An Amish Paradox

by Charles E. Hurst

  The Amish guardedness in discussing pregnancy is suggested by a story related by a Holmes County chiropractor who has many Amish patients. A “lower” (i.e., Swartzentruber) order Amish woman who was six to seven months pregnant came in to see him, “And she had also brought her 14–15-year-old son in with her. So I had been talking to her about him, and then I turned to her, how’s your pregnancy going? She sent him out of the room. She said: ‘We don’t talk about things like that in front of the children.’ I took the opportunity and said: ‘What age do you think he should know where babies come from and that kind of thing?’ And she said: ‘Well, basically, we won’t say anything to him’ … They’re not even going to touch that.” A rural midwife who has delivered children for Old Order and more conservative Amish families has had similar experiences: “I don’t know if you’ve noticed, but children don’t know if [the mothers are] expecting a baby.” In visiting pregnant women at “low-church” homes, she said that on occasion she had “been asked to park my car on the other side of the barn so somebody driving by won’t see my car when I’m there during pre-natal.” The differences among the church orders in their treatment of pregnancy is also noticeable in that New Order mothers are more likely than others to have baby showers before a baby is born.

  When an Amish woman is pregnant, one of the decisions the husband and wife have to make is where to give birth to the baby. The main alternatives are a hospital, a birthing center, and home. Occasionally, a woman gives birth in a doctor’s office or at another person’s home. When asked whether the Amish are more likely than others to home-birth or go to a birthing center rather than a hospital, an employee at a well-established birth center replied, “Yes, definitely.” This report is supported by governmental data indicating that while home births composed well under 1 percent of all births in Ohio in 2005, more than 7 percent of all births in Holmes County, which is heavily Amish, took place at home. An earlier survey of 144 Amish families, sponsored by the Wayne County Department of Public Health, obtained similar data.4 In that study, only 59 percent of the Old Order and New Order Amish births, compared to 84 percent of English births, occurred at a hospital. The results were even more dramatic among the very conservative Swartzentruber Amish; only 18 percent of these mothers gave birth at a hospital. One doctor mentioned that part of the Amish philosophy is that “these things rest in God’s hands,” so being close to emergency services or in a hospital is not important or a cause for worry.

  The literal resignation that one’s health rests “in God’s hands” was probably most fully espoused when most Amish farmed and did not have the money to seek health care on a regular basis. Now that many Amish are off the farm and work in more lucrative occupations, the reaction to serious health problems is less passive. It is only after seeking medical help to care for the body as God’s temple, and finding that the care has proved ineffective and too expensive, that they let go, acknowledging that life is ultimately in God’s hands.

  Dr. Elton Lehman had this view confirmed in a case involving the transfer of a premature baby to another hospital for additional care. The Amish grandfather stated his position clearly: “Well, as I see it … if God is in control of everything that happens, as we believe he is, then why should we try to change what he has allowed to take place? Besides, if heaven is our goal for our families, then why should we struggle so hard and strap ourselves so deep into debt to all stay together down here?”5 As we will see in a later section, this perspective is perhaps especially noticeable when costly terminal illnesses strike their families. For the Amish, the Bible’s message provides guidance and solace for all families, regardless of wealth.

  The Amish of the various orders account for the vast majority of births at home and at birthing centers in Wayne and Holmes counties. The birthing center in Mount Eaton recorded 484 live births in 2004, while the care center in Fresno, Ohio, had 113 births in 2004, and the midwifery center in Berlin had 35 births between September 2004 and September 2005, its first year of operation. Almost all of these births involved either Amish or Mennonite mothers.

  The mode of operation in some centers in the Holmes County Settlement is more “medicalized” than in others; that is, they vary in the extent to which they follow a mainstream medical model and use licensed doctors or other degreed professionals. The Mount Eaton Care Center, which is the oldest, most popular, and most medicalized center and is licensed by the state, has medical doctors and nurse midwives on its staff who do the deliveries. The center also contains more medical technology available to use in the event of difficulties.6 The doctors there have delivered babies at area homes as well as at the center. At the next-most-medicalized center, the Doughty View Midwifery Center in Berlin, Ohio, Certified Nurse Midwives conducted the deliveries, and licensed nurses assisted them. The Berlin center closed in late 2008. Births at the New Bedford Care Center, which is unlicensed and is the least-medicalized center, are supervised by certified professional midwives and lay midwives. The second and third centers are served by boards whose members are primarily Amish and Mennonite. Medical professionals are least likely to be on the board of the third center.

  Controversy and strong feelings abound among professionals and the Amish regarding the relative qualifications and desirability of each birthing center. On one side are licensed physicians and nurses, who are concerned about the standard of care that patients are given at an unlicensed center. We interviewed several physicians, both doctors of osteopathy (D.O.’s) and doctors of medicine (M.D.’s) in Holmes and Wayne Counties, who had eight to forty years of experience in working with Amish patients. In speaking about the unlicensed care center, one M.D.’s comment is representative of the medical community’s view: “We see a lot of bad cases come out of that one … We would blame it of course on the fact that they aren’t well-trained midwives there. I suppose just being farther away from the hospital makes it look worse too, because it takes longer to get somewhere.”

