The price of being the best.....is having to BE the best - Or: On how to make Homebirth even... - Page 2

[Kanna]

Originally Posted by Storm Bride 

FWIW, I've been through exactly that, and I disagree with you on most of your points.

You said "most" of my points. Which are the ones you agree with?

I also have to point out that your assertion here:

"Anecdotal data welcome, but mark it as such. It's useful to illustrate a point, but not enough to prove one."

contains a fairly major flaw. It carries the implication that the data does prove these points. It doesn't. There is nowhere near enough data, nor complete enough data (and I doubt there ever will be, for a lot of reasons) to prove one side or the other of the "homebirth is safer" vs. "hospital birth is safer" debate. The issues are far, far too complex. For example, my case , where my baby died during an attempted homebirth, but after transfer, and there were multiple factors going back to my first "birth" 14 years prior, and even to my own "birth" 39 years prior, that affected the outcome. There is no data set in the world that would show everything that went into that, and since every birth is different, the data isn't going to prove a point about which is safer for any individual woman/baby dyad.

Actually Evidence based medicine (or in this case midwifery) is a matter of statistics and probability. If one thing is mostly dangerous or safe to a few hundred moms, it is probable that it will be mostly safe or dangerous for others too.

"Proving" in this case means "having the greatest likelihood and is therefore recommendable". An anecdote is looking at just one case. Statistics look at a few hundred or a few thousand cases, so a statistic has a better chance of being "right"

[Kanna]

Thoughts on quality management:

Before you try to start improving something, it might be a good idea to find out what the problem is.

Question to the midwives out there:

Why and how do you think negligence happens?

Is it (as we've been assuming...which is not really a good thing to do) really a matter of education and accountability?

Are there maybe psychological factors at play?

What do you think?

[Storm Bride]

Maybe I'll try to elaborate on where we agree/disagree tomorrow, but probably not (I have a lot going on this week, as well as my period - hit me early this month, which explains why I've been in such a cranky mood the last couple days - and a bug of some kind), as it will involve a lot of time consuming jumping back and forth between this and the other thread. I'll see if I can get back to it in a few days, if the thread is still active.

Proving doesn't mean that, though. And, I don't want care based on statistics and probability, when it completely overlooks my specific case. That's one of the things I hate most about obstetric  and hospital care. (One good example is the endless stuff about overweight and obese mothers, such as me, being "high risk". When pinned down about what makes us "high risk", there's ineveitably a bunch of stuff about blood pressure, GD, etc....but if said overweight/obese moms show no symptoms of any of those things, the weight alone is enough for the "high risk" label. Statistically, there's an increased probability that overweight/obese moms-to-be will have high blood pressure, develop GD, etc. But, that doesn't "prove" that any specific overweight/obese woman is "high risk". I don't want "evidence" based care that's about stuffing me in a pigeonhole, and giving me "care" that applies to many/most of the other women in that pigeonhole, but doesn't apply to me.)

[Kanna]

Originally Posted by Storm Bride 

Maybe I'll try to elaborate on where we agree/disagree tomorrow, but probably not (I have a lot going on this week, as well as my period - hit me early this month, which explains why I've been in such a cranky mood the last couple days - and a bug of some kind), as it will involve a lot of time consuming jumping back and forth between this and the other thread. I'll see if I can get back to it in a few days, if the thread is still active.

Proving doesn't mean that, though. And, I don't want care based on statistics and probability, when it completely overlooks my specific case. That's one of the things I hate most about obstetric  and hospital care. (One good example is the endless stuff about overweight and obese mothers, such as me, being "high risk". When pinned down about what makes us "high risk", there's ineveitably a bunch of stuff about blood pressure, GD, etc....but if said overweight/obese moms show no symptoms of any of those things, the weight alone is enough for the "high risk" label. Statistically, there's an increased probability that overweight/obese moms-to-be will have high blood pressure, develop GD, etc. But, that doesn't "prove" that any specific overweight/obese woman is "high risk". I don't want "evidence" based care that's about stuffing me in a pigeonhole, and giving me "care" that applies to many/most of the other women in that pigeonhole, but doesn't apply to me.)

