January 5, 2007 06:36 PM
(in response to Archived User)
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
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
- The rate of excess interventions is considered as residing in the
category of inconvenience unless there is a fatality to be
- 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
- 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
CSI = ?? (Cij*Ri*Dij)
i = Intervention or event
j = Defects (e.g. intrapartum fatality, miscarriage due to C/S,
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
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