Spring
Psychosocial
Determinants
of
Pregnancy
Outcomes
Among
the
Amish
Jennifer
J.
Stuart,
‘09
Special
Studies:
Public
Health
Honors
Thesis
SPC
490:
Pregnancy
Outcomes
Among
the
Amish
Honors
Awarded:
May
7,
2009
Graduation
Date:
May
16,
2009
Franklin
&
Marshall
College
Lancaster,
Pennsylvania
2009
ABSTRACT
Lancaster County has North America’s oldest and most densely populated Amish
settlement and the second largest in the United States. Despite a relative lack of prenatal care,
Amish women appear to have slightly better pregnancy outcomes than non-Amish women.
Lancaster County Amish women report less stress, fewer symptoms of depression, higher mental
health status, and higher levels of social support, which may be causative agents of the positive
pregnancy outcomes. Utilizing datasets from the Central Pennsylvania Women’s Health Survey
(CePAWHS) in 2004 and 2008, the authors examined longitudinal relationships between
psychosocial determinants—stress, depression, social support, locus of control, self-esteem—and
pregnancy outcomes—low-birth weight infants, preterm delivery, stillbirth, miscarriage—among
Lancaster County Amish (n=288) and women in Central Pennsylvania (n=2,002). While having
more pregnancies than Central Pennsylvanian women, the Amish exhibit equal incidences of
low-birth weight infants and preterm delivery and half as much stillbirth. A significant
relationship was found between high self-esteem and improved pregnancy outcomes among the
Amish. This analysis is believed to be one of the first longitudinal studies of population-based
survey data in Amish. The authors are working to further explore the observed relationship
between self-esteem and pregnancy outcomes and validate the instrument through interviews
with Amish women.
INTRODUCTION
The Old Order Amish of Lancaster County are one of the best-known Anabaptist sects
that broke from the established churches in Europe and migrated to America seeking refuge from
religious persecution. The Amish operate within a family-oriented, labor-intensive economic
framework striving for self-sufficiency (Hostetler 1983). They have retained the customs and
technologies that characterized rural 19th-century society and have rejected most modern
technologies such as electricity and telephones (Hostetler 1993). Large family size, spurred on
by birth control restrictions, the labor demands of agriculture, the use of modern medicine, and
their religious values, has caused this closed population to grow (Kraybill 2001). Over the course
of the 20th century, Lancaster County’s Amish population doubled in size approximately every
twenty years, growing from 500 to over 27,000 (Kraybill 2008). This growth has shifted
occupational patterns, resulting in the rise of nonfarm work since the late 1960s. Today, half of
Amish households derive their primary income from commercial activities rather than farming
(Martineau & MacQueen 1977; Hostetler 1983; Kraybill 2001).
1
The Amish differ from their non-Amish neighbors, despite living in the same regional
environment, due to behaviors and genetic characteristics that cause differences in their health.
The Amish are more likely to marry, live in large households, end education early, and engage in
agriculture than non-Amish (Kraybill 2001). The Amish report lower rates of alcohol and
tobacco consumption. The Amish favor home remedies and tend to pay less attention to
prescribed preventative care, perhaps due to a lack of formal education. The absence of
preventative medicine among the Amish is seen in the relative lack of immunizations and
prenatal care (Hostetler 1963-1964; Adams & Leverland 1986; Huntington 2003). For maternal
care during pregnancy and delivery, the Amish traditionally favor the use of Amish midwives.
However, they have been shown to utilize physicians at certain times such as the initial diagnosis
of pregnancy (Cross 1976; Adams & Leverland 1986; Lucas et al. 1991). While the Amish
sometimes deliver their first babies in hospitals, they prefer to deliver at home. The Amish
fertility rate has remained constant from the late 19th century into the late 20th century and has
been characterized as a representation of natural fertility, falling between 6.5 and 7.0 (Cross &
McKusick 1970; Ericksen et al. 1979; Wood et al. 1994). Amish birth intervals are similar to
those of other high fertility groups exhibiting shorter intervals between births and longer
reproductive spans. Natural fertility, low infant mortality, and selective use of Western
biomedicine have been identified as strong cultural patterns that have allowed for reproductive
success among the Amish (Hewner 1998).