I can see where you're coming from an I think it's great you posted about this, because I feel you brought up an important point about which a lot of other moms are concerned too.

You're right about studies and statistics not being the end-all and be-all of things.

To give an anecdotal example:

MOST babies delivered with a birthweight over 4.5 kg would probably weigh that much because mom had gestational diabetes that was badly controlled. My daughter weighed a whopping 4.8 kg when I gave birth and it WASN'T gestational diabetes (she was also 60 cm's long and thus quite slim). In both sides of her family, people are TALL, with no one being below 1,80 m. So she was simply big because she comes from a family of tall people.

Still, the docs were especially careful to check on her, so they wouldn't miss problems if there were any, because MOST kids that heavy would have been born to moms with GD, which would have had health implications for her and me. They had to rule out that besides a genetic/familial component if there had also been a component of GD, which totally could have been the case. Once they did that, they sent us both home with a clean bill of health.

To sum it up: I think that studies and statistics make a good foundation for care, because they will be true in MOST cases. You also need to check if the case you're looking at fits the criteria for "most" cases. If it doesn't, then you can/must adapt your standard of care to fit the specific / special needs of the patient.

Ot, to quote a saying from the business world: "Think global and local, act accordingly"

[Kanna]

Originally Posted by Turquesa 

Kanna, one quick point before I proceed with my busy day: The EFM study that you referenced makes no mention of a comparison group to auscultation (bolding my own). 

I will try to read it more thoroughly during my baby's nap this afternoon (I just briefly perused the section on methodology), but if it's the study I'm thinking of, it was industry-funded and compares EFM to no EFM at all.  In the context of our debate, we'd need to see how it compares to auscultation. I'll post more later on the research supporting auscultation.

Hi Turquesa,

the thing is over 10 years old, and I didn't have time to give it an in-depth reading, but I stumbled across this article and this one sentence kinds struck out: The American College of Obstetricians and Gynecologists (ACOG) states that with specific intervals, intermittent auscultation of the FHR is equivalent to continuous EFM in detecting fetal compromise.

Maybe if you're interested, you can have a further in-depth look at it at your leisure  ^_^

http://www.aafp.org/afp/990501ap/2487.html

[Storm Bride]

Originally Posted by Kanna 


You're right about studies and statistics not being the end-all and be-all of things.

To give an anecdotal example:

MOST babies delivered with a birthweight over 4.5 kg would probably weigh that much because mom had gestational diabetes that was badly controlled. My daughter weighed a whopping 4.8 kg when I gave birth and it WASN'T gestational diabetes (she was also 60 cm's long and thus quite slim). In both sides of her family, people are TALL, with no one being below 1,80 m. So she was simply big because she comes from a family of tall people.

Still, the docs were especially careful to check on her, so they wouldn't miss problems if there were any, because MOST kids that heavy would have been born to moms with GD, which would have had health implications for her and me. They had to rule out that besides a genetic/familial component if there had also been a component of GD, which totally could have been the case. Once they did that, they sent us both home with a clean bill of health.

To sum it up: I think that studies and statistics make a good foundation for care, because they will be true in MOST cases. You also need to check if the case you're looking at fits the criteria for "most" cases. If it doesn't, then you can/must adapt your standard of care to fit the specific / special needs of the patient.

I haven't found that there's much adapting done. Of couse, that's just my experience (and that of my friends and family). But, whether this is a foundation for good care depends on whether the "checking" is benign or not. GD is a particular "thing" of mine. I've never had it. My children's sugars have all been fine (determined by sticking them - why bother putting me through that disgusting GTT, if they're not going to trust the results, anyway?), despite having a fat mom, and being over 10 lbs. - well dd2 was 9lb. 15oz. DH and his brothers, born to my very short and slight MIL, were all between 9.5 lbs. and 10 lbs. They didn't test for GD back then (they didn't do that one when I had my first, either - he was much smaller...but he also had a different dad), but there was no evidence of any issue, except that they were big. It runs in dh's family.

