Women s Health Issues 17 (2007)

Transcription

1 Women s Health Issues 17 (2007) HEALTH STATUS, HEALTH CONDITIONS, AND HEALTH BEHAVIORS AMONG AMISH WOMEN Results from the Central Pennsylvania Women s Health Study (CePAWHS) Kirk Miller, PhD a *, Berwood Yost, MA b, Sean Flaherty, PhD c, Marianne M. Hillemeier, PhD d, Gary A. Chase, PhD e, Carol S. Weisman, PhD e, and Anne-Marie Dyer, MS e 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 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. Funded in part under grant number with the Pennsylvania Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations, or conclusions. * Correspondence to: Kirk Miller, Department of Biology, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA Kirk.Miller@fandm.edu Copyright 2007 by the Jacobs Institute of Women s Health. Published by Elsevier Inc. The Old Order Amish of Lancaster County, Pennsylvania are perhaps the best known of the Anabaptist sects that broke from mainstream Protestant and Catholic beliefs in 16th-century central Europe and migrated to America to avoid religious persecution. The Amish separate themselves from the larger society to a great extent and retain some aspects of a 19th-century agrarian lifestyle, including no electricity or telephones in their homes and dependence on horse and buggy for personal transport, although half of Amish households receive their primary income from commercial activities, not from farming (Kraybill, 2001). Curiosity about their apparent separation from modern ways of living drives a very large tourism industry in Lancaster County (Kraybill, 2001; Luloff, Bridger, & Ploch, 2002). The Amish population in Lancaster County was estimated to be 22,300 in 2000 (Kraybill, 2001), when the population of Lancaster County was 470,658 (U.S. Census Bureau, 2000). Amish children have a relatively high incidence of certain rare genetic diseases (and a low incidence of others) because the Amish population was founded by relatively few individuals. The Amish keep meticulous records of births, deaths, and marriages and /07 $-See front matter. doi: /j.whi

2 K. Miller et al. / Women s Health Issues 17 (2007) they are, perhaps surprisingly, quite open to research when they believe it benefits their community and others. As a result, the Amish are an invaluable resource for the study of the genetic basis for human disease (McKusick, 1978). The Strasburg, Pennsylvania Clinic for Special Children was founded to treat Amish and Mennonite children with Glutaric Aciduria type I and Maple Syrup Urine Disease. Over 14 years, its workers have catalogued 60 heritable disorders among Amish and Mennonite populations of southeastern Pennsylvania and found treatments for some of them (Morton et al., 2003). In other respects, the Amish are known principally through stereotype and misconception (Good, 1985). The Old Order Amish community of Lancaster, Pennsylvania is on the border of the complex of large cities in the northeastern United States, and their seemingly bucolic lifestyle is iconic, especially for people living in a developed culture (Hostetler, 1993). Much of what we know about Amish behavior and culture is based on first-person accounts or clinic surveys (Armstrong & Feldman, 1986; Kaiser, 1986; Stoltzfus, 1994; Thomas, Menon, Ferguson, & Hiermer 2002). There is very little evidence-based research on Amish health care, Amish women, and pregnancy and childbirth among the Amish (Thomas et al., 2002). It 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 social network that often influences their medical decisions (Campanella, Korbin, & Acheson, 1993). Amish women are also reported to favor home births (Campanella et al., 1993) and most births are in the home (Hostetler, 1993; Armstrong & Feldman, 1986). Amish women, reportedly, do not use birth control (Armer & Radina, 2002). Nevertheless, pregnancy outcomes for Amish women are reported to be similar to those in the general population (Lucas, O Shea, Zielezny, Freudenheim, & Wild, 1991); the Amish have similar rates of perinatal mortality when adjusted for mother s age, but they may not suffer increased perinatal mortality with increasing mother s age (Resseguie, 1974); and they have a high and, apparently, stable fertility rate, and a population structure very different from the general U.S. population (Hewner, 1998). We report herein the results of a survey of the demographics, behaviors, and exposures of 288 randomly selected Amish women of childbearing age residing in Lancaster County, Pennsylvania. We compare our findings with those of a concurrent survey of 2,002 women in Central Pennsylvania generally (Weisman et al., 2006). Both surveys were part of the Central Pennsylvania Women s Health Study. Methods The Center for Opinion Research at Franklin & Marshall College conducted a household survey of Amish women of childbearing age (ages 18 45) living in Lancaster County, Pennsylvania, between