Preterm birth—defined as occurring at less than 37 weeks gestational age—and low-birth
weight—defined as infants weighing less than 2,500 grams at birth—are the leading causes of
perinatal morbidity and mortality in developed countries and have risen in recent decades.
Personal and family history of preterm birth, black race, periodontal disease, low maternal body-
2
mass index, low socioeconomic status, biologic or genetic markers, young maternal age, and
adverse behaviors, such as poor nutrition and use of illicit drugs and smoking, place women at
increased risk for preterm birth. Depression and social support are also related to preterm birth in
varying degrees. Even after adjustment for the effects of sociodemographic, medical, and
behavioral risk factors, mothers exposed to stressful conditions and who experience high levels
of psychological or social stress are at risk of preterm birth nearly two-fold that of women
without such exposures (Lobel et al., 1992; Copper et al. 1996; Goldenberg et al. 2005; Romero
et al. 2006; Goldenberg et al. 2008).
In addition to stress, other psychosocial factors, such as low levels of pregnancy health
locus of control, and social factors, such as an insufficient amount of time and money for nonessentials, have also been shown to correlate with preterm birth. Locus of control in pregnancy
refers to a woman’s perception of the effect of her health behaviors on her pregnancy outcomes
(Misra et al. 2001). Environmental factors may also interact with social and psychosocial factors
in pregnancy outcomes. Recent research into the health of rural women concludes that farm
residence may both protect women from poor mental health while also disguising cases through
decreased access to screening and treatment that results in fewer diagnoses of depression and
other conditions. Low self-esteem among rural women is significantly associated with an
increased likelihood of depressive symptoms. However, the mechanism associating self-esteem
and mental health within a rural environment remains unclear (Hillemeier et al. 2008). Mental
health among the Amish remains an understudied area of research, although Egeland and
Hostetter first studied affective disorders among the Amish from 1976-1980 (1983).
Miller et al. (2007) present the results of the first systematic, population-based surveys of
women in Amish culture. Utilizing data from the original CePAWHS survey collected from
3
2004-2005 (Weisman et al. 2006) and a second 2008 follow-up survey, I report the results of the
demographics, behaviors, and exposures of 202 of the 288 original randomly selected Amish
women of childbearing age residing in Lancaster County, Pennsylvania. I compare my results
with previous findings from the Amish and Central Pennsylvania women generally as well as
within follow-up data from 1,040 of the 2,002 original Central Pennsylvania respondents. I
examine the relationship between depression, mental health, self-esteem, social support, locus of
control, and pregnancy outcomes including preterm birth, low-birth weight, stillbirth, and
miscarriage.
MATERIALS AND METHODS
The methods for the first phase of the household survey of Amish women of childbearing
age (18-45) living in Lancaster County, Pennsylvania are described elsewhere. Weisman et al.
(2006) provides an overview of the instrument; Yost et al. (2005) describes how the instrument
was adapted for use with in-person interviews among the Amish; Miller et al. (2007) highlights
the health status and behaviors of Amish respondents from the first survey.
The Center for Opinion Research at Franklin & Marshall College conducted a two-year
follow-up household survey of the same Amish women from December 2007 to April 2008. The
same liaisons and interviewers utilized in the first phase of the survey were used in the second
phase (Berwood Yost, Center for Opinion Research at Franklin & Marshall College, personal
correspondence, 2008). 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). Questions on experiences with and knowledge of depression
and mental health were added to the second Amish survey. Of the 288 Amish women who
4
participated in the first survey, 202 participated in the second survey. The second survey
response rate (American Association for Public Opinion Research [AAPOR], 2008) was 71.6%
(AAPOR response rate 1); the cooperation rate was 73.2% (AAPOR cooperation rate 4).
Stress was measured through the use of a twelve-item Prenatal Psychosocial Profile
Hassles Scale adapted by Misra, O’Campo, and Strobino (2001) from the Prenatal Psychosocial
Profile (Curry, Campbell, & Christian 1994). Social support was measured through the use of
eight of the nineteen items on the Medical Outcomes Study (MOS) Social Support Survey
(Sherbourne & Stewart 1991). Symptoms of depression were measured using six of the twenty
items of the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff 1977)
modified into a dichotomous indicator by Sherbourne, Dwight-Johnson, and Klap (2001).
