Nemaha Valley Community Hospital Addresses Health Equity in Local Amish Community

In April 2017, church elders from the nearby Amish community met with two physicians and a social worker from Nemaha Valley Community Hospital (NVCH) to discuss concerns about recent poor birth outcomes in both mothers and babies in the local Amish community.  A meeting between physicians and church elders to solve health care issues is not the norm in healthcare, but in this case, was the most logical and culturally appropriate means to address an issue, which was vital to both the Amish community and the hospital.

NVCH is a 24 bed Critical Access Hospital located in Seneca, KS, which is situated in northeast Kansas, 12 miles south of the Nebraska state line.  The hospital employs 160 staff members and provides clinic services in its Rural Health Clinic. The physicians and staff at NVCH became increasingly concerned about the birth and postpartum outcomes in the Amish community. The birthing preferences of mothers in the community at that time were varied but most were not receiving maternity care from licensed healthcare professionals, and most were delivering at home.  Recently, families presented to the Emergency Department in distress during delivery or after delivery in situations which may have been prevented had the patients received maternity care in a traditional hospital setting.  These poor outcomes were not only tragic for the families, but also for the hospital staff.

The Amish community in the area is located approximately 30 miles from Seneca.  Healthcare for the local Amish, traditionally has been limited due to lack of insurance and transportation barriers. Most Amish are uninsured, choosing to pay cash for services.  They often are conservative health care consumers, forgoing wellness care and limiting services based on need and cost of services.  Though the Amish travel locally by horse and buggy or by tractor, they must hire drivers for the longer trips to communities for health care services, thus adding to the expense of seeking care.

Together, the church elders and the hospital created a plan for safer births for mothers and babies while respecting the customs and beliefs of the community.  Communication was key throughout the process.  The church elders were open to discussing the issues and open to considering that there may be a better way to provide maternity care.  The group discussed the issues at hand and discussed alternatives in care for the Amish community that could be provided at NVCH while addressing cultural and religious beliefs and preferences as well as financial issues and transportation barriers.  The church shared information with the community members about the plans for safer births and the community moved forward with a relationship with NVCH for their health care needs.

Health literacy in this population was relatively low initially, because of difference in educational systems as well as lack of exposure to modern healthcare delivery systems and technology.  It took time to build trust between patients and staff and to build personal relationships with the Amish community.  Staff understood the importance of explaining diagnostic testing and treatment plan options to the families so they could make informed decisions as patients and as consumers of health care. 

Hospital staff learned that this population is very stoic.  They learned that they cannot perceive what the patient needs or what the patient is communicating through facial expressions in the same way that they might with some patients.  Instead, they encouraged the patients to communicate their needs and wants verbally so all parties were communicating effectively.  They learned about their culture and customs and that though they are perhaps more reserved than most patients they care for, they each have their own family dynamics and individual personalities, just like all humans.

Babies Best Start is a program that Nemaha Valley Community Hospital began in 2011 to help provide qualifying newborns with basic infant supplies. NCVH, recognized the cost of raising a child is great, and their goal is to alleviate some of the cost, so families can focus on caring for their infant without the worry of the extra financial burden. The Babies Best Start program has been well received by Amish families.  Families are given necessary supplies to help meet their needs such as diapers, wipes, car seats and health supplies such as thermometers.  This program operates solely on donations from the local community. 

Dana Deters OB Supervisor, RN, IBCLC, Babies Best Start Program Coordinator says, “We know families are using the car seats because when they return with the next pregnancy, they return with the car seat we provided through Babies Best Start.”  Though the primary means of transportation for many families are tractors or buggies which likely aren’t equipped with safety belts, when the families travel to appointments in hired cars, they are diligently using the infant car seats and that confirms to Dana that their work is making a difference in child safety.

Amish families have found safe, dignified, reliable maternity care at NVCH and have returned for multiple pregnancies since.  Those early relationships have expanded to treating chronic illnesses in the community well beyond those early discussions with the church elders.

The US-Canadian Amish population is growing and expected to reach 500,000 people by 2030.  As this population grows, more rural communities may have the opportunity to bridge the gaps in care for the Amish community and learning about the culture and beliefs of the community they serve is the first step in meeting those health care needs.

Tips for Successfully Providing Culturally Sensitive Health Services to Amish Patients

• Work with local bishops and opinion leaders who can legitimize a program and provide feedback about its appropriateness. Involve Amish in program promotion and administration, such as through an advisory board. ¹
• Beliefs and customs may vary greatly between Amish communities and churches.
• A polite handshake is acceptable but not further affectionate touch. ¹
• Maintain an appropriate physical distance—usually no closer than hand-shaking distance—especially across gender lines. ¹
• Amish are usually good listeners who have a slower conversational pace. Watch for non-verbal cues passed among themselves, especially during important conversations. ¹
• Limited formal education may impact communication and health literacy. Assess health literacy, ensure communication is understood, and elicit information using direct, close-ended questions and simple explanations. ¹
• Though usually appreciative of services, Amish may appear socially distant, possibly as a precaution to protect private matters until trust is established; silence is not consent. ¹
• Amish usually internalize pain rather than make a show or complain; consequently, practitioners should ask directly about pain levels. ¹
• Hospital discharges should be made with enough forewarning that the Amish have time to arrange to be picked up. ¹
• Training materials should be written with cultural sensitivity and have culturally specific illustrations. Nudity, even anatomically correct illustrations, may be considered offensive. Use caution. ¹
• Amish have household technology limits, though they vary widely. For communication, many rely either on written letters or phone service outside the home, such as at a neighbor’s or in an outdoor shelter. Patients should be asked whether communications, such as voicemail, are private. ¹
• Amish transportation is limited to hired drivers or slow-moving vehicle, so accessing services may be timely and costly. Avoid last minute cancellations or appointment rescheduling. ¹
• Be sensitive to travel patterns during certain times and seasons, and consider providing a hitching post or bike rack. ¹
• Amish also have limited sources of electricity, if any, in the home. When discharging Amish patients, inquire about the ability to use electronic devices at home and the heating/cooling facilities available. ¹

References:

1. The Amish Health Culture and Culturally Sensitive Health Services: An Exhaustive Narrative Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8431948/