| Reply To Message: |
| Posted By |
AUSER on 1/5/2007 4:36:18 PM |
| Subject: |
A public challenge to Henci Goer |
| Message: |
Hi Henci,
Great job managing Amy’s assault. I think your remarks show a much higher degree of professionalism than Amy displays. Well done! I would be worried about her being my ambassador if I were an obstetrician.
I was hoping to pulse your thoughts on a topic that Amy would not engage after I suggested it to her on a number of occasions. As I have observed and participated in the debate of the safety of homebirth, I have seen several fundamentals:
- The Industrial Medical Complex’s (Amy’s) point of view is that there will be an excess of intrapartum fatalities with homebirth. In fact, it is Amy’s mission in life to try and illustrate that the hospital (intrapartum+neonatal) mortality rate is lower than Johnson and Daviss established in their fine study of home birth.
- The rate of excess interventions is considered as residing in the category of inconvenience unless there is a fatality to be counted.
- Our side tends to argue that the (excess) interventions in hospitals degrade safety when safety is viewed beyond counting dead babies and dead moms.
So, the engineer in me says we need a common currency to roll up all of the (technical) issues related to the safety of the birth setting (or the birth model). It seems to me we need a Composite Safety Index (CSI). This is a thing I have not seen. I have not thought this through entirely, but I think this metric might have the following attributes:
- There is a single numerical value representing the safety of the setting.
- Every defect associated with an intervention is identified.
- The rate of interventions is reasonably established.
- There is a reasonable transfer function that relates the defects associated with hospital birth to an intrapartum fatality. In other words, a single maternal mortality per 1000 births might have a score of 2 while a neonatal fatality might have a score of 1 (lower is better). Now…an inadvertent hysterectomy due to a C/S may score equal to an intrapartum fatality (i.e. a lost opportunity dead baby). Similarly, excess miscarriages due to excess C/S count equally as an intrapartum fatality. A long term, but not fatal injury (e.g. skeletal damage associated with forceps), would carry a lower score (perhaps 0.5 or 0.1). Moderate issues (i.e. pneumonia acquired in the hospital that is adequately addressed) carry a low score (perhaps 0.01 to 0.1).
- Inconvenience carries no penalty.
- So, this safety index could be a summation of the following form:
CSI = ?? (Cij*Ri*Dij)
Where,
i = Intervention or event
j = Defects (e.g. intrapartum fatality, miscarriage due to C/S, etc…)
Cij = Defect Score (e.g. 2 for maternal mortality, 1 for intrapartum mortality, etc…)
Ri = Intervention Rate (e.g. 5% C/S rate for home birth and 30% for hospital)
Dij = Probability of a Defect per intervention
For every intervention (i) there could be a number of defects (j). While I’m sure that the Defect Score would be meat for lots of argument and it would be a lot of work to survey the studies to estimate the probability of a defect, it seems to me this could be helpful in setting policy (which is why I have been arguing with Amy for some months – my wife is a CPM and we live in one of the few states left that does not license non-nurse midwives).
Has such a thing been attempted?
Please keep up the effort. Amy will likely continue to growl at you. If she continues to make her case on your forum, I am very confident that our point of view will be shown in a favorable way.
Best Regards,
Russ
By: Midhusband |
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