Maternal locus of control was measured using Pregnancy Outcomes Locus of Control (Misra et.
al. 2001) with two items added by Weisman on preconception locus of control and beliefs about
women’s health. Self-esteem was measured with the ten-item Rosenberg self-esteem scale
(Rosenberg 1965). All measures appeared on both the first and second survey with the exception
of the Rosenberg Self-Esteem Scale and the Pregnancy Outcomes Locus of Control measure,
which appeared only on the first survey.
Poor pregnancy scores were calculated for each respondent according to the frequency of
low-birth weight, preterm birth, stillbirth, and miscarriage (no Amish survey respondents
reported any abortions or ectopic/tubal pregnancies although those options existed in the survey).
Two poor pregnancy variables were created to distinguish between outcomes that may have
some genetic roots—miscarriage and, to a lesser extent, stillbirth—and those that may have
environmental and behavioral roots—low-birth weight and preterm delivery. This method
allows for some duplication in scoring.
5
SPSS version 16.0 was used to conduct the reported analyses. A merged dataset was
constructed including data from the first and second phases of the Amish survey.
RESULTS
The second phase of the Amish survey yielded follow-up surveys for 202 (70.1%) of the
288 Amish women of childbearing age (18-45) who participated in the first phase. Three
demographic characteristics from the first survey—age group, educational attainment, number of
pregnancies—were utilized to compare the sample of Amish women who took both the first and
second surveys (n=202) with those who only participated in the first survey (n=86) (Table 1).
Using χ2 analysis, the data provide sufficient evidence to conclude that Amish women who
completed both surveys did not differ from those who only took the first survey (age groups,
P=0.484; education attainment, P=0.362; number of pregnancies, P=0.177).
Of the 202 Amish women who completed both surveys, 178 (88.1%) experienced at least
one pregnancy in their lifetime and 138 (68.3%) experienced at least one live birth since the first
survey. At the time of the second survey, 26 women (12.9%) were pregnant. All live births
occurring from pregnancies between the two surveys were singleton births. The majority (82.4%)
of women who experienced a pregnancy between the two surveys had at least one live birth; 87
women had only one live birth while 24 women had two live births and one woman had three
live births. Low-birth weight and preterm birth occurred in only 3 (2.2%) live births to Amish
women who completed both surveys during the time between surveys. Two babies born between
the surveys were preterm and one baby was both preterm and low-birth weight. The three women
who experienced these preterm and low-birth weight infants do not appear to share any common
characteristics, such as parity or maternal age. Poor pregnancy scores utilizing first survey data
were also used to compare women who completed both surveys to those who only completed the
6
first survey. The pregnancy outcomes of women who completed both surveys did not differ
significantly from those of women who completed only the first survey (genetic poor pregnancy
score P=0.302; environmental/behavioral poor pregnancy score P=0.135).
Table 1. Demographic characteristics of Amish women ages 18-45 in Lancaster County,
Pennsylvaniaa
First Survey Only
(n=86)
n
%
Variable
Both First and Second
Surveys (n=202)
n
%
Age groups (years)
18-20
7
8.1
10
5.0
21-25
18
20.9
39
19.3
26-30
26
30.2
59
29.2
31-35
20
23.3
41
20.3
36-40
12
14.0
34
16.8
41-45
3
3.5
19
9.4
Less than high school
85
98.8
200
99.0
High school graduate or equivalent
0
0.0
1
0.5
Some college or vocational program
0
0.0
1
0.5
Refused
1
1.2
0
0.0
0
13
15.3
41
20.3
1
9
10.6
4
2.0
2
10
11.8
19
9.4
3
7
8.2
21
10.4
4
11
12.9
27
13.4
5
11
12.9
20
9.9
6
5
5.9
21
10.4
7
6
7.1
24
11.9
8
5
5.9
7
3.5
9
3
3.5
7
3.5
10
2
2.4
7
3.5
11-21
3
3.6
4
2.0
Educational attainment
b
Number of pregnancies
a
Data are derived from first survey responses of Amish women in 2004-2005 (n=288)
For the sample of women who only responded to the first survey, one respondent did not provide information on the number of
pregnancies. Therefore, valid percents are presented in the table to account for this missing datum
b
Of the 1,420 Central Pennsylvanian women who completed both surveys, 1,155 (81.3%)
experienced at least one pregnancy in their lifetime and 162 (11.4%) experienced at least one live
7
birth between the two surveys. Of the 162 live births, 8.7 percent (n=14) were preterm and 6.2
percent (n=10) were low-birth weight. At the time of the second survey, only 2 (0.2%) women
were pregnant from the Central Pennsylvania population. Comparing the 1,155 women from
Central Pennsylvania with the 178 Amish women, all of whom experienced at least one
pregnancy in their lifetime and completed both surveys, the Amish, despite experiencing more
pregnancies in their lifetime, present lower numbers of low-birth weight infants (10.1% versus
12.4%), relatively equal numbers of preterm delivery (14.5% versus 15.0%), and less stillbirth
(1.1% versus 2.4%). As expected with a higher number of pregnancies, more Amish women
experience at least one miscarriage than women in Central Pennsylvania (44.1% versus 29.7%).