I also think that, when a "patient" explains what's going on, and a particular standard clearly doesn't apply to said "patient", then applying said standard is a pretty good indicator that the standard is more important than the patient. (As an example of the kind of thing I'm talking about - dh's family all being big babies, combined with my "passing" the GTT tends to strongly suggest that GD wasn't at play, even though I'm fat - and I told the OB dh's family history of both "post-dates" and "macrosomia". My kids still got heel sticks, and one ped insisted on supplementing with formula to stabilize ds2's sugars, even though they were within normal ranges. As far as he was concerned "big baby = GD". Period. The OB paid no attention to family history or test results, and the ped didn't even know about them. All they cared about was that the baby was 10lb. 8oz, and clearly mom had GD and baby had sugar issues, because he was 10lb. 8oz.).

Ot, to quote a saying from the business world: "Think global and local, act accordingly"

I have no idea if the doctors I've encountered were thinking globally and locally or not. They were acting as if every "patient" fits precisely into the random pigeonhole they were assigned to. I didn't fit the pigeonholes, in multiple ways, and the repeated attempts to stuff me into one didn't protect me. They caused me tremendous emotional - and physical - trauma. Having more "standards" (ie. trying to standardize individuals, which doens't work) actually terrifies me. I want my daughters to have not only "standards", but options.

[Right of Passage]

Do you have studies proving beyond a shadow of doubt that homebirth increases fetal deaths? The Wax study is a flawed study, and here a few links saying such
http://www.medscape.com/viewarticle/739987  (you need a medscape account)
http://blogs.nature.com/news/2011/04/critiques_of_homebirth_study_a.html 
http://www.homebirth.net.au/2011/04/wax-homebirth-study.html 

http://www.midwiferytoday.com/articles/ajog_response.asp 

Some studies or articles about studies showing the safety of homebirth
http://www.medicalnewstoday.com/articles/164804.php 

http://www.washingtonmidwives.org/netherlands-study.shtml 
 

Studies are often flawed:
http://www.lamaze.org/Research/WhenResearchisFlawed/Homebirth/tabid/172/Default.aspx 

The reality is there aren't really any good studies that have been done stateside.

Birth is not inherently dangerous as you claimed in the other thread (again show me studies), if it was our species would have died out long ago. Man(not the male gender but humans) have increased risk of birth by messing with it. There was no proof necessary to move birth (dangerously) into hospitals, and now that there seems to be more women wanting to go back to traditional birthing options people are up in arms. Every women is her own, she gets to decide what "risks" she's willing to take.

Quote:

Originally Posted by Kanna 

 neonatal mortality IS higher with homebirth than with hospital birth and saving lives sounds kinda like a priorty to me.

[Right of Passage]

Originally Posted by Alenushka 

I do not understand why CPMs are allowed to take a NARM exam simply with portfolio which is not even checked by anyone. To me, a MW should have a BA to start with, then a required list of medical courses (Anatomy, Physiology, microbiology etc) and  then no less that 3 years of clinical work under constant supervision in different setting.  I think working for at least 6 month in the hospital would teach one how to recognize when things are outside "normal an low risk".  Then the exam. CEUs and  malpractice insurance.

How would being exposed to altered and interferred with birth teach midwives what normal birth looks like? If they never see it, they'll never recognize it. If you learn to always yank on a baby's head during birth you'll think not doing so was some sort of flawed birth. Seeing normal birth is what teaches normal birth. Just like a normal penis is an intact one, yet if you only see circumcised penises the intact one looks wrong and you have to fix it. Or breastfeeding is what's normal, but if you only see bottlefeeding, it's breastfeeding that's wrong. I could go on and on.

As a side note I think the NARM exam is very entry level at a minimum. I don't understand what having a bachelors proves for a midwife. And yes, a&p, microbiology, etc are things midwives should be very knowledgable about, but passing a class doesn't mean the student has retained the material. And what clinical work would a midwife need? What is clinically relative to normal physiological birth? I'm racking my brain to understand how applying casts, assisting in surgery, etc is relavent to midwifery. Malpractice does one primary thing, increase costs. What NEEDS to happen is parents need to be the primary caregivers, midwives and doctors need to follow parent's orders.

