Many Old Order Amish families deliver at home or at a birth center with a midwife, only coming in contact with the traditional health care system when complications arise. To provide culturally competent care, the nurse caring for the Old Order Amish family needs to be aware of family communication, education, childbearing practices, and community expectations (Weyer, et al, 2003)

A 22 y/o G₂ P₁ presented with preterm labor at 24² weeks gestation. Upon arrival, exam revealed hourglassing membranes and transfer ensued to a tertiary center for delivery of an extremely premature infant.

Examination there confirmed cervical dilatation of 9 cm with frank breech presentation. The obstetric resident recommended cesarean delivery. At this gestational age, this would mean a "classical" or vertical uterine incision, with considerable ramifications for a young Amish woman who would probably bear 4-8 more children.

The attending obstetrician initiated a frank discussion with family, including cesarean vs. vaginal delivery for breech presentation, infant survival & outcomes at this gestation, and implications for future childbearing. The parents and family were provided with time to make a decision.

The family chose vaginal delivery with full resuscitation. An epidural was offered and accepted. Delivery itself was uneventful, with a birth weight of 520 grams and Apgar scores of 1 and 7.

The infant was transferred to the NICU intubated. Despite aggressive care for 14 hours, a chest X-ray demonstrated a right pneumothorax. After 2 chest tubes had been placed without subsequent improvement in oxygenation, the family opted to withdraw support.

The nurse caring for the family acknowledged the cultural/religious difference and reviewed standard memory items offered. Even though photography is forbidden for the Old Order Amish, we still offered the option of memorial pictures, and the father chose to have pictures taken. A nurse living in Pennsylvania also provided a ride home for the grandparents.

Cultural competence, defined as "the ability to understand and work effectively with patients whose beliefs, values, and histories differ from one’s own" (Capell, Dean, & Veenstra, 2008), is an essential part of caring for all families, especially in crisis situations centered on life events. Lack of cultural competence by health care workers can adversely affect patient outcomes (Capell et al, 2008). Since health disparities are accentuated by a lack of cultural competence (Broome & McGuinness, 2007), access to cultural education is key for staff to be able to provide competent care.

We encourage staff to review standard procedures with families, and then ask how we can best assist them according to their beliefs in order to promote positive outcomes (Broome & McGuiness, 2007)), even in the difficult situation of perinatal loss.

In order to promote access to necessary information about the variety of cultures, our goal is to develop a table, describing the belief systems of frequently encountered faiths and cultures, which will assist with understanding, rather than assuming, cultural preferences "allows for the customization of care to meet specific individual, family, and community needs in culturally appropriate ways" (Schim et al., 2007).