The risk of experiencing a low-birth weight baby is 31.99 per 1,000 live births in the Amish and
70.8 per 1,000 in Central Pennsylvania. The risk of experiencing a preterm delivery is 54.50 per
1,000 live births in the Amish and 92.23 per 1,000 in Central Pennsylvania. The risk of
experiencing a miscarriage is 161.14 per 1,000 live births in the Amish and 206.7 per 1,000 in
Central Pennsylvania. The risk of experiencing a stillbirth is 2.37 per 1,000 live births in the
Amish and 11.7 per 1,000 in Central Pennsylvania. These risks are the most comparable statistics
for comparison between the two populations. They are not comparable to annual statistics
outside of this study as my data are derived from lifetime experience prior to the second survey.
Psychosocial Determinants
Stress, determined by the Prenatal Psychosocial Profile Hassles Scale, ranges from 12-48
with a higher score representing higher stress. Scores for Amish women ranged from 12-28 and
from 12-37 for women in Central Pennsylvania. The mean stress score was 15.13 (SD 2.713) for
Amish women and 17.03 (SD 3.89) for women in Central Pennsylvania. Stress scores were
significantly different between Amish women and women in Central Pennsylvania (χ2=18.85,
8
P<0.001) (Table 2).
Social support, determined by MOS Social Support Survey, ranges from 8-40 with a
higher score representing higher perceived social support. Scores for Amish women ranged from
21-40 and from 8-40 for women in Central Pennsylvania. The mean social support score was
36.58 (SD 4.12) for Amish women and 35.51 (SD 5.71) for women in Central Pennsylvania.
Social support scores were significantly different between Amish women and women in Central
Pennsylvania (χ2=8.968, P=0.030) (Table 2).
Depression, determined by the CES-Depression Scale, ranges from 0-12, with higher
scores indicating a higher level of depression. Scores ranged from 0-5 among Amish women and
from 0-11 among women in Central Pennsylvania. The mean CES-D score was 0.82 (SD 1.14)
for Amish women and 1.88 (SD 2.15) for women in Central Pennsylvania. In the CES-D scale, a
score above “4” indicates depression. Despite the larger range of scores from the first Amish
survey, the second survey identified more respondents as depressed with 3 women scoring above
a 4 compared with 1 woman in the first survey scoring above a 4. Depression scores were
significantly different between Amish women and women in Central Pennsylvania (χ2=29.87,
P<0.001) (Table 2).
Maternal locus of control, determined by the Pregnancy Outcomes Locus of Control
measure, was assessed only on the first survey. Pregnancy Outcomes Locus of Control scores
range from 7-28, with a higher score representing a higher degree of perceived control. Scores
for Amish women ranged from 16-28 and from 17-28 for women in Central Pennsylvania. The
mean locus of control score for Amish women was 20.15 (SD 1.72) and was 24.28 (SD 2.69) for
women in Central Pennsylvania. Maternal locus of control scores were significantly different
between Amish women and women in Central Pennsylvania (χ2=13.27, P<0.001) (Table 2).