November 2004 and June Amish women who worked for the Clinic for Special Children served as liaisons and advised us on the composition of the survey (Yost, Abbott, Harding, & Knittle, 2005). The purpose of the survey was to estimate the prevalence of behaviors and exposures that may lead to adverse pregnancy outcomes. The study was approved by the Institutional Review Board of Franklin & Marshall College and a Certificate of Confidentiality was obtained from the National Institutes of Health (NIH; CC- HD-04-24). The methods for the concurrent randomdigit dial (RDD) survey of women ages in the general Central Pennsylvania population have been described elsewhere (Weisman et al., 2006). Because the RDD survey included oversampling of rural areas and communities with high minority populations, weighted data are used for purposes of comparing the RDD sample with the Amish sample. Comparison of these 2 representative survey samples provides the first description, to our knowledge, of how Amish women compare with women in the general population with regard to health and childbearing experiences. Amish Population and Sample The 2002 Church Directory of the Lancaster County Amish (Gallagher & Beiler, 2002) was used as the sampling frame. The Church Directory was used because it provides the most comprehensive listing of Amish households available. The Directory provides a list of names and addresses as well as information about household composition, the birthdates of householders, and detailed maps that identify the location of Amish households. The Directory appears to provide broad coverage of the Lancaster County Amish. Kraybill (2001) estimated the population of Lancaster County s Old Order Amish was 22,300 persons in 2000 and he projected it to grow to approximately 33,000 persons by The 2002 church directory listed 6,635 households, of which an estimated 4,246 (64%) were located within the county. The survey (see below) shows the average Amish household contains 2.4 adults and 3.7 children, or 6.1 persons. This yields an estimated 25,900 persons listed in the directory, suggesting that the sample frame s coverage is high when compared with Kraybill s (2001) estimates. Before the church directory was selected as the sampling frame for our survey, we considered several other sampling frames. The NIH developed and maintains a list of Amish households that were identified through various NIH-funded research projects that

3 164 K. Miller et al. / Women s Health Issues 17 (2007) relied on self-selected samples. This list is described as incomplete by its creators and it is, likely, not representative (Alejandro Schaffer, NIH, personal correspondence, October 6, 2004). The Lancaster County Planning Commission at one time developed a list of Amish households to identify Amish properties, but this list is no longer maintained (Maggie Weidinger, Manager, Lancaster County IT/GIS & CSR, personal correspondence, October 12, 2004). The deficiencies in other possible sample frames made the 2002 Church Directory of the Lancaster County Amish the best available frame. The population of interest for this research, women of childbearing age, is a subset of the larger population listed in the sample frame because the Church Directory includes Amish who reside outside of Lancaster County, Amish of all ages, and Amish of both genders. Because the population of interest is a subset of the sample frame, we randomly selected a total of 1,106 households from the Directory with the intention of producing a final sample of 500 eligible women. A sample size of 500 was determined by dividing the desired number of completed interviews (300) by the product of the estimated hit rate, estimated eligibility rate, and the estimated response rate. Of the 1,106 households initially sampled, 400 (36%) were outside of the county and 183 (17%) did not contain a female between the ages of 18 and 45; because the listing of each household s members included names and birthdates, we could identify households with age-eligible females during the sampling process without making a visit to each home. Eight (1%) additional cases contained no household information. This yielded a final sample size of 515 eligible households. Eighty-four of the 515 eligible households contained 1 eligible woman. In these instances, 1 woman was randomly selected for the interview. Amish Survey Methods We surveyed 288 Amish women of childbearing age (18 45 years old). The instrument consisted of questions on sociodemographics, health status, health habits, health care access, stress and exposures, and pregnancy and childbirth, parallel to a larger survey of central Pennsylvania women of childbearing age. An overview of the instrument is in Weisman et al. (2006); Yost et al. (2005) describes how the instrument was adapted to face-to-face interviews of women from the Amish culture. Women from Central Pennsylvania were