HEALTH STATUS, HEALTH CONDITIONS, AND HEALTH BEHAVIORS AMONG AMISH WOMEN
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Women’s Health Issues 17 (2007) 162–171
HEALTH STATUS, HEALTH CONDITIONS, AND HEALTH
BEHAVIORS AMONG AMISH WOMEN
Results from the Central Pennsylvania Women’s Health Study
(CePAWHS)
Kirk Miller, PhDa*, Berwood Yost, MAb, Sean Flaherty, PhDc,
Marianne M. Hillemeier, PhDd, Gary A. Chase, PhDe, Carol S. Weisman, PhDe,
and Anne-Marie Dyer, MSe
a
Department of Biology, Franklin & Marshall College, Lancaster, Pennsylvania
b
Floyd Institute Center for Opinion Research, Franklin & Marshall College, Lancaster, Pennsylvania
c
Department of Economics, Franklin & Marshall College, Lancaster, Pennsylvania
d
Pennsylvania State University, College of Health and Human Development, University Park, Pennsylvania
e
Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
Received 26 January 2007; revised 26 February 2007; accepted 27 February 2007
We performed one of the first systematic, population-based surveys of women in Amish
culture. We used these data to examine health status and health risks in a representative
sample of 288 Amish women ages 18 – 45 living in Lancaster County, Pennsylvania, in
particular for risks associated with preterm and low birthweight infants, compared with a
general population sample of 2,002 women in Central Pennsylvania. Compared with women
in the general population, Amish women rated their physical health approximately at the
same level, but reported less stress, fewer symptoms of depression, and had higher aggregate
scores for mental health. Amish women reported low levels of intimate partner violence, high
levels of social support, and they perceived low levels of unfair treatment owing to gender
compared with the general population. Amish women also reported higher fertility, fewer low
birthweight babies, but the same number of preterm births as the general population. The
findings suggest that these outcomes may be due to higher levels of social support and better
preconceptional behavior among Amish women.
T he Old Order Amish of Lancaster County, Penn-
sylvania are perhaps the best known of the
Anabaptist sects that broke from mainstream Protes-
tricity or telephones in their homes and dependence
on horse and buggy for personal transport, although
half of Amish households receive their primary in-
tant and Catholic beliefs in 16th-century central Eu- come from commercial activities, not from farming
rope and migrated to America to avoid religious (Kraybill, 2001). Curiosity about their apparent sepa-
persecution. The Amish separate themselves from the ration from modern ways of living drives a very large
larger society to a great extent and retain some aspects tourism industry in Lancaster County (Kraybill, 2001;
of a 19th-century agrarian lifestyle, including no elec- Luloff, Bridger, & Ploch, 2002). The Amish population
in Lancaster County was estimated to be 22,300 in
2000 (Kraybill, 2001), when the population of Lan-
Funded in part under grant number 4100020719 with the Penn- caster County was 470,658 (U.S. Census Bureau, 2000).
sylvania Department of Health. The Department specifically dis- Amish children have a relatively high incidence of
claims responsibility for any analyses, interpretations, or conclu- certain rare genetic diseases (and a low incidence of
sions.
others) because the Amish population was founded by
* Correspondence to: Kirk Miller, Department of Biology, Frank-
lin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003. relatively few individuals. The Amish keep meticu-
E-mail: Kirk.Miller@fandm.edu lous records of births, deaths, and marriages and
Copyright © 2007 by the Jacobs Institute of Women’s Health. 1049-3867/07 $-See front matter.
Published by Elsevier Inc. doi:10.1016/j.whi.2007.02.011K. Miller et al. / Women’s Health Issues 17 (2007) 162–171 163
they are, perhaps surprisingly, quite open to re- Methods
search when they believe it benefits their commu-
The Center for Opinion Research at Franklin & Mar-
nity and others. As a result, the Amish are an
shall College conducted a household survey of Amish
invaluable resource for the study of the genetic basis women of childbearing age (ages 18 – 45) living in
for human disease (McKusick, 1978). The Strasburg, Lancaster County, Pennsylvania, between November
Pennsylvania Clinic for Special Children was founded 2004 and June 2005. Amish women who worked for
to treat Amish and Mennonite children with Glutaric the Clinic for Special Children served as liaisons and
Aciduria type I and Maple Syrup Urine Disease. Over advised us on the composition of the survey (Yost,
14 years, its workers have catalogued ⬎60 heritable Abbott, Harding, & Knittle, 2005). The purpose of the
disorders among Amish and Mennonite populations survey was to estimate the prevalence of behaviors
of southeastern Pennsylvania and found treatments and exposures that may lead to adverse pregnancy
for some of them (Morton et al., 2003). outcomes. The study was approved by the Institu-
In other respects, the Amish are known princi- tional Review Board of Franklin & Marshall College
pally through stereotype and misconception (Good, and a Certificate of Confidentiality was obtained
1985). The Old Order Amish community of Lan- from the National Institutes of Health (NIH; CC-
caster, Pennsylvania is on the border of the complex HD-04-24). The methods for the concurrent random-
of large cities in the northeastern United States, and digit dial (RDD) survey of women ages 18 – 45 in the
their seemingly bucolic lifestyle is iconic, especially general Central Pennsylvania population have been
for people living in a developed culture (Hostetler, described elsewhere (Weisman et al., 2006). Because
1993). Much of what we know about Amish behav- the RDD survey included oversampling of rural
ior and culture is based on first-person accounts or areas and communities with high minority popula-
clinic surveys (Armstrong & Feldman, 1986; Kaiser, tions, weighted data are used for purposes of compar-
1986; Stoltzfus, 1994; Thomas, Menon, Ferguson, & ing the RDD sample with the Amish sample. Compar-
Hiermer 2002). ison of these 2 representative survey samples provides
There is very little evidence-based research on the first description, to our knowledge, of how Amish
women compare with women in the general popula-
Amish health care, Amish women, and pregnancy and
tion with regard to health and childbearing experi-
childbirth among the Amish (Thomas et al., 2002). It
ences.
