedative effect. This herb, in Chinese medicine, is considered a blood building tonic as it is high in iron, magnesium, and niacin. This Chinese herb is sometimes referred to as a female ginseng and is used extensively in China as a postpartum tonic.
Squaw Vine Root: This herb is used to prepare the uterus for childbirth and is also used to speed up delivery and encourage regular contractions. It has an antispasmodic action. (Pederson, 1987; Willard, 1991; Tarr, 1984, Block, 1984).
The Amish have no major taboos or requirements for labor and delivery. The women labor in soft pastel colored gowns. Men may be present and most husbands choose to be involved. Delivery may be at home with a midwife, at the birthing center, or at a hospital.
VISITING THE AMISH COMMUNITY
Their simple life style practices numerous social controls to avoid modernization. However, interaction with the outside world often occurs in the health care arena when an Amish person requires hospitalization for medical care. To better understand the Amish culture related to obstetrical care several nursing faculty visited an Amish Birthing Center in Indiana called the "New Eden Care Center" which is located in the beautiful countryside of Topeka, Indiana. An adaptation by the Amish to modern medical and nursing practices are the Amish Birthing Centers (Kreps & Kreps 1997).
This Amish Birthing Center was built in 1997, not from local, state, or federal government funds but from private subscriptions and donations mainly from the surrounding community. This facility is designed to be an alternative for those who prefer not going to the hospital for the delivery of their babies but who recognize the need for skilled care before, during, and after delivery. New Eden Care Center is a place where the physician or midwife can bring their patient for delivery in a more relaxed, home-like environment (Philosophy of New Eden Care Center). Since this facility provides services for the low risk population, all women are screened by their physician or nurse midwife before their arrival. Admission to the facility is opened to anyone upon recommendation and approval of their physician or nurse midwife. The need for this birthing center came from the fact that many of the people in the area are Amish and do not have commercial insurance or coverage for obstetrical care. Thus the Amish prefer not to go to the hospital with its high cost. This center features a plain relaxing decor with no television sets or phones in the patient's rooms, and no separate nursery or delivery room. Labor, delivery and postpartum care are all given in the patient's room, better known as LDRP rooms. Newborn babies stay in the room with the mothers.
Fees for the use of the New Eden Care Center cover current expenses, repairs, and maintenance of this facility. A flat fee is charged for the birth itself and 72 hours of care starting from the time of admission. There are additional fees for extra supplies such as PKU screening, intravenous solutions, and medications. The nurse midwives and physicians fees are separate from the birthing center fees. At times the fees are bartered for. For example, one of the nurse midwives had a new front porch put on her home to cover for her fee. In addition meats have been given for payments.
Services of the birthing center included general nursing care, housekeeping, and meals brought in during the patient's stay. Families bring in food for the delivering mother and often eat together in the large home-like kitchen area provided at the birthing center. The center includes 3 MSN prepared nurse midwives and 9 physicians. No prenatal classes are offered by the center but the classes are provided by a staff RN from the center at a nearby church. Prenatal care is provided by the midwives either at their offices, located at the center, or in the homes of their patients. Many of the mothers prefer coming to the midwives offices for the prenatal classes as they enjoy the private and quiet time. The care center provides "hitching posts" with special parking areas for the traditional horse and buggy as well as a barn for overnight lodging of the Amish horses. Since there are no phones in Amish homes, a red bag tied to a large hook placed on the top of the barn is used to signal neighbors whenever additional help is needed in the center (cleaning and laundry).
All of the midwives, upon request, will do home deliveries. Suction, oxygen, and IV equipment are a few of the supplies they routinely take with them. One of the midwives described her experience following a home delivery. "It was a very foggy night and it took me awhile to get to the Amish home. It was well worth the difficult drive when following the delivery a great peace seemed to take over in the still of the night as I listened to the singing of the dad to the newborn, the creaking of the dad's rocking chair, and the hum from the kerosene lantern. Where else could one hear such beautiful, peaceful sounds".
Culture exerts a great influence on the prenatal family and determines the appropriate interventions to be given to provide competent nursing care. It is increasingly necessary to understand the cultural and behavioral patterns of the individuals whom we serve in our practices. Rapid growth of the Amish population and diverse geographical locations augment the probability that health care practitioners may care for Amish families. Health care practitioners can tailor their delivery of care for Amish families if they understand the Amish cultural practices and modify their services to keep it simple.
This Amish Birthing Facility, New Eden Care Center, is an example of wonderful adaptation by the Amish people to modern nursing and medical practices while at the same time maintaining their values of simplicity, low cost and accommodation to the use of their horse and buggy. Here the Amish can remain separate from the wider "English" society while still interfacing with it when health care is involved in "birthing babies". Obstetrical Amish health care can be of excellent quality, with licensed medical and nursing personnel, at a reduced cost to both the Amish and the "English" society. This is an important consideration in today's ever increasing health care costs.