questioned on smoking, drug taking, and alcohol consumption, but these questions were deemed too sensitive for the Amish community (Yost et al., 2005). Yost et al. (2005) also discusses possible biases in the selection technique. Interviewers were trained to conduct themselves appropriately and to respect the sensibilities of the Amish culture (Yost et al. 2005). The response rate (American Association for Public Opinion Research [AAPOR], 2006) was 61% (AAPOR response rate 1); the cooperation rate was 63% (AAPOR cooperation rate 4) in the survey of Amish women. Measures Health status was measured with the Short Form 12 (SF-12) v.2 Health Survey (Ware, Kosinski, Turner- Bowker, & Gandek, 2005), which is scored into 2 summaries representing physical and mental health, in addition to questions about diagnoses of 28 acute and chronic medical conditions. Self-esteem was measured with the Rosenberg self-esteem scale (Rosenberg, 1965) and symptoms of depression using the Center for Epidemiologic Studies Depression Scale (Radloff, 1977) modified into a dichotomous indicator by Sherbourne, Dwight-Johnson, and Klap (2001). Women were also asked about use of a variety of prescription medications. Women were questioned about regular physical exercise and body mass index (BMI) was computed from self-reported height and weight. The Prenatal Psychosocial Profile (Curry, Campbell, & Christian, 1994) adapted by Misra, O Campo, and Strobino (2001) into the Psychosocial Profile Hassles Scale referring to stress during pregnancy was modified to a 12-item scale measuring stress in the past 12 months, the Psychosocial Hassles Scale. Intimate partner violence was measured using 8 items taken from the Conflict Tactics Scale (Straus, 1979) by the 1998 Commonwealth Fund Survey of Women s Health (Collins et al., 1999). Social support was measured with a subset of 8 questions from the 19-question Medical Outcomes Study (MOS) Social Support Survey (Sherbourne & Stewart, 1991). Unfair treatment owing to race or ethnicity or due to gender was assessed using questions adapted from Krieger (1999). Women were also asked about the source of their drinking water, exposure to agricultural chemicals, and changing the litter for a cat. Each woman who had had 1 live birth was questioned about her behavior, stress, and the medical aspects of the pregnancy that resulted in her first live birth. Respondent s beliefs about the impact of her behavior during pregnancy were measured by the 4-item Internal Control of Birth Outcomes Scale, adapted from the Pregnancy Beliefs Scale (Tinsley & Holtgrave, 1989; Misra et al., 2001). All women were asked about using birth control. SPSS version 11.0 was used to conduct the reported analyses. A merged dataset was constructed including data from the Amish women and women from the RDD general population survey. Depending on the form of the variables, analyses to compare Amish and RDD samples used cross-tabulations and the 2 statis-

4 K. Miller et al. / Women s Health Issues 17 (2007) Table 1. Sociodemographic characteristics of Amish women ages in Lancaster County, Pennsylvania, compared with the general population of women ages in Central Pennsylvania Amish Sample (n 288) General Population* (n 2,002) n % % p-value Age group (yrs) Number of adults in home 1 (respondent only) Number of children 18 in home Number of pregnancies Employed full or part time High school diploma Live on a farm Own home Attend religious services 2/mo Trouble paying for basic needs A lot Some None *Based on random-digit dial (RDD) telephone survey of 2,002 women ages in a 28-county region of Central Pennsylvania, with oversampling of rural counties and areas estimated to include 30% 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 F-statistic. Results The 288 Amish women surveyed ranged in age from years with a median age of 30 (Table 1); 249 (86.8%) were married and 38 never married (1 woman did not respond to this question). None of the unmarried women reported living with a partner or ever being pregnant. In the general Central Pennsylvania population of women aged 18 45, the median age was 33; 55.7% were married and 13.6% living with a partner. Table 1 shows that Amish women were more likely to be living in a household with two adults more likely to have more children in the household, and more likely to have been pregnant and to have been pregnant more times, compared with the general population of Central Pennsylvania women. Amish women were also much less likely to be employed outside the home (Table 1); but while 18.1% of married Amish women were employed full or part time, 92.1% of unmarried Amish women were employed full or part time. In contrast, among women in the general population who were married or living with a partner, 73.7% were employed full or part time; among women never married, widowed, separated, or divorced, 78.8% were employed full or part time. Amish women were less likely than women in the general population to have a high school diploma (Table