has been reported, based on interviews of health care
providers, that Amish women often seek prenatal care
from lay practitioners and female relatives and have a Amish Population and Sample
social network that often influences their medical The 2002 Church Directory of the Lancaster County Amish
decisions (Campanella, Korbin, & Acheson, 1993). (Gallagher & Beiler, 2002) was used as the sampling
Amish women are also reported to favor home births frame. The Church Directory was used because it
(Campanella et al., 1993) and most births are in the provides the most comprehensive listing of Amish
home (Hostetler, 1993; Armstrong & Feldman, 1986). households available. The Directory provides a list of
Amish women, reportedly, do not use birth control names and addresses as well as information about
(Armer & Radina, 2002). Nevertheless, pregnancy household composition, the birthdates of household-
outcomes for Amish women are reported to be similar ers, and detailed maps that identify the location of
to those in the general population (Lucas, O’Shea, Amish households. The Directory appears to provide
broad coverage of the Lancaster County Amish. Kray-
Zielezny, Freudenheim, & Wild, 1991); the Amish
bill (2001) estimated the population of Lancaster
have similar rates of perinatal mortality when ad-
County’s Old Order Amish was 22,300 persons in 2000
justed for mother’s age, but they may not suffer
and he projected it to grow to approximately 33,000
increased perinatal mortality with increasing mother’s
persons by 2010. The 2002 church directory listed
age (Resseguie, 1974); and they have a high and, 6,635 households, of which an estimated 4,246 (64%)
apparently, stable fertility rate, and a population were located within the county. The survey (see
structure very different from the general U.S. popula- below) shows the average Amish household contains
tion (Hewner, 1998). 2.4 adults and 3.7 children, or 6.1 persons. This yields
We report herein the results of a survey of the an estimated 25,900 persons listed in the directory,
demographics, behaviors, and exposures of 288 ran- suggesting that the sample frame’s coverage is high
domly selected Amish women of childbearing age when compared with Kraybill’s (2001) estimates.
residing in Lancaster County, Pennsylvania. We com- Before the church directory was selected as the
pare our findings with those of a concurrent survey of sampling frame for our survey, we considered several
2,002 women in Central Pennsylvania generally (Weis- other sampling frames. The NIH developed and main-
man et al., 2006). Both surveys were part of the Central tains a list of Amish households that were identified
Pennsylvania Women’s Health Study. through various NIH-funded research projects that164 K. Miller et al. / Women’s Health Issues 17 (2007) 162–171
relied on self-selected samples. This list is described as Amish culture (Yost et al. 2005). The response rate
incomplete by its creators and it is, likely, not repre- (American Association for Public Opinion Research
sentative (Alejandro Schaffer, NIH, personal corre- [AAPOR], 2006) was 61% (AAPOR response rate 1);
spondence, October 6, 2004). The Lancaster County the cooperation rate was 63% (AAPOR cooperation
Planning Commission at one time developed a list of rate 4) in the survey of Amish women.
Amish households to identify Amish properties, but
this list is no longer maintained (Maggie Weidinger,
Measures
Manager, Lancaster County IT/GIS & CSR, personal
Health status was measured with the Short Form 12
correspondence, October 12, 2004). The deficiencies in
(SF-12) v.2 Health Survey (Ware, Kosinski, Turner-
other possible sample frames made the 2002 Church
Bowker, & Gandek, 2005), which is scored into 2
Directory of the Lancaster County Amish the best avail-
able frame. summaries representing physical and mental health,
The population of interest for this research, women in addition to questions about diagnoses of 28 acute
of childbearing age, is a subset of the larger popula- and chronic medical conditions. Self-esteem was mea-
tion listed in the sample frame because the Church sured with the Rosenberg self-esteem scale (Rosen-
Directory includes Amish who reside outside of Lan- berg, 1965) and symptoms of depression using the
caster County, Amish of all ages, and Amish of both Center for Epidemiologic Studies Depression Scale
genders. Because the population of interest is a subset (Radloff, 1977) modified into a dichotomous indicator
of the sample frame, we randomly selected a total of by Sherbourne, Dwight-Johnson, and Klap (2001).
1,106 households from the Directory with the inten- Women were also asked about use of a variety of
tion of producing a final sample of 500 eligible prescription medications. Women were questioned
women. A sample size of 500 was determined by about regular physical exercise and body mass index
dividing the desired number of completed interviews (BMI) was computed from self-reported height and
(300) by the product of the estimated hit rate, esti- weight.
mated eligibility rate, and the estimated response rate. The Prenatal Psychosocial Profile (Curry, Campbell,
Of the 1,106 households initially sampled, 400 (36%) & Christian, 1994) adapted by Misra, O’Campo, and
were outside of the county and 183 (17%) did not Strobino (2001) into the Psychosocial Profile Hassles
contain a female between the ages of 18 and 45; Scale referring to stress during pregnancy was modi-
because the listing of each household’s members in- fied to a 12-item scale measuring stress in the past 12
cluded names and birthdates, we could identify months, the Psychosocial Hassles Scale. Intimate part-
households with age-eligible females during the sam- ner violence was measured using 8 items taken from
pling process without making a visit to each home. the Conflict Tactics Scale (Straus, 1979) by the 1998
Eight (1%) additional cases contained no household Commonwealth Fund Survey of Women’s Health
information. This yielded a final sample size of 515 (Collins et al., 1999). Social support was measured
eligible households. Eighty-four of the 515 eligible with a subset of 8 questions from the 19-question
households contained ⬎1 eligible woman. In these Medical Outcomes Study (MOS) Social Support Sur-
instances, 1 woman was randomly selected for the vey (Sherbourne & Stewart, 1991). Unfair treatment
interview. owing to race or ethnicity or due to gender was
assessed using questions adapted from Krieger (1999).