[Kanna]

Originally Posted by Right of Passage 

Do you have studies proving beyond a shadow of doubt that homebirth increases fetal deaths? The Wax study is a flawed study, and here a few links saying such
http://www.medscape.com/viewarticle/739987  (you need a medscape account)
http://blogs.nature.com/news/2011/04/critiques_of_homebirth_study_a.html 
http://www.homebirth.net.au/2011/04/wax-homebirth-study.html 

http://www.midwiferytoday.com/articles/ajog_response.asp 

Some studies or articles about studies showing the safety of homebirth
http://www.medicalnewstoday.com/articles/164804.php 

http://www.washingtonmidwives.org/netherlands-study.shtml 
 

Studies are often flawed:
http://www.lamaze.org/Research/WhenResearchisFlawed/Homebirth/tabid/172/Default.aspx 

The reality is there aren't really any good studies that have been done stateside.

Birth is not inherently dangerous as you claimed in the other thread (again show me studies), if it was our species would have died out long ago. Man(not the male gender but humans) have increased risk of birth by messing with it. There was no proof necessary to move birth (dangerously) into hospitals, and now that there seems to be more women wanting to go back to traditional birthing options people are up in arms. Every women is her own, she gets to decide what "risks" she's willing to take.

Quote:

Please take a look at the statistics from the CDC, Wisconsin, etc. that we posted in the original thread and then get back to us. (Yes I know, I still have to look at the ones paigekitten posted. I'll read up on that as soon as possible (and the links you posted), so everybody is on the same page.

[Turquesa]

Originally Posted by Kanna 

Please take a look at the statistics from the CDC, Wisconsin, etc. that we posted in the original thread and then get back to us. (Yes I know, I still have to look at the ones paigekitten posted. I'll read up on that as soon as possible (and the links you posted), so everybody is on the same page.

Kanna, we've already established that those data are insufficient.  From my post in the last thread:

Every baby must be issued a birth certificate, and providers generally fill out the necessary information.  This information is compiled as public health data by both state health departments and federal agencies such as the Centers for Disease Control.  This is the data that Wisconsin's health department compiles and relies on.

Each state gets to choose what kind of form to use.  A boilerplate form was released in 1989, which you can view here: http://upload.wikimedia.org/wikipedia/commons/c/c3/United_States_long_form_birth_certificate.gif

In 2003, the federal government issued a new form and encouraged states to adopt it.  Here is an explanation of that changeover process.

http://www.marchofdimes.com/Peristats/calculations.aspx?reg=&top=&id=6

And here is the 2003 form: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf

You will note that both the 1989 and 2003 forms have the category OTHER MIDWIFE.  There is no category for a CPM.  But here's the important part: The OTHER category on both forms has the words "please specify."    There is room, in other words, to specify CPM.  And apparently, nobody did, or we'd have some concrete data on CPM outcomes.  

ETA: I'm not sure if Wisconsin uses the 1989 or 2003 form to compile its data, but either way, we have the "Other Midwife" conundrum.

Because Wisconsin and the CDC don't have actual data for CPM-attended births, it kind of puts the whole premise of your thread into question...

[Turquesa]

Kanna, the topic of EFM is getting slightly tangential to this thread, but at least it addresses how HOSPITALS can improve maternity care.    Here goes...

The only perceivable advantage of routine, continuous EFM is prevention of neonatal seizures.  Otherwise, they are associated with inferior patient care, restricted movement, and an increase in cesarean and instrumental births...with no relevant difference in neonatal outcomes. 

http://www2.cochrane.org/reviews/en/ab006066.html

http://www.ncbi.nlm.nih.gov/pubmed/14501630

And from the American College of Obstetricians and Gynecologists: http://rumcobgyn.org/ACOGFHR.pdf

I'm unable to copy and paste, but read if you have no other time, read through the summary on page 7.  One notable quote that I can C&P:

Despite its widespread use, there is controversy about the efficacy of EFM. Moreover, there is evidence that the use of EFM increases the rate of cesarean and operative vaginal deliveries. Given that the available data do not clearly support the use of EFM over intermittent ausculation, either option is acceptable in a patient without complications.

