Dear Ms. Goer,

As I have already written, the true spirit of science is the willingness to present, and the ability to defend, your positions publicly. So I am offering a public challenge to debate and defend your positions and the scientific papers you depend on for those positions. You may not wish to hold it within the context of a support forum on the Lamaze site. In that case, we can hold it here, or you can create a new forum on the Lamaze site, or your personal site, or we can hold it jointly on two sites so there is no chance of one person changing the other person's comments.

You write for lay people who cannot really evaluate the scientific validity of your arguments. If your claims are really true, it should not be difficult to defend them in a debate with me. Indeed, it could only increase respect for your point of view, if you could defend your positions.

I look forward to your response.

Sincerely,
Amy Tuteur, MD By: ATuteur

Well, at least we agree on something: The true spirit of science does, indeed, include willingness to defend one's position publicly, as I have been doing here and have said I am willing to continue doing. To repeat what I have written before, you are welcome to post a criticism to any analysis of mine. I will respond. That will make our positions both clear and public. Readers will then have everything they need to decide which one of us suffers from a case of "my mind is made up; don't confuse me with the facts." But I won't be baited. Your posts on this Forum--including this one--and the Lamaze blog make it abundantly clear that you want a fair, fact-based debate on birth issues about as much as Bill O'Reilly wants one on political issues. I won't play that game. You have your own blog for your rants. You will get no platform for them here or from me.

-- Henci By: Henci Goer

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

As it turns out, what you have proposed is an example of "great minds thinking alike." The American College of Nurse-Midwives has developed the Optimality Tool, a method for measuring the quality of maternity care systems. An optimal birth is one in which the best outcomes have been achieved with the least use of medical intervention. It has a yes/no scoring system for labor events and outcomes that incorporates obstetric history and current health so that apples can be compared with apples. All items are based in the research evidence. For more information, go to Optimality Index. My boss at Lamaze, a nurse midwife herself, envisions a day when women will compare their Optimality scores the way they sometimes compare Apgar scores today.

-- Henci By: Henci Goer

I am offended by your comment that we as lay people can not "evaluate the scientific validity" of what Henci may have to say. I am a lay person and am quite capable of reading scietific journals or medical research. If I come across something I don't understand I get out the dictionary or do a online search. Maybe it is the hope of OBs that we can't understand and that we don't seek out our own information. What you have said in your post is why there is such a backlash. The total arrogance is unbelievable. In all the postings I've read Henci always gives references and links to helpful information. It's not as if she is telling us "lay people", who can not think for ourselves, that what she says is absolute truth, and just blindly follow it. Can that be said for OBs?
Heather By: Heather

So not only do our bodies not work properly, our minds don't either...
I had the same thoughts, Heather. Thank you for standing up. I feel quite capable of reading the research myself too, and I applaud Henci for pointing people who are looking for information in the right direction, enabling them to be autonomous.
maria. By: maria

If I may correct some of the information in your post, it is true that countries with the lowest mortality rates have midwives in charge of most births, but only one developed country: the Netherlands, has a substantial proportion of women birthing at home. And just to clarify, it is also true, but often not understood by people unfamiliar with international maternity care systems, that in many countries, midwives function as labor and delivery nurses do here, and in other countries, midwives catch babies, but obstetricians set policies. Under these circumstances, women may be treated just as abysmally as they may be treated here.

-- Henci

Dear Ms. Tuteur,

I am offended by your notion that lay people are incapable of understanding the results of scientific studies.  For the sake of fellow "lay people", I sincerely hope you are not still practicing medicine.  You seem to have an over-active ego which goes untempered by even a minimal degree of humility or respect for those you are supposedly serving.