Amish Survey Methods Women were also asked about the source of their
We surveyed 288 Amish women of childbearing age drinking water, exposure to agricultural chemicals,
(18 – 45 years old). The instrument consisted of ques- and changing the litter for a cat.
tions on sociodemographics, health status, health hab- Each woman who had had ⱖ1 live birth was ques-
its, health care access, stress and exposures, and tioned about her behavior, stress, and the medical
pregnancy and childbirth, parallel to a larger survey of aspects of the pregnancy that resulted in her first live
central Pennsylvania women of childbearing age. An birth. Respondent’s beliefs about the impact of her
overview of the instrument is in Weisman et al. (2006); behavior during pregnancy were measured by the
Yost et al. (2005) describes how the instrument was 4-item Internal Control of Birth Outcomes Scale,
adapted to face-to-face interviews of women from the adapted from the Pregnancy Beliefs Scale (Tinsley &
Amish culture. Women from Central Pennsylvania Holtgrave, 1989; Misra et al., 2001). All women were
were questioned on smoking, drug taking, and alcohol asked about using birth control.
consumption, but these questions were deemed too SPSS version 11.0 was used to conduct the reported
sensitive for the Amish community (Yost et al., 2005). analyses. A merged dataset was constructed including
Yost et al. (2005) also discusses possible biases in the data from the Amish women and women from the
selection technique. RDD general population survey. Depending on the
Interviewers were trained to conduct themselves form of the variables, analyses to compare Amish and
appropriately and to respect the sensibilities of the RDD samples used cross-tabulations and the 2 statis-K. Miller et al. / Women’s Health Issues 17 (2007) 162–171 165
Table 1. Sociodemographic characteristics of Amish women ages 18 – 45 in Lancaster County, Pennsylvania, compared with the general
population of women ages 18 – 45 in Central Pennsylvania
Amish Sample (n ⫽ 288) General Population* (n ⫽ 2,002)
n % % p-Value†
Age group (yrs)
18–20 18 16.3 14.5
21–25 61 21.2 14.6
26–30 84 29.2 14.5
31–35 57 19.8 17.7
36–40 47 16.3 20.5
41–45 21 7.3 18.3 ⬍.0001
Number of adults in home
1 (respondent only) 3 1.0 12.8
2 223 77.4 59.6
3 30 10.4 17.2
4 21 7.3 8.0
5–7 11 3.8 2.4 ⬍.0001
Number of children ⬍18 in home
0 31 10.8 28.9
1 28 9.7 28.2
2 41 14.2 25.7
3 42 14.6 11.3
4 48 16.7 4.0
5–14 98 34.0 1.9 ⬍.0001
Number of pregnancies
0 54 18.8 27.9
1 14 4.9 15.7
2 29 10.1 23.7
3 28 9.7 15.9
4 38 13.2 7.7
5 31 10.8 4.4
6–21 94 32.6 4.6 ⬍.0001
Employed full or part time 80 27.9 75.2 ⬍.0001
High school diploma 2 0.7 88.3 ⬍.0001
Live on a farm 178 61.8 7.2 ⬍.0001
Own home 170 59.9 70.7 ⬍.0001
Attend religious services ⱖ2/mo 288 100.0 48.0 ⬍.0001
Trouble paying for basic needs
A lot 2 0.7 4.6
Some 74 26.2 26.5
None 206 73.0 68.9 0.008
*Based on random-digit dial (RDD) telephone survey of 2,002 women ages 18 – 45 in a 28-county region of Central Pennsylvania, with
oversampling of rural counties and areas estimated to include ⱖ30% minority populations. Data are weighted to take stratified sampling
design into account.
†
p-Value for appropriate test of statistical significance between the Amish sample and the weighted RDD sample.
tic, t-tests and the t-statistic, or ANOVA and the adults more likely to have more children in the
F-statistic. household, and more likely to have been pregnant
and to have been pregnant more times, compared
with the general population of Central Pennsylvania
Results women. Amish women were also much less likely to
The 288 Amish women surveyed ranged in age from be employed outside the home (Table 1); but while
18 – 45 years with a median age of 30 (Table 1); 249 18.1% of married Amish women were employed full
(86.8%) were married and 38 never married (1 woman or part time, 92.1% of unmarried Amish women were
did not respond to this question). None of the unmar- employed full or part time. In contrast, among women
ried women reported living with a partner or ever in the general population who were married or living
being pregnant. In the general Central Pennsylvania with a partner, 73.7% were employed full or part time;
population of women aged 18 – 45, the median age among women never married, widowed, separated, or
was 33; 55.7% were married and 13.6% living with a divorced, 78.8% were employed full or part time.
partner. Table 1 shows that Amish women were Amish women were less likely than women in the
more likely to be living in a household with two general population to have a high school diploma (Table166 K. Miller et al. / Women’s Health Issues 17 (2007) 162–171
1), reflecting the Amish tradition of schooling only to 8th (12.5%) were pregnant. Among the general popula-
grade, and were more likely to attend religious services. tion, 72.1% had been pregnant at least once and 68.4%
For 98.3% of the Amish, Pennsylvania Dutch was the had at least 1 live birth (Table 1); 3.9% were pregnant
main language spoken at home; English is the language when surveyed.
spoken at home for 98.8% of women in the general Of 231 Amish women who ever had a pregnancy
population. Amish women were more likely to live on a resulting in a live birth, 25 (10.8%) had at least 1 low
farm and less likely to own their home compared with birthweight (LBW; ⬍2500 g) baby and 41 (17.8%) at
women in the general population (Table 1). least 1 preterm (⬍37 weeks gestation) baby. Among
No Amish women were in households that had Central Pennsylvania women who ever had a preg-
received any government welfare support, social se- nancy resulting in a live birth, 14.2% had at least one
curity, or unemployment in the past year, whereas LBW baby and 16.6% at least 1 preterm baby.