5 166 K. Miller et al. / Women s Health Issues 17 (2007) ), reflecting the Amish tradition of schooling only to 8th grade, and were more likely to attend religious services. For 98.3% of the Amish, Pennsylvania Dutch was the main language spoken at home; English is the language spoken at home for 98.8% of women in the general population. Amish women were more likely to live on a farm and less likely to own their home compared with women in the general population (Table 1). No Amish women were in households that had received any government welfare support, social security, or unemployment in the past year, whereas 29.5% of women in the general population had received some form of government support in the past year. Amish women were somewhat less likely than women in the general population to have trouble paying for basic needs (Table 1). Among the Amish women, 234 (81.3%) had been pregnant at least once and 231 (80.2%) had at least 1 live birth (Table 1). At the time of the survey, 36 (12.5%) were pregnant. Among the general population, 72.1% had been pregnant at least once and 68.4% had at least 1 live birth (Table 1); 3.9% were pregnant when surveyed. Of 231 Amish women who ever had a pregnancy resulting in a live birth, 25 (10.8%) had at least 1 low birthweight (LBW; 2500 g) baby and 41 (17.8%) at least 1 preterm ( 37 weeks gestation) baby. Among Central Pennsylvania women who ever had a pregnancy resulting in a live birth, 14.2% had at least one LBW baby and 16.6% at least 1 preterm baby. The health status of Amish women surveyed is summarized in Table 2. Amish women are approximately the same height but weighed less and thus had a lower average BMI compared with women in the general population. Amish women rated their physical health at approximately the same level but their mental health at higher levels. Amish women had more diagnoses of anemia, thyroid problems, and Table 2. Health status of Amish women ages in Lancaster County, Pennsylvania, compared with the general population of women ages in Central Pennsylvania Amish Sample (n 288) General Population* (n 2,002) p-value Height (inches; mean [range]) (48 71) (48 80).0002 Weight (lbs; mean [range]) (92 250) (85 430).0001 BMI ( ) ( ).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 Mental health 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 (%) 2.5% 22.0%.0001 Self-esteem (mean SD) Currently take prescription medications (%) 8.3% 45.2%.0001 *Based on random-digit dial (RDD) telephone survey of 2,002 women ages in a 28-county region of Central Pennsylvania, with oversampling of rural counties and areas estimated to include 30% 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. Percentage scoring at high risk for psychological distress, especially depression (Sherbourne et al., 2001). Scale scores range from Scores between 25 and 35 are within the normal range (Rosenberg, 1965).

6 K. Miller et al. / Women s Health Issues 17 (2007) blood clots and fewer diagnoses of urinary tract infections, high cholesterol, and depression. Fewer Amish women scored at high risk for depression; they scored slightly lower in self-esteem, and fewer take prescription medications compared with the general population of women in Central Pennsylvania. The health behaviors and causes of stress among Amish women surveyed are summarized in Table 3. Amish women were less likely to engage in physical exercise other than work, were more likely to perceive themselves at an appropriate weight, and were less likely to be trying to lose weight compared with the general population. Amish women perceived themselves to have fewer sources of stress, except with regard to pregnancy, and scored lower on the Psychosocial Hassles Scale (Curry et al., 1994; Misra et al., 2001) compared with the general population. Amish women perceived themselves to have experienced approximately the same levels of unfair treatment due to ethnicity but much lower levels of unfair treatment due to gender, compared with the general population of women in Central Pennsylvania. Intimate partner violence was reported by 2 Amish women (0.7%) in our sample, whereas it was reported by 7.0% of women in the general population. The Amish women in our sample reported a mean of 11.6 (range, 1 87) people to whom they can turn for Table 3. Health behaviors and stress in Amish women ages in Lancaster County, Pennsylvania, compared with the general population of women ages in Central Pennsylvania Amish Sample (n 288) General Population* (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 Married women Never married women Married women with children 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 in a 28-county region of Central Pennsylvania, with oversampling of rural counties and areas estimated to include 30% 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).