9
Table 2. Psychosocial characteristics of Amish women in Lancaster County, Pennsylvania and
women in the general Central Pennsylvania populationa
Amish Sample
(n=202)
Psychosocial Variable
n
P-Valuec
General Population
(n=1,040)
n
%
%
Prenatal Psychosocial Hassles Scale
<0.001
First Quartile [12-21]
196
97.0
1225
86.3
Second Quartile [22-30]
6
3.0
180
12.7
Third Quartile [31-39]
0
0
14
1.0
Fourth Quartile [40-48]
0
0
0
0
MOS Social Support
0.030
First Quartile [8-15]
0
0
16
1.1
Second Quartile [16-23]
3
1.5
55
3.9
Third Quartile [24-31]
18
9.0
188
13.3
Fourth Quartile [32-40]
180
89.6
1157
81.7
CES-Depression Scale
<0.001
First Quartile [0-3]
192
96.0
1140
80.3
Second Quartile [4-6]
8
4.0
219
15.4
Third Quartile [7-9]
0
0
53
3.7
Fourth Quartile [10-12]
0
0
6
0.4
Pregnancy Outcomes Locus of Control
b
<0.001
First Quartile [7-11]
0
0
0
0
Second Quartile [12-16]
2
2.4
0
0
Third Quartile [17-22]
77
91.7
110
27.7
Fourth Quartile [23-28]
5
6.0
287
72.3
b
<0.001
Rosenberg Self-Esteem Scale
First Quartile [0-7]
0
0
1
0.1
Second Quartile [8-14]
3
2.1
42
3.0
Third Quartile [15-22]
134
94.4
645
46.0
Fourth Quartile [23-30]
5
3.5
713
50.9
a
Data are derived from second survey responses of Amish women (n=202) and general Central Pennsylvanian
women (n=1,040) in 2008
b Data for self-esteem and locus of control are derived from the first survey responses of the 202 Amish and
1,040 Central Pennsylvanian women who completed the follow-up/second survey in 2008.
c
p-Value for appropriate test of statistical significance between the Amish sample and the Central Pennsylvania sample
Self-esteem, determined by the Rosenberg Self-Esteem Scale, was assessed only on the
first survey. Self-esteem scores range from 0-30, with higher score representing higher selfesteem. Scores ranged from 12-27 for Amish women and from 6-27 for women in Central
10
Pennsylvania. The mean self-esteem score was 18.48 (SD 1.84) for Amish women and 22.28
(SD 3.75) for women in Central Pennsylvania. Self-esteem scores were significantly different
between Amish women and women in Central Pennsylvania (χ2=12.23, P<0.001) (Table 2).
Amish women who completed the second phase of the survey were also questioned on
their feelings surrounding depression. Amish women most commonly responded that when an
individual says she is “depressed” she is indicating that she feels sad, blue, down, not happy,
downhearted, and or has negative thoughts. The plurality of respondents (n=55, 44.7%) in the
second phase indicated that feeling depressed was common among the Amish. The most
common events, experiences, or situations indentified as causing feelings of depression among
the Amish were 1) new babies, childbirth, postpartum, hormonal change (n=21) 2) workload,
tired, worn out, under pressure (n=19) and 3) family or friend illness/death (n=13).
Bivariate Analyses of Psychosocial Determinants
Stress was not significantly related to lifetime poor pregnancy scores for Amish women
(environmental/behavioral χ2=6.418, P=0.179; genetic χ2=4.596, P=0.331) or for women in
Central Pennsylvanian (environmental/behavioral χ2=0.924, P=0.630; genetic χ2=5.544,
P=0.063). However, for women in Central Pennsylvania, stress and environmental/behavioral
pregnancy outcomes present an intriguing trend worthy of future study. Social support scores
were not significantly related to Amish poor pregnancy scores (environmental/behavioral
χ2=3.109, P=0.540; genetic χ2=3.761, P=0.439) or to Central Pennsylvania poor pregnancy
scores (environmental/behavioral χ2=1.892, P=0.388; genetic χ2=3.552, P=0.169). The
relationship between CES-D scale scores on the second survey and lifetime poor pregnancy
scores was not statistically significant for Amish women (environmental/behavioral χ2=0.421,
P=0.810; genetic χ2=1.772, P=0.412) nor was it significant among Central Pennsylvanian
11
Table 3. Bivariate analyses of psychosocial determinants and pregnancy outcomes among Amish
women in Lancaster County, Pennsylvania and women in the general Central Pennsylvania
populationa
Pregnancy Outcomes Variable
Amish Sample (n=202)
Psychosocial Variable
Genetic
General Population (n=1,040)
Environmental/
Genetic
Environmental/
Behavioral
2
χ
2
P
χ
P
Behavioral
2
P
χ
χ2
P
Prenatal Psychosocial Hassles Scale
4.596
0.331
6.418
0.179
5.544
0.063
0.924
0.630
3.761
0.439
3.109
0.540
3.552
0.169
1.892
0.388
1.772
0.412
0.421
0.810
6.609
0.158
2.898
0.575
0.907
0.635
5.182
0.075
1.313
0.519
1.204
0.548
MOS Social Support
CES-Depression Scale
Pregnancy Outcomes Locus of Control
b
b
Rosenberg Self-Esteem Scale
Significant*
14.690
Significant*
0.001
8.581
0.014
Significant*
3.805
0.149
7.839
0.020
a
Data are derived from second survey responses of Amish women (n=202) and general Central Pennsylvanian
women (n=1,040) in 2008 who have experienced at least one pregnancy in their lifetime
b Data for self-esteem and locus of control are derived from the first survey responses of the 202 Amish and
1,040 Central Pennsylvanian women who completed the follow-up/second survey in 2008.