29.5% of women in the general population had re- The health status of Amish women surveyed is
ceived some form of government support in the past summarized in Table 2. Amish women are approxi-
year. Amish women were somewhat less likely than mately the same height but weighed less and thus had
women in the general population to have trouble a lower average BMI compared with women in the
paying for basic needs (Table 1). general population. Amish women rated their physi-
Among the Amish women, 234 (81.3%) had been cal health at approximately the same level but their
pregnant at least once and 231 (80.2%) had at least 1 mental health at higher levels. Amish women had
live birth (Table 1). At the time of the survey, 36 more diagnoses of anemia, thyroid problems, and
Table 2. Health status of Amish women ages 18 – 45 in Lancaster County, Pennsylvania, compared with the general population of women
ages 18 – 45 in Central Pennsylvania
Amish Sample General Population*
(n ⫽ 288) (n ⫽ 2,002) p-Value†
Height (inches; mean [range]) 63.85 (48–71) 64.47 (48–80) .0002
Weight (lbs; mean [range]) 141.71 (92–250) 157.57 (85–430) ⬍.0001
BMI 24.49 (15.8–45.8) 26.62 (14.3–73.8) ⬍.0001
Self-assessment of health, past 4 weeks (%)
Overall health fair or poor 8.0% 8.9% .5939
Daily activities limited by physical health some, most, or all 12.5% 17.0% .0523
of the time
Felt downhearted or depressed some, most, or all of the time 14.1% 25.3% ⬍.0001
Accomplished less than they wanted because of emotional 9.4% 24.2% ⬍.0001
problems some, most, or all of the time
SF-12v2 aggregate scores (mean ⫾ SD)‡
Physical health 51.51 ⫾ 6.78 51.95 ⫾ 8.75 .3328
Mental health 52.81 ⫾ 6.44 48.43 ⫾ 10.30 ⬍.0001
Diagnoses, past 5 years (%)§
Anemia or low iron 42.4% 20.3% ⬍.0001
Vaginal yeast infection 29.9% 24.7% .0617
Thyroid problems 12.8% 6.6% .0002
Urinary tract infection 12.8% 23.1% ⬍.0001
Anxiety or depression 10.1% 28.9% ⬍.0001
Hypertension 7.6% 10.8% .1020
High cholesterol 4.5% 9.7% .0042
Blood clot 3.1% 1.1% .0056
Periodontal disease 10.1% 7.2% .0867
Depressive symptoms scale (%)储 2.5% 22.0% ⬍.0001
Self-esteem (mean ⫾ SD)¶ 28.74 ⫾ 2.13 32.80 ⫾ 4.88 ⬍.0001
Currently take prescription medications (%) 8.3% 45.2% ⬍.0001
*Based on random-digit dial (RDD) telephone survey of 2,002 women ages 18 – 45 in a 28-county region of Central Pennsylvania, with
oversampling of rural counties and areas estimated to include ⱖ30% minority populations. Data are weighted to take stratified sampling
design into account.
†
p-Value for appropriate test of statistical significance between the Amish sample and the weighted RDD sample.
‡
Scores have a mean of 50 and a standard deviation of 10 in the general U.S. population; higher scores indicate better health status (Ware et
al., 2005).
§
Fewer than 6 (2.1%) Amish women reported receiving a diagnosis of heart disease, stroke, epilepsy, asthma, chronic lung disease, obesity,
eating disorder, cancer, arthritis, endometriosis, chlamydia, herpes, gonorrhea, syphilis, bacterial vaginosis, HIV/AIDS, hepatitis B, pelvic
inflammatory disease, or diabetes.
储
Percentage scoring at high risk for psychological distress, especially depression (Sherbourne et al., 2001).
¶
Scale scores range from 10 – 40. Scores between 25 and 35 are within the normal range (Rosenberg, 1965).K. Miller et al. / Women’s Health Issues 17 (2007) 162–171 167
blood clots and fewer diagnoses of urinary tract except with regard to pregnancy, and scored lower
infections, high cholesterol, and depression. Fewer on the Psychosocial Hassles Scale (Curry et al., 1994;
Amish women scored at high risk for depression; they Misra et al., 2001) compared with the general pop-
scored slightly lower in self-esteem, and fewer take ulation. Amish women perceived themselves to
prescription medications compared with the general have experienced approximately the same levels of
population of women in Central Pennsylvania. unfair treatment due to ethnicity but much lower
The health behaviors and causes of stress among levels of unfair treatment due to gender, compared
Amish women surveyed are summarized in Table 3. with the general population of women in Central
Amish women were less likely to engage in physical Pennsylvania.
exercise other than work, were more likely to per- Intimate partner violence was reported by 2 Amish
ceive themselves at an appropriate weight, and women (0.7%) in our sample, whereas it was reported
were less likely to be trying to lose weight compared by 7.0% of women in the general population.