  The concerns of physicians apply as well to the lay midwives who assist at home births, because complications do arise in a small percentage of births, and in a home there is no support structure for dealing with those complications: “In deliveries 90 percent are normal. It’s the other 10 percent that you have to know what you’re doing.” Lay midwives who do not have formal training or education in their field are not recognized by the state of Ohio. The doctors we interviewed believe that there should be one standard of care for all birthing centers, and that the standard should require the presence of licensed and degreed professionals.

  The views of certified professional midwives (C.P.M.’s) and lay midwives are quite different, however. They think that many medical doctors fail to fully understand the natural birthing process, “because [they weren’t] trained that way, [don’t] practice that way, [and don’t] see it done, so [they don’t] understand it … [they] only know how to do protocol one way.” One osteopath believes the medical model “has ceased to treat childbirth as a natural process, and this has allowed unlicensed individuals to fill the gap.” The workers at the unlicensed birthing center are aware that physicians in Holmes County “don’t like this place [New Bedford Care Center].” One of the workers commented, “Ohio does not offer licensure for the type of midwife I am.”

  They have strong reservations about the need for and benefits of state licensing. “If you license it, you medicalize it,” argued one C.P.M. She feels that a main reason women come to her birthing center is “because they want the midwifery care. And it’s about the only place in the state you can get it that’s not a home birth midwife.” She argued that the whole issue has become politicized by the powerful medical profession, which has dominated, controlled, and held in check the ability of midwives to operate freely and guide those prospective mothers who wish to experience pregnancy and birthing as fully natural processes, “as God intended it to be.” In the midwives’ view, to medicalize it is to turn the birth process into a problematic and artificial one. “And most doctor
s never do see normal physiological childbirths. Never.” Just because it is natural, however, does not mean childbirth is painless: “Very few women have that … [Just like farming,] nobody expects painless farming. So why are we talking about painless childbirth?” Childbirth is one terrain on which the traditional and the modern clash, and one on which disagreements exist about the relative effectiveness and appropriateness of care.

  The controversial case of the lay midwife Freida Miller illustrates the conflict between lay midwifery and the medical profession.7 In 2002 Miller was found guilty of giving a mother two drugs to stem bleeding after she had given birth. Lay midwives are not legally permitted to possess and administer prescription drugs. Her sentence was suspended, but she was then sent to jail for refusing to disclose the source of the drugs to a local grand jury. She was later released on bond. Supporters hailed her as a hero and an example of how the medical profession has oppressed and hassled lay midwives. Opponents from the medical profession, the state, and insurance companies argued that the issues were ones of safety and a consistent, high standard of care for the birthing process.

  The Amish themselves appear split on the kind of care they deem desirable. To some extent, location and cost affect their choices of who assists in a birth and where it occurs. While most might prefer a birthing center to a hospital and see birth as a natural process, they differ regarding the specific site they think is best for childbirth. On one end, Swartzentruber Amish are more likely than other Amish to prefer giving birth at home. Some are even hesitant to go to a midwifery center, because “it’s not Amish enough.” Commenting on how Amish midwives conduct home visits, one English midwife said, “It’s actually better for the Amish … They can just have someone come in and stay with them.” She went on to mention that some members of the Swartzentruber churches “cannot afford” to come to the center, so a midwife may go to their home. So the site chosen for birth is a result of a combination of location, cost, and beliefs. The geographic distribution of different Amish groups affects the professional’s practice, while the professional’s practice affects the choice made by the Amish.

  There are occasional out-of-wedlock births among the Amish, but the rate does not appear to be as high as is found among non-Amish women. An analysis of every fifth church district in the 2005 Ohio Amish Directory, covering Holmes, Wayne, Coshocton, and parts of surrounding counties, found that 4.7 percent of households with children (48 out of 1,012) contained a child who was born before the marriage date of the couple.8 Some of these may have been adoptions, however. As one female physician put it: “It doesn’t happen with great frequency. It is much lower among the Amish. I do 250–270 deliveries a year; two or three might be out-of-wedlock. Almost all will marry the father, in contrast with other groups.” But she noted that in cases of premarital pregnancy, couples generally wait to be married until after the child’s birth, unless it is quite early in the pregnancy and the woman is not “showing” yet.