* Indicates statistical significance at P≤0.05
women (environmental/behavioral χ2=2.898, P=0.57; genetic χ2=6.609, P=0.158). For Amish
women, maternal locus of control score was not significantly related to either poor pregnancy
score (environmental/behavioral χ2=5.182, P=0.075; genetic χ2=0.907, P=0.635). Despite this,
the relationship between maternal locus of control and environmental/behavioral pregnancy
outcomes presents yet another trend worthy of further study. Maternal locus of control within
Central Pennsylvania was not significantly related to either poor pregnancy measure
(environmental/behavioral χ2=1.204, P=0.548; genetic χ2=1.313, P=0.519) (Table 3).
Self-esteem score was significantly related to both poor pregnancy measures among the
Amish (environmental/behavioral χ2=8.581, P=0.014; genetic χ2=14.69, P=0.001). Amish
women with higher self-esteem were more likely to experience no poor pregnancy outcomes
12
than those with lower self-esteem (Table 4). In the analyses, for Amish women who had a poor
pregnancy score greater than zero, three out of the four residuals were positive among women
with low self-esteem for genetic poor pregnancy scores and four out of five of the residuals were
positive among women with lower self-esteem for environmental/ behavioral poor pregnancy
scores. Within the Central Pennsylvania population, self-esteem was significantly related to the
environmental/behavioral poor pregnancy variable (χ2=7.839, P=0.020) but not the genetic poor
pregnancy variable (χ2=3.805, P=0.149) (Table 3).
Table 4. Relationship between self-esteem and poor pregnancy outcomes among Amish women
in Lancaster County, Pennsylvaniaa
Number of Poor Pregnancy Outcomes Experienced
Pregnancy Outcome Category
None
One
Two or More
% (n)
% (n)
% (n)
Genetic
Lower Self-Esteem
34.0% (18)
45.3% (24)
20.8% (11)
Higher Self-Esteem
64.3% (45)
15.7% (11)
20.0% (14)
Lower Self-Esteem
73.6% (39)
5.7% (3)
20.8% (11)
Higher Self-Esteem
92.9% (65)
1.4% (1)
5.7% (4)
Environmental/Behavioral
a
Data are derived from second survey responses of Amish women (n=202) in 2008 who have experienced at least one pregnancy
in their lifetime
Religion and Health
The majority of Amish women (60.9%, n=109) attend religious services twice per month
while 39.1 percent (n=70) attend three to five times per month. Among women in Central
Pennsylvania, 35.6 percent (n=410) indicated that they never attend religious services while 41.8
percent (n=482) replied that they attend four or more times per month. For women in Central
Pennsylvania, religious service attendance is significantly related to higher self-esteem
(χ2=18.16, P=0.001) and social support scores (χ2=16.29, P=0.012) and lower scores for
depression (χ2=15.48, P=0.017). Religious service attendance among women in Central
13
Pennsylvania was not related to any pregnancy outcomes. Religious service attendance among
Amish women was significantly related to genetic poor pregnancy scores (χ2=8.585; P=0.014).