with the general population. Amish women per- The Amish women in our sample reported a mean
ceived themselves to have fewer sources of stress, of 11.6 (range, 1– 87) people to whom they can turn for
Table 3. Health behaviors and stress in Amish women ages 18 – 45 in Lancaster County, Pennsylvania, compared with the general
population of women ages 18 – 45 in Central Pennsylvania
Amish Sample General Population*
(n ⫽ 288) (n ⫽ 2,002) p-Value†
Exercise and dieting
Participated in physical exercise other than work, past month (%) 41.8% 68.9% ⬍.0001
Don’t exercise because of lack of time (%) 50.9% 67.5% ⬍.0001
Don’t exercise because of being tired (%) 25.5% 56.8% ⬍.0001
Perceived weight (%)
Very overweight 3.5% 17.6%
Slightly overweight 47.9% 50.8%
Just right or underweight 48.6% 31.6% ⬍.0001
Trying to lose weight (%)
By eating less 15.3% 45.1% ⬍.0001
Through exercise 12.9% 40.5% ⬍.0001
Under a physician’s care 0.3% 6.6% ⬍.0001
Sources of stress, past 12 months (%)
Feeling overloaded 7.7% 26.2% ⬍.0001
Illness of family member/friend 6.3% 19.2% ⬍.0001
Pregnancy 6.0% 3.3% .0230
Money worries 4.9% 26.5% ⬍.0001
Recent loss of loved one 3.8% 13.9% ⬍.0001
Psychosocial Hassles Scale (mean ⫾ SD)‡
All women 14.68 ⫾ 2.79 17.24 ⫾ 4.32 ⬍.0001
Married women 14.56 ⫾ 2.63 16.88 ⫾ 3.89 ⬍.0001
Never married women 15.41 ⫾ 3.68 17.78 ⫾ 5.03 .0006
Married women with children 14.42 ⫾ 2.39 16.49 ⫾ 3.67 ⬍.0001
Unfair treatment due to race, ethnicity, or cultural background (%)
Ever experienced
In school 8.0% 3.6% .0005
In a public setting 5.2% 6.7% .3416
At work 3.8% 7.8% .0156
Getting medical care 1.4% 2.6% .2208
Any unfair treatment, past 12 months 4.2% 11.7% .0001
Unfair treatment due to gender (%)
Ever experienced:
In school 1.0% 4.4% .0067
In a public setting 0.7% 11.0% ⬍.0001
Getting a job 0.3% 11.3% ⬍.0001
At work 0.3% 17.9% ⬍.0001
Getting housing 0.3% 1.6% .1032
Any unfair treatment, past 12 months 1.0% 19.2% ⬍.0001
*Based on random-digit dial (RDD) telephone survey of 2,002 women ages 18 – 45 in a 28-county region of Central Pennsylvania, with
oversampling of rural counties and areas estimated to include ⱖ30% minority populations. Data are weighted to take stratified sampling
design into account.
†
p-Value for appropriate test of statistical significance between the Amish sample and the weighted RDD sample.
‡
Scale based on Misra et al. (2001).168 K. Miller et al. / Women’s Health Issues 17 (2007) 162–171
Table 4. Social support among Amish women ages 18 – 45 in Lancaster County, Pennsylvania, compared with the general population of
women ages 18 – 45 in Central Pennsylvania
Amish Sample General Population*
(n ⫽ 288) (n ⫽ 2,002) p-Value†
Types of social support (% reporting support is available most or all of the time)‡
Tangible support
Someone to take you to the doctor if you need it 93.7% 86.2% .0004
Someone to help with daily chores if you were sick 92.3% 68.3% ⬍.0001
Emotional support
Someone to confide in or talk to about yourself or your problems 93.7% 87.9% .0034
Someone to share your private worries and fears with 92.3% 83.5% .0001
Positive interaction
Someone to get together with for relaxation 82.5% 76.4% .0211
Someone to do something enjoyable with 92.0% 82.5% ⬍.0001
Affective support
Someone who shows you love and affection 98.3% 90.6% ⬍.0001
Someone to love and make you feel wanted 97.9% 87.0% ⬍.0001
*Based on random-digit dial (RDD) telephone survey of 2,002 women ages 18 – 45 in a 28-county region of Central Pennsylvania, with
oversampling of rural counties and areas estimated to include ⱖ30% minority populations. Data are weighted to take stratified sampling
design into account.
†
p-Value for appropriate test of statistical significance between the Amish sample and the weighted RDD sample.
‡
Items selected from the MOS Social Support Survey (Sherbourne & Stewart, 1991).
support and almost all of them scored very high on (50.0%) Amish women and their partners who use
questions from the MOS Social Support Survey (Sher- birth control. In the general population, 59.6% re-
bourne & Stewart 1991). Women in the general popu- ported using birth control; birth control pills are the
lation reported a mean of 7.0 (range, 0 –75) people to most common type.
whom they can turn for support and had lower scores Among Amish women, the mean score was 11.6
on the Social Support Survey (Table 4). (range, 8 –16) on the 4-item Internal Control of Birth
Among Amish women, 256 (90.1%) drink water Outcomes scale (Tinsley & Holtgrave, 1989; Misra et
from a private well, and large numbers reported using al., 2001). Among Central Pennsylvania women, the
agricultural chemicals in the past 12 months: 225 mean score was 14.1 (range, 7–16).