  The percentage of premarital conceptions is more difficult to determine, but review of data from the Directory reveals a similarly low percentage of such conceptions, especially if the possibility of premature births is ruled out. Our analysis of every fifth church district in the 2005 Holmes County Ohio Amish Directory indicated that just under 2 percent of all children were conceived out of wedlock. Most of these conceptions may be for the first births, since Donnermeyer and Cooksey concluded that more than 10 percent of first births in the Holmes County Settlement occurred either before the parents were married or within seven months after their marriage. In 2006 the percentage of unwed births in Holmes County was less than one-fourth that found in Ohio as a whole.9 The greater commonality of premarital conceptions among the Old Order Amish as compared with the New Order may be related to the Old Order’s greater tolerance of rumspringa among its youth.10

  In prenatal and preventive care, differences appear to exist between the Amish and the English and also among the Amish. In the 1984 Wayne County study mentioned earlier, fully 100 percent of the English patients saw their doctor, nurse, or midwife sometime during the first three months of pregnancy, compared to 10 percent of Swartzentruber Amish and 28 percent of other Amish. More recently, vital statistics for Ohio revealed that more than half of pregnant women in the state receive prenatal care during their first trimester of pregnancy. However, according to a review of all births in Holmes County during 2003–5, only about 26 percent of women who gave birth received such care, indirectly suggesting that rates of early prenatal care continue to be lower among the Amish, who make up a significant proportion of the Holmes County population. Those most likely not to receive care until after the first trimester in the Holmes study tended to be older married women with no more than an eighth-grade education who had given birth before and had delivered outside a hospital setting. These characteristics are generally associated with Amish women.11 As one osteopath remarked in a conversation with the authors, “A lot of them tend to come in kind of late in the pregnancy. But it’s hard for me to train them to come in earlier … Usually if they had a problem previously, they come in earlier the next time … But most of them come in rather late compared to non-Amish patients. They’re too busy … They have to get a driver, pay the driver.” But if they can be convinced that they will save money in the long run by coming in early, they will do so, according to the experience of another doctor.

  Preventive Care and Genetics

  In general, the Amish are less likely than the population at large to seek preventive or dental care or to obtain annual physical examinations and regular immunizations.12 A 2003 study in Holmes County showed that non-Amish persons were almost twice as likely as Amish individuals to have received a routine examination within the past year. The same research indicated that Amish respondents were less likely than others to have seen a dentist or to have received a flu or pneumonia shot in the past year.13 As one physician who was raised in an Old Order family put it: “They are more prudent about coming in. They don’t come in every time they sneeze.” It appears that the more conservative the church, the less likely the Amish are to be proactive in their health care. The most conservative also tend to be poorer, suggesting that a combination of being highly traditional and lacking money largely accounts for the lower rate of health care service usage. In the view of one physician, the Swartzentruber Amish will “take whatever comes.” However, they are more likely to get immunized or see a doctor if their English neighbors might be endangered by their reluctance to see a health care provider. Thus, they balance their own concerns against those of their neighbors.

  In addition to differences rooted in church affiliation and income, there are gender differences in health care. As in the wider society, Amish men are less likely than women to seek medical help. “Men are usually macho … You usually drag them in, you know, when they’re just about dying or whatever. Whereas the women, they have a problem, they’ll do something about it.” A chiropractor explained what he believed to be Amish logic: “If you’re not sick, you don’t go to the doctor. You don’t go to the doctor when you feel good, and we’re asking them to do the exact opposite. We’re saying ‘come to the doctor while you’re feeling good.’ And you’ve got this obscure goal of ‘we’re going to keep you from feeling bad.’ But see, that’s not tangible … So you’re kind of working against a lot of human nature there.”

  Childhood immunizations are also relatively infrequent, especially among the more conservative orders. The Amish population is among those groups that underutilize immunization.14 Immunization for children “is one area where they do not do well at all,” observed a physician. “There is a major distrust with immunizations,” said another. Two of the reasons for this distrust are that many of their parents and grandparents did not get immunizations and suffered few, if any, health problems as a consequence; and some Amish people still associate immunizations with other health problems, for example, autism. Swartzentruber Amish are especially likely to avoid immuniza
tions. In the 1984 Wayne County study, only 6 percent of Swartzentruber parents said their children got their “baby shots,” compared to 63 percent of Amish parents overall and 85 percent of English parents. In general, Swartzentruber Amish are less likely than others to use any kind of immunization or screening clinic; 87 percent of this order also said they would not use a child immunization clinic either. In addition, location or easy access to health care appears to be more important to more Amish, especially Swartzentrubers, than to English patients.

  The hesitancy on the part of some Amish groups to participate in immunization programs opens them up to a greater probability of certain illnesses such as polio and rubella. The Amish also have higher rates of some genetic diseases than the general population. This susceptibility is due to the small size of the founding group, the relatively high level of genetic isolation within that group, and the fact that relevant recessive genes happened, through genetic drift, to have existed in some founders and their offspring. The common ancestry and insularity of the genetic pool creates a “founder effect,” which magnifies the effect of certain recessive genes. “Because members keep to themselves and marry within their communities, they rarely get to shuffle their genetic decks, and they are afflicted with a wide variety of rare diseases in far greater frequency than the population as a whole.”15