DISCUSSION
I believe this analysis is among the first longitudinal studies of systematic, populationbased survey data in Amish culture (Miller et al. 2007). My results allow for comparison with
previous findings from the CePAWHS and with other American women. Further, it is my hope
that research within the Amish population can serve to diminish the weight of stereotype in
understanding Amish culture (Kraybill 2001). This representative longitudinal sample allows for
evaluation of beliefs, behaviors, and outcomes over time for 202 Amish women in Lancaster
County, Pennsylvania. Examining behaviors and pregnancy outcomes within the Amish
population allows us to better understand the social, behavioral, and biological determinants at
work during pregnancy by removing factors such as alcohol and drug use and certain
technologies from the observed environment.
Given the low incidence of low-birth weight and preterm births between the first and
second surveys, I suspected that woman who had more poor outcomes opted out of the second
survey. However, women who completed both surveys did not differ in any detectable way from
those who participated only in the first survey and both groups had similar poor pregnancy
scores at the time of the first survey. It is more likely that Amish women actually are
experiencing much lower rates of preterm birth and low-birth weight in recent years. I am
working to further illuminate the change in Amish pregnancy outcomes over time to assist in
identifying the cause of reduced low-birth weight and preterm birth. It is also possible that these
202 Amish women experienced fewer cases of preterm birth and low-birth weight because the
first survey educated them to further consider the relationship between their behavior and their
14
outcomes such that they may have modified their behavior, reducing the incidence of poor
pregnancy outcomes.
It is possible that Amish women experience fewer poor pregnancy outcomes when
compared with the general population as they are more prepared for pregnancy and have the
social support within their community necessary for positive outcomes (Miller et al. 2007).
While increased use of assisted reproductive technologies has contributed to the recent overall
rise of preterm births, these technologies are not used in the Amish population and may explain
part of the reason for the lower rate of low-birth weight in the population. Technology, in
general, is only accepted among the Amish in select cases that assist in “making a living”
(Goldenberg et al. 2008; Kraybill 2001).
The Amish women who participated in the second survey did not present many cases of
depression and the vast majority of women surveyed indicated that they never had depressive
feelings. Stress levels also remained relatively low for the Amish and Amish women
overwhelmingly expressed strong social support from their family and community. Social ties to
the community are known to play a beneficial role in the maintenance of psychological wellbeing (Kawachi and Berkman 2001). It is important to note, however, that involvement in close
social structures does not always lead to improved mental health outcomes. The lower levels of
stress and depression found in both the first and second survey may be causative agents of the
lower rates of poor outcomes or may be due to a lack of education and diagnosis. While an
established relationship exists between stress, depression, social support, and health, none of
these psychosocial factors were related to poor pregnancy outcomes in our analyses. In contrast
to the Amish, Central Pennsylvania women indicated higher levels of stress and depression and
lower levels of social support.
15
Central Pennsylvania women scored higher than Amish women on measures of locus of
control and self-esteem. Higher levels of maternal health locus of control in the general
population have been shown to be positively associated with infants receiving timely and
appropriate well-baby examinations and immunizations. As a mother’s perceived control over
her infant’s health increases so does the frequency and timeliness of preventative health care
access, which is related, in turn, to infant health status (Tinsley and Holtgrave 1989). Extending
this knowledge to the pregnancy timeframe, women with a higher locus of control would be
more likely to access prenatal care. Until recently, early access to prenatal care has been viewed
as a means to reduce prematurity. However, recent research indicates that this association is most
likely derived from the high rate of preterm birth among women without prenatal care than from
the content of care administered (Iams et al. 2008). It is possible that the community support
present in the Amish population serves as a substitute for the support of medical professionals
received through prenatal care by women in the general population. Further, the reduced sense of
control among the Amish may be due to a lack of understanding or, perhaps, due to Amish
reliance upon religious faith, rather than on the self, to deliver a healthy infant.
In addition to social support, internal resources, such as self-esteem, are also known to
buffer the negative effects of stress on mental health (Bovier et al. 2004). Social support and
locus of control are two psychosocial factors that play a significant role in modifying stress and
health levels and may mediate the relationship between the two (Israel & Schurman 1990).