(81.2%) used weed killers, 205 (74.8%) used crop
insecticides, 8 (3.5%) used grain-bin fumigants, 148
(59.0%) used fertilizers, and 137 (52.5%) used livestock
Discussion
insecticides. Among women in the general population,
34.7% drink water from a private well, and 21.2% used We believe our work is among the first systematic,
weed killers, 23.8% used crop insecticides, 0.8% used population-based surveys of women in Amish culture
grain bin fumigants, 16.3% used fertilizers, and 3.6% beyond educated conjecture, first-person accounts,
used livestock insecticides. One hundred eighty and clinic-based surveys (Levinson, Fuchs, Stoddard,
Amish women (62.5%) have a cat, but only 1 reported Jones, & Mullet, 1989; Fuchs, Levinson, Stoddard,
using kitty litter; in the general population, 43.2% of Mullet, & Jones, 1990; Thomas et al., 2002). Our results
women have a cat and, of those, 60.1% change the allow comparison with other American women and
kitty litter. perhaps reduce the force of stereotype in our under-
The 231 Amish women who had ⱖ1 live birth were standing of Amish culture (Kraybill, 2001). Recently,
questioned about the pregnancy that resulted in their an outbreak of polio in a small Amish community in
first live birth. These data are summarized in Table 5. Minnesota was the occasion for much reference to
All but 2 of Amish first live births was a singleton stereotype in newspaper reports including reference
birth. Among first live births to women in the general to “19th century ways that include a deep-rooted
population, 1.4% were twins and 0.1% were triplets. suspicion of vaccination” (Harris, 2005) although the
Among Amish women who had ⱖ1 live birth, 22 index patient is immunodeficient and the virus was
(9.5%) had ⱖ1 baby born with a birth defect; among vaccine-derived (Bahta et al., 2005).
women in the general population who had ⱖ1 live Our representative sample of Amish women, com-
birth, 7.6% had ⱖ1 baby born with a birth defect. pared with a representative sample of women from
Of the 249 Amish women who responded to ques- the general population in Central Pennsylvania, pro-
tions on birth control, 52 (20.9%) said they were vides important information about how the health and
currently using birth control. Condoms are the most health risks of Amish women compare with those of
frequently used form of birth control, used by 26 of 52 women in the general population. The Amish lead aK. Miller et al. / Women’s Health Issues 17 (2007) 162–171 169
Table 5. Experiences during the first pregnancy resulting in a live birth among Amish women ages 18 – 45 in Lancaster County,
Pennsylvania, compared with the general population of women ages 18 – 45 in Central Pennsylvania
Amish Sample General Population* p-Value†
Pregnancy intent (%)
Wanted to be pregnant at that time 70.9% 47.6%
Wanted to be pregnant sooner 13.9% 9.3%
Wanted to be pregnant later 14.3% 28.6%
Did not want to be pregnant 0.4% 13.1% ⬍.0001
Health problems (%)
Vaginal yeast infection 16.9% 11.7% .0282
Hypertension before pregnancy 0.9% 2.6% .1038
Hypertension started during pregnancy 10.0% 13.3% .1545
Urinary tract infection 9.1% 12.1% .1856
Diabetes before pregnancy 0.0% 0.3% .3972
Diabetes started during pregnancy 3.5% 6.8% .0538
Periodontal disease 0.9% 2.0% .2504
Daily multivitamin use (%)
Used for 7–9 mos of pregnancy 69.6% 76.7% .0194
Vitamin contained folic acid 73.5% 61.1% .0016
Had any prenatal care (%) 94.8% 97.9% .0045
Complications of pregnancy (%)
Placenta abruptio 0.0% 1.2% .0964
Placenta previa 0.9% 1.3% .6190
Premature rupture of membranes 23.8% 11.2% ⬍.0001
Bed rest or hospitalization due to premature labor 4.8% 9.0% .0332
Weight gain during pregnancy (lbs; mean ⫾ SD) 27.67 ⫾ 11.79 36.23 ⫾ 16.53 ⬍.0001
Prenatal Psychosocial Hassles Scale (mean ⫾ SD)‡ 13.68 ⫾ 2.01 16.13 ⫾ 4.54 ⬍.0001
Delivery (%)
C-section 6.1% 21.1% ⬍.0001
Gave birth in a hospital 46.3% 98.5%
Gave birth in a birthing center 11.7% 0.8%
Gave birth at home 41.1% 0.6% ⬍.0001
Birth outcome (%)
Preterm birth (⬍37 weeks) 8.7% 10.0% .5278
Low birthweight (⬍2500 g) 4.3% 8.9% .0195
Very low birthweight (⬍1500 g) 0.4% 1.6% .1796
*Based on random-digit dial (RDD) telephone survey of 2,002 women ages 18 – 45 in a 28-county region of Central Pennsylvania, with
oversampling of rural counties and areas estimated to include ⱖ30% minority populations. Data are weighted to take stratified sampling
design into account. This table is based on subsamples who have had ⱖ1 live birth (80% of Amish sample and 73% of RDD sample).
†
p-Value for appropriate test of statistical significance between the Amish sample and the weighted RDD sample.
‡
Scale based on Misra et al. (2001).
lifestyle that is, stereotypically at least, very different likely to have had a LBW infant, and equally likely to
from that of other American women. Although the have had a preterm infant, despite having had more
Amish stereotypically eschew modern life and tech- children, compared with women in the general pop-
nological conveniences, in reality their life is a balance ulation. Further, Amish women rated their physical
between a traditional way of life and those modern health approximately the same as did women in the
conveniences that strengthen their community, and general population, although Amish women had dif-
this balance is constantly changing (Kraybill, 2001). ferent numbers of various diagnoses, weighed less,
In some ways, Amish women conform to our ste- and took fewer prescription medications. However,
reotype of them. Compared with women in the gen- Amish women rated their mental health much higher,
eral population, Amish women were more likely to be had fewer diagnoses of depression, perceived them-
married, to live in a household with 2 adults, to have selves to experience less stress, less intimate partner
been pregnant more times and to live in a household violence, less unfair treatment due to gender, and to
with more children, to have less formal education, to have had higher levels of social support compared
live on a farm and drink water from a private well, with women in the general population.
and to not be employed outside the home. Amish Amish women scored only slightly lower than
women were also less likely to have trouble paying for women in the general population on beliefs about
basic needs and none of them received any govern- internal control of birth outcomes, suggesting that
ment welfare support. both groups believe their own behavior has approxi-
Interestingly, however, Amish women were less mately the same impact on the outcome of a preg-170 K. Miller et al. / Women’s Health Issues 17 (2007) 162–171
nancy. Also, some Amish women reported using the women surveyed, and will examine geographic
contraception, although a number of sources report divisions among Amish women of childbearing age in
birth control forbidden in the Amish community Lancaster County, Pennsylvania.