The foremost reason for routine, continuous EFM of all laboring women is for provider convenience, provider protection (monitoring strip used in court) and hospital cost-cutting (ability to short-staff maternity floors for less personal care).

The real kicker: Physicians are not informing women of these factors; rather, they are kowtowing to hospital "protocols" and strapping women down without evidence to support it.  When women aren't given their options in a truthful and thorough manner (informed consent, after all, requires disclosing even those facts that you don't like!), the practice of medicine is nothing short of unethical.

ETA: I disagree with the ACOG opinion that either option is "acceptable."  Gee, they both work, but one of them has a high false-positive rate AND increases the chance of a cesarean delivery?  Not a tough choice.  And as the health care consumer, I---and I alone--will decide which option is acceptable for my body and my baby.

Edited by Turquesa - 8/11/11 at 1:53pm

[Right of Passage]

Wisconsin is ONE state, and with the data MidwifeErika found "othermidwife" attended births were safer than hospitals births or CNM attened births. You had no response to that post though.

And as Turquesa said, both sources have been proven insufficent in data. So I ask again, where is the information PROVING that homebirth INCEASES neonatal deaths? I haven't found the study, so by all means if you have do share. You can't make these claims without the data to back it, your orinigal post is with out data or proof.

I will go back to what I said, birth is NOT inherently dangerous, the things that have increased risks are mostly man made. They best things that have come about for improving outcomes is sanitation. BTW, I read the whole first thread but sat on my fingers.

[Turquesa]

Originally Posted by Kanna 

Thoughts on quality management:

Before you try to start improving something, it might be a good idea to find out what the problem is.

Question to the midwives out there:

Why and how do you think negligence happens?

Fair questions, but don't always be putting the burden solely on midwives.  Sorry to resort to tu quoque, but there are GRAVE problems with how physician negligence is handled in the U.S.: http://www.citizen.org/documents/1937.pdf

[Adaline'sMama]

Originally Posted by Kanna 

>Please take a look at the statistics from the CDC, Wisconsin, etc. that we posted in the original thread and then get back to us. (Yes I know, I still have to look at the ones paigekitten posted. I'll read up on that as soon as possible (and the links you posted), so everybody is on the same page.

Really? Who is this "we" "us" you refer to? Are you more than one person?

Do you realize how rude this sounds? "Please take a look at this and then get back to us." This isnt a job interview, its a message board.

[Gena 22]

Don't know the whole history of these threads, only what's here.  Guess I'm late to the conversation. 

But I think this is a very important question for homebirth advocates.  How to weed out / warn women about unskilled MWs.

This is a question that has been on my mind a lot, since my babes were born, and especially since there was a local high profile case with my MW.

Here's my anecdotal story:

I was pregnant with twins.  Don't really want to discuss the appropriateness of home birthing twins.  I did my research, had a perfect pregnancy, and was satisfied that home birth was as safe or more so than the hospital.  But finding a midwife was tricky.  CNMs won't touch a twin mom in my area.  Which is OK.  I'm against licensing because I strongly suspect it would ban MWs from taking on certain women - like me with my twins.  I want my MWs skilled and independent to make the call that's right for the woman at the time.  So I called around and was happy to find a MW who would take me on.  She had all the right answers to my questions, and I spoke to a former twin mom of hers who was positive.

As my due date got closer, MW and I disagreed on a few things.  She thought I was psychologically afraid of birth and that was preventing labor.  Totally false, and insulting.  At her encouragement I took B&B cohashes, and eventually the castor oil that prompted labor.  At 39 weeks.  Dysfunctional labor - long and lots of puking.  Again my state of mind was blamed.  Had my MW not had to leave for vacation 12 hours into my labor, i would have had to transferred.  Which wouldn't have been the end of the world, just unnecessary surgery.  Fortunately, I gave her back-up, a MW I had never met, a chance.  The back-up MW brought an IV, which MW #1 did not have and which I badly needed, since I couldn't keep anything down.  Once rested and hydrated, the back-up MW tried a few positions for pushing.  She found one that worked for me, and my girls were born within 5 / 6 hours of her arrival.  Great birth.