While social support may also directly improve mental health by elevating self-esteem, the
collectivist nature of Amish society may discourage Amish individuals from exhibiting high
levels of self-esteem (Diener & Diener 1995). Research has shown that relationship between
self-esteem and life satisfaction is lower in collectivistic societies, such as the Amish, when
16
compared with individualistic societies, such as the general population examined in Central
Pennsylvania (Diener & Diener 1995).
While social support and self-esteem may buffer the effects of depression and stress
among the Amish, religion may also serve to further insulate their mental health and improve
physical health. Unlike religious individuals in the general population who attend services once a
week, the Amish attend what is known as their preaching service every other Sunday (Hostetler
1993). All Amish women indicated regular attendance at religious services compared with over
a third of women in Central Pennsylvania who do not attend regularly. Regular attendance at
religious services results in higher reported mental health component scores than those attending
less than once per week (King et al. 2005). While stress, depression, and self-esteem were
significantly related to religious service attendance among women in Central Pennsylvania, none
of the psychosocial determinants were significantly related to religious attendance among the
Amish—perhaps due to a lack of variance in attendance among the Amish. Religion is at the
foundation of Amish society and, while not shown in the data, it remains likely that religious
faith provides a resource for coping with stress, depression, and other illness. This relationship
may be observed when considered outside of church attendance alone.
Regular attendance at religious services has also been shown to reduce health decline and
improve physical health such as through lowering blood pressure particularly when paired with
regular prayer (King et al. 2005; Koenig et al. 1988; Scotch 1963; Walsh 1980; Benson et al.
1977; Timio 1985). Religious involvement also provides another source of social support, which
benefits women above men and may be mediated by neuroendocrine mechanisms (King et al.
2005). Religious service attendance was related to a reduction in genetic poor pregnancy
outcomes among the Amish but not among women in Central Pennsylvania. Given that all
17
Amish women surveyed indicate regular religious service attendance, it is possible that the
relationship between religious service attendance, mental health, and physical health may help
explain the improved pregnancy outcomes.
While religion can improve mental health, it may also be the cause of lower self-esteem
scores among the Amish. Within the Amish faith, pride—a component of self-esteem—is viewed
as sin and is, therefore, discouraged. However, 78.9 percent of Amish women in the survey
rejected the statement “I feel that I do NOT have much to be proud of.” The statement that
elicited the highest response indicating low self-esteem levels was “I wish I could have more
respect for myself” with 57.8 percent of the Amish women agreeing or strongly agreeing. Selfesteem was the only psychosocial characteristic significantly related to pregnancy outcome
among Amish women. In order to further examine the observed relationship between selfesteem and both poor pregnancy variables among the Amish and to validate the Rosenberg SelfEsteem Scale within the population, the authors are currently conducting interviews with Amish
women. These interviews are being conducted through use of the Rosenberg Self-Esteem Scale
and a “talk aloud” process in conjunction with specific questions on self-esteem, pride, and
respect in the community.
My research seeks to explore the factors that contribute to better mental health status and
pregnancy outcomes despite a relative lack of preventative care among Amish women. The
pervasiveness of religion in the community, a common set of values, and a social structure
unique to the Amish population may be the basis of their mental health. The community support
derived from these characteristics may cause better mental health by increasing social support
and self-esteem and limiting depressive symptoms. These positive mental health indicators may
improve physical health. Further research into the experience and conception of self-esteem in
18
the Amish community will allow for a better understanding of the interaction between mental
health and physical health in pregnancy. Additional research is required to understand the low
incidence of poor pregnancy outcomes in the Amish when compared with women in Central
Pennsylvania.
FUNDING
This work was supported by the Pennsylvania Department of Health [grant number
4100020719]. The Department specifically disclaims responsibility for any analyses,
interpretations, or conclusions.
ACKNOWLEDGEMENTS
Thank you to Berwood Yost, Kirk Miller, Alison Kibler, and Sean Flaherty for their course,
“Public Health Research: Pregnancy Outcomes in American Women” that first introduced me to
data analysis and this specific data set and inspired me to pursue a future in reproductive
epidemiology. Thank you to Misty Bastian, Alison Kibler, and Berwood Yost for their
involvement in my Honors Defense Committee. Thank you to Donald Kraybill for his insight
and encouragement to pursue further assessment of self-esteem among the Amish population.
Thank you also to Kirk Miller for his advising, instruction, and encouragement throughout my
research process.
19
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