(Campanella et al., 1993; Cross & McKusick, 1970;
Ericksen, Ericksen, Hostetler, & Huntington, 1979;
Fuchs et al., 1990; Hostetler, 1993; Hewner, 1998; but
Acknowledgments
see Markle and Pasco, 1977; Kraybill, 2001). Nancy Krieger provided resources to help us interpret
For the pregnancy that resulted in their first live findings on unfair treatment. The Morris Rosenberg Foun-
birth, the Amish women we sampled were more likely dation provided resources for the interpretation of the
to welcome their pregnancy, had approximately the Rosenberg self-esteem scale. Cathy Sherbourne helped us to
same numbers of health problems, were approxi- score her depressive symptoms survey. Holmes Morton and
mately as likely to take a multivitamin containing folic Donald Kraybill encouraged us to study the Amish culture.
acid and to have prenatal care, had approximately the We thank our students in Public Health Research for asking
same numbers of complications of pregnancy, gained questions about surveys and this survey in particular that
less weight, perceived themselves under less stress, helped us to see its import more clearly. We thank Sara
Baker and the Central Pennsylvania Center of Excellence for
were much more likely to give birth at home but were
Research on Pregnancy Outcomes for continuing inspiration
surprisingly likely to give birth in a hospital, and were
in the study of maternal and infant health. Amish liaisons
equally likely to give birth to a premature infant, and Naomi Fisher, Barbie Stoltzfus, Fannie Stoltzfus, Katie
less likely to give birth to a LBW infant compared with Stoltzfus, Fannie Fisher, Lavina Stoltzfus, Ruth Stoltzfus,
women of childbearing age in Central Pennsylvania. Susie Stoltzfus, and Dorothy Esh helped us design the
We remain aware that Amish culture and social survey and helped provide entry to Amish households.
forces shaped women’s answers to our survey; we Interns Margaret Charleroy, Stacy Ellen, Samantha Ha-
attempted to bridge the gap between our and their gelstein, and Eileen Keever helped us to give and interpret
understanding of the questions by consultation with the survey. Two anonymous reviewers helped us commu-
Amish liaisons. The cultural barriers that confronted nicate more clearly.
our survey design, although minimized, were not
fully eliminated and must be considered as a limita-
tion of this study. Another is that some of the mea- References
sures (e.g., the depressive symptoms scale and the American Association for Public Opinion Research (AAPOR).
(2006). Standard definitions: Final dispositions of case codes and
measure of self-esteem) have not been validated in the outcome rates for surveys (4th ed.). Lenexa, KS: Author.
Amish population and may contain items that are not Armer, J. M., & Radina, M. E. (2002). Definition of health and health
entirely culturally relevant to the Amish. For example, promotion behaviors among Midwestern Amish families. Journal
lower scores on self-esteem (Table 2) may reflect the of Multicultural Nursing and Health, 8, 43–52.
Amish value of submission to the community rather Armstrong, P., & Feldman, S. (1986). A midwife’s story. New York:
Arbor House.
than a negative individual self-image (Hostetler, 1993; Bahta, L., Bartkus, J., Besser, J., Crouch, N., Cebelinski, E., Ehres-
Kraybill, 2001). mann, K., et al. (2005). Poliovirus infections in four unvaccinated
Information from the Amish may confound gener- children—Minnesota, August–October 2005. MMWR Dispatch,
alizations about the relationship between socioeco- 54, 1–3.
nomic variables and birth outcomes. Amish women, Campanella, K., Korbin, J. E., & Acheson, L. (1993). Pregnancy and
childbirth among the Amish. Social Science and Medicine, 36,
as a group, have limited formal education, relatively 333–342.
low incomes, are self-insured, and have many chil- Collins, K. S., Schoen, C., Joseph, S., Duchon, L., Simantov, E., &
dren, yet they also have a lower than expected pro- Yellowitz, M. (1999). Health concerns across a woman’s lifespan: The
portion of low birthweight infants. Amish women Commonwealth Fund 1998 Survey of Women’s Health. New York:
may also have better preconceptional health status: The Commonwealth Fund.
Cross, H. E., & McKusick, V. A. (1970). Amish demography. Social
lower BMI, less stress, less depression, and much Biology, 17, 83–101.
greater social support. They also do not drink or Curry, M. A., Campbell, R. A., & Christian, M. (1994). Validity and
smoke and they are less likely to use prescription reliability testing of the prenatal psychosocial profile. Research in
drugs. These may explain their better than expected Nursing & Health, 17, 127–135.
birth outcomes. Amish women may be more prepared Ericksen, J. A., Ericksen, E. P., Hostetler, J. A., & Huntington, G. E.