7 168 K. Miller et al. / Women s Health Issues 17 (2007) Table 4. Social support among Amish women ages in Lancaster County, Pennsylvania, compared with the general population of women ages in Central Pennsylvania Amish Sample (n 288) General Population* (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 in a 28-county region of Central Pennsylvania, with oversampling of rural counties and areas estimated to include 30% 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 questions from the MOS Social Support Survey (Sherbourne & Stewart 1991). Women in the general population reported a mean of 7.0 (range, 0 75) people to whom they can turn for support and had lower scores on the Social Support Survey (Table 4). Among Amish women, 256 (90.1%) drink water from a private well, and large numbers reported using agricultural chemicals in the past 12 months: 225 (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 insecticides. Among women in the general population, 34.7% drink water from a private well, and 21.2% used weed killers, 23.8% used crop insecticides, 0.8% used grain bin fumigants, 16.3% used fertilizers, and 3.6% used livestock insecticides. One hundred eighty Amish women (62.5%) have a cat, but only 1 reported using kitty litter; in the general population, 43.2% of women have a cat and, of those, 60.1% change the kitty litter. The 231 Amish women who had 1 live birth were questioned about the pregnancy that resulted in their first live birth. These data are summarized in Table 5. All but 2 of Amish first live births was a singleton birth. Among first live births to women in the general population, 1.4% were twins and 0.1% were triplets. Among Amish women who had 1 live birth, 22 (9.5%) had 1 baby born with a birth defect; among women in the general population who had 1 live birth, 7.6% had 1 baby born with a birth defect. Of the 249 Amish women who responded to questions on birth control, 52 (20.9%) said they were currently using birth control. Condoms are the most frequently used form of birth control, used by 26 of 52 (50.0%) Amish women and their partners who use birth control. In the general population, 59.6% reported using birth control; birth control pills are the most common type. Among Amish women, the mean score was 11.6 (range, 8 16) on the 4-item Internal Control of Birth Outcomes scale (Tinsley & Holtgrave, 1989; Misra et al., 2001). Among Central Pennsylvania women, the mean score was 14.1 (range, 7 16). Discussion We believe our work is among the first systematic, population-based surveys of women in Amish culture beyond educated conjecture, first-person accounts, and clinic-based surveys (Levinson, Fuchs, Stoddard, Jones, & Mullet, 1989; Fuchs, Levinson, Stoddard, Mullet, & Jones, 1990; Thomas et al., 2002). Our results allow comparison with other American women and perhaps reduce the force of stereotype in our understanding of Amish culture (Kraybill, 2001). Recently, an outbreak of polio in a small Amish community in Minnesota was the occasion for much reference to stereotype in newspaper reports including reference to 19th century ways that include a deep-rooted suspicion of vaccination (Harris, 2005) although the index patient is immunodeficient and the virus was vaccine-derived (Bahta et al., 2005). Our representative sample of Amish women, compared with a representative sample of women from the general population in Central Pennsylvania, provides important information about how the health and health risks of Amish women compare with those of women in the general population. The Amish lead a

8 K. Miller et al. / Women s Health Issues 17 (2007) Table 5. Experiences during the first pregnancy resulting in a live birth among Amish women ages in Lancaster County, Pennsylvania, compared with the general population of women ages 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) Prenatal Psychosocial Hassles Scale (mean SD) 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 in a 28-county region of Central Pennsylvania, with oversampling of rural counties and areas estimated to include 30% minority populations. Data are weighted to take stratified sampling design into account. This table is based on subsamples who have had 1 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 from that of other American women. Although the Amish stereotypically eschew modern life and technological conveniences, in reality their life is a balance between a traditional way of life and those modern conveniences that strengthen their community, and this balance is constantly changing (Kraybill, 2001). In some ways, Amish women conform to our stereotype of them. Compared with women in the general population, Amish women were more likely to be married, to live in a household with 2 adults, to have been pregnant more times and to live in a household with more children, to have less formal education, to live on a farm and drink water from a private well, and to not be employed outside the home. Amish women were also less likely to have trouble paying for basic needs and none of them received any government welfare support. Interestingly, however, Amish