(1979). Fertility patterns and trends among the Old Order Amish.
to become pregnant in that they expect it, desire it, Population Studies, 33, 255–276.
lead a lifestyle that supports it, and have the social Fuchs, J. A., Levinson, R. M., Stoddard, R. R., Mullet, M. E., & Jones,
support necessary to have a successful outcome. The D. H. (1990). Health risk factors among the Amish: Results of a
Amish may help us to understand the interaction survey. Health Education Quarterly, 17, 197–211.
between socioeconomic status and lifestyle variables Gallagher, T. E., Jr., & Beiler, K. (2002). Church directory of the
Lancaster County Amish. Pequea, PA: Pequea.
on birth outcomes. Future research will explore these Good, M. (1985). Who are the Amish? Intercourse, PA: Good Books.
links. Future work will also examine predictors of low Harris, G. (2005, November 8). 5 cases of polio in Amish group raise
birth weight and birth defects among the children of new fears. New York Times. Section A, p1.K. Miller et al. / Women’s Health Issues 17 (2007) 162–171 171
Hewner, S. J. (1998). Fertility, migration and mortality in an Old Straus, M. A. (1979). Measuring intrafamily conflict and violence:
Order Amish community. American Journal of Human Biology, 10, the conflict tactics (CT) scales. Journal of Marriage and the Family,
619 – 628. 41, 75– 88.
Hostetler, J. A. (1993). Amish society. Baltimore, MD: The Johns Thomas, M. K., Menon, U., Ferguson, S. E., & Hiermer, M. A. (2002).
Hopkins University Press. Health-related research among Amish women: A review of
Kaiser, G. (1986). Dr. Frau. Intercourse, PA: Good Books. findings. Current Women’s Health Reports, 2, 208 –213.
Kraybill, D. B. (2001). The riddle of Amish culture (rev. ed.). Baltimore, Tinsley, B. J., & Holtgrave, D. R. (1989). Maternal health locus of
MD: The Johns Hopkins University Press. control beliefs, utilization of childhood preventive health ser-
Krieger, N. (1999). Embodying inequality: A review of concepts, vices, and infant health. Developmental and Behavioral Pediatrics,
measures, and methods for studying health consequences of 10, 236 –241.
discrimination. International Journal of Health Services, 29, 295–352. U.S. Census Bureau. (2000). Lancaster County, Pennsylvania fact
Levinson, R. M., Fuchs, J. A., Stoddard, R. R., Jones, D. H., & Mullet, sheet. Available: http://factfinder.census.gov. Accessed 6 Sep-
M. (1989). Behavioral risk factors in an Amish community. tember 2006.
American Journal of Preventive Medicine, 5, 150 –156. Ware, J. E., Jr., Kosinski, M., Turner-Bowker, D. M., & Gandek, B.
Lucas, C., O’Shea, R., Zielezny, M., Freudenheim, J. L., & Wild, J. F. (2005). How to score version 2 of the SF-12 Health Survey (with a
(1991). Rural medicine and the closed society: Pregnancy out- supplement documenting version 1). Lincoln, RI: QualityMetric Inc.
comes among Amish and non-Amish women. New York State Weisman, C. S., Hillemeier, M. M., Chase, G. A., Dyer, A., Baker, S.,
Journal of Medicine, 91, 49 –52. Feinberg, M., et al. (2006). Preconceptional health: Risks of
Luloff, A. E., Bridger, J. C., & Ploch, L. A. 2002. The Old Order adverse pregnancy outcomes by reproductive life stage in the
Amish community 50 years later. In A. E. Luloff & R. S. Krannich Central Pennsylvania Women’s Health Study (CePAWHS). Wom-
(Eds.), Persistence and change in rural communities: A 50-year en’s Health Issues, 16, 216 –224.
follow-up to six classic studies (pp. 143–170). New York: CABI. Yost, B., Abbott, C., Harding, J. & Knittle, A. (2005, June). Among
Markle, G. E., & Pasco, S. (1977). Family limitation among the Old the Amish: Interviewing unique populations on sensitive topics.
Order Amish. Population Studies, 31, 267–280. Public Opinion Pros 2005.
McKusick, V. A. (1978). Medical genetic studies of the Amish selected
papers. Assembled, with commentary. Baltimore, MD: The Johns
Hopkins University Press. Author Descriptions
Misra, D. P., O’Campo, P., & Strobino, D. (2001). Testing a socio- Kirk Miller, PhD, is a biostatistician with an interest
medical model for preterm delivery. Paediatric and Perinatal
in social epidemiology.
Epidemiology, 15, 110 –122.
Morton, D. H., Morton, C. S., Strauss, K. A., Robinson, D. L., Berwood Yost, MA, is Director of the Center for
Puffenberger, E. G., Hendrickson, C., et al. (2003). Pediatric Opinion Research at Franklin and Marshall College.
medicine and the genetic disorders of the Amish and Mennonite Sean Flaherty, PhD, is an economist with an interest
people of Pennsylvania. American Journal of Medical Genetics Part in local economic issues and in educational reform.
C (Semin Med Genet), 121C, 5–17.
Marianne M. Hillemeier, PhD, MPH, is a sociologist/
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale
for research in the general population. Applied Psychological demographer with research interests in maternal and
Measurement, 1, 385– 401. child health disparities.
Resseguie, L. (1974). Pregnancy wastage and age of mother among Gary A. Chase, PhD, is a biostatistician with inter-
the Amish. Human Biology, 46, 633– 639. ests in human genetics, mental health and women’s
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton health.
NJ: Princeton University Press.
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support
Carol S. Weisman, PhD, is a sociologist and health
survey. Social Science and Medicine, 32, 705–714. services researcher with a principal interest in women’s
Sherbourne, C. D., Dwight-Johnson, M., & Klap, R. (2001). Psycho- health care.
logical distress, unmet need, and barriers to mental health care Anne-Marie Dyer, MS, is a biostatistician whose
for women. Women’s Health Issues, 11, 231–243. interests include the analysis of categorical data in
Stoltzfus, L. (1994). Amish women: Lives and stories. Intercourse, PA:
cross-sectional and longitudinal studies.
Good Books.You can also read