women were less likely to have had a LBW infant, and equally likely to have had a preterm infant, despite having had more children, compared with women in the general population. Further, Amish women rated their physical health approximately the same as did women in the general population, although Amish women had different numbers of various diagnoses, weighed less, and took fewer prescription medications. However, Amish women rated their mental health much higher, had fewer diagnoses of depression, perceived themselves to experience less stress, less intimate partner violence, less unfair treatment due to gender, and to have had higher levels of social support compared with women in the general population. Amish women scored only slightly lower than women in the general population on beliefs about internal control of birth outcomes, suggesting that both groups believe their own behavior has approximately the same impact on the outcome of a preg-

9 170 K. Miller et al. / Women s Health Issues 17 (2007) nancy. Also, some Amish women reported using contraception, although a number of sources report birth control forbidden in the Amish community (Campanella et al., 1993; Cross & McKusick, 1970; Ericksen, Ericksen, Hostetler, & Huntington, 1979; Fuchs et al., 1990; Hostetler, 1993; Hewner, 1998; but see Markle and Pasco, 1977; Kraybill, 2001). For the pregnancy that resulted in their first live birth, the Amish women we sampled were more likely to welcome their pregnancy, had approximately the same numbers of health problems, were approximately as likely to take a multivitamin containing folic acid and to have prenatal care, had approximately the same numbers of complications of pregnancy, gained less weight, perceived themselves under less stress, were much more likely to give birth at home but were surprisingly likely to give birth in a hospital, and were equally likely to give birth to a premature infant, and less likely to give birth to a LBW infant compared with women of childbearing age in Central Pennsylvania. We remain aware that Amish culture and social forces shaped women s answers to our survey; we attempted to bridge the gap between our and their understanding of the questions by consultation with Amish liaisons. The cultural barriers that confronted our survey design, although minimized, were not fully eliminated and must be considered as a limitation of this study. Another is that some of the measures (e.g., the depressive symptoms scale and the measure of self-esteem) have not been validated in the Amish population and may contain items that are not entirely culturally relevant to the Amish. For example, lower scores on self-esteem (Table 2) may reflect the Amish value of submission to the community rather than a negative individual self-image (Hostetler, 1993; Kraybill, 2001). Information from the Amish may confound generalizations about the relationship between socioeconomic variables and birth outcomes. Amish women, as a group, have limited formal education, relatively low incomes, are self-insured, and have many children, yet they also have a lower than expected proportion of low birthweight infants. Amish women may also have better preconceptional health status: lower BMI, less stress, less depression, and much greater social support. They also do not drink or smoke and they are less likely to use prescription drugs. These may explain their better than expected birth outcomes. Amish women may be more prepared to become pregnant in that they expect it, desire it, lead a lifestyle that supports it, and have the social support necessary to have a successful outcome. The Amish may help us to understand the interaction between socioeconomic status and lifestyle variables on birth outcomes. Future research will explore these links. Future work will also examine predictors of low birth weight and birth defects among the children of the women surveyed, and will examine geographic divisions among Amish women of childbearing age in Lancaster County, Pennsylvania. Acknowledgments Nancy Krieger provided resources to help us interpret findings on unfair treatment. The Morris Rosenberg Foundation provided resources for the interpretation of the Rosenberg self-esteem scale. Cathy Sherbourne helped us to score her depressive symptoms survey. Holmes Morton and Donald Kraybill encouraged us to study the Amish culture. We thank our students in Public Health Research for asking questions about surveys and this survey in particular that helped us to see its import more clearly. We thank Sara Baker and the Central Pennsylvania Center of Excellence for Research on Pregnancy Outcomes for continuing inspiration in the study of maternal and infant health. Amish liaisons Naomi Fisher, Barbie Stoltzfus, Fannie Stoltzfus, Katie Stoltzfus, Fannie Fisher, Lavina Stoltzfus, Ruth Stoltzfus, Susie Stoltzfus, and Dorothy Esh helped us design the survey and helped provide entry to Amish households. Interns Margaret Charleroy, Stacy Ellen, Samantha Hagelstein, and Eileen Keever helped us to give and interpret the survey. 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