What's unique and humbling about my experience is that I got to see two MW's approach the same problem, and with radically different results. 

I didn't bear my first MW any ill will, and have always been careful not to say anything that would affect her reputation.  If I had been more experienced, I could have made better choices along the way - like letting labor start more naturally.  And my babies and I were never in any danger.  But I am 100% confident that my first MW did not have the skill to get my babies out at home.  If not for her well-timed vacation, I would have ended up at a hospital.

So I kept my mouth shut, and in the past year my first MW has had 2 babies die, one of them a twin.  Now, I can't know what happened at these births, and loss can happen with even the best care.  But there are reasons to suspect hers was not the best care, and that there'd be better outcomes with a skilled provider.  From my experience, I feel I would have been better off UC'ing than having my first MW in attendance.  And these poor families paid such a high price for the lack of honest discussion about MW reputation.

As conflicted as I was, it pained me not to donate to the MW's defense fund, while at the same time my husband wanted me to volunteer as a witness for the prosecution!

What should our communities do in these situations?  Certainly not rally around negligent MWs. 

Because I believe so very strongly in enabling women to safely give birth at home, I can't join the voices of the hospitals and doctors and condemn even this MW.  But I have begun to quietly talk to friends that understand.  And maybe that's how things should work.  When there's a loss, and the parents feel a MW was in someways to blame, make the case public.  Does the community rally around and enthusiastically support the MW?  If so, maybe she's a good one and maybe it was just an unfortunate circumstance.  If not, maybe she shouldn't be attending births.

I'd like the same done for OBs.  Who really knows what cases OBs have settled?  There's the beginnings of accountability and patient reviews, and we need more of this for all providers.

[Jane93]

"You will note that both the 1989 and 2003 forms have the category OTHER MIDWIFE.  There is no category for a CPM.  But here's the important part: The OTHER category on both forms has the words "please specify."    There is room, in other words, to specify CPM.  And apparently, nobody did, or we'd have some concrete data on CPM outcomes."

Turquesa -- isn't the REAL reason we don't have concrete data on CPM outcomes is that MANA refuses to release data on the thousands of CPM birth outcomes that it has in its possession?  Do you have a theory as to why they refuse to do so?

[Jane93]

Isn't it also true that we don't have accurate information about CPM attended births in the State of Oregon because the State Board of Midwifery (headed by Melissa Cheyney) has failed require such data be provided to it EVEN THOUGH the State Board is required by state statute to obtain such data?

[Jane93]

Gena -- can you dispute that it is in the best economic interest of midwives to broaden the scope of their practice as much as possible?   The pool of women willing to even contemplate homebirth is so small.  I can see where there might be an monetary motive to keep homebirth interested women in the pool of potential clients even though their pregnancy contains factors that make a homebirth ill advised. 

Also, if a midwife is unlicensed isn't is true that she has had no external examination of her past personal history and ethics?  Or even any evidence that she has made any study or consideration of medical ethics at all?  The most recent homebirth death out of Oregon, where 2 unlicensed midwives allegedly left a woman to labor for 8 days, and then isolated her from her friends and family (to the extent of not letting her husband, then out of the country, speak to her by phone) is instructive on this point.

[Turquesa]

Originally Posted by Jane93 

Turquesa -- isn't the REAL reason we don't have concrete data on CPM outcomes is that MANA refuses to release data on the thousands of CPM birth outcomes that it has in its possession?  Do you have a theory as to why they refuse to do so?

Um, because they're disorganized and haven't compiled the most current data?  Because they already did release some data for 2000 data for the Johnson and Daviss study?  Because they  have an evil plot to kill babies and not tell anybody?   Sorry Charlie, but I've never been one for speculation and conspiracy theories.  And the baseless canard about midwives nefariously hiding dead-baby data fits that bill.  Are you familiar with the Burden of Proof concept?  The person making the claim--in this case, that MANA is deliberately hiding data because a large percentage of CPM-attended births result in dead babies--is responsible for proving that claim.  Concretely.  With actual evidence.  And so far, I haven't heard any proof--not from you, and not from the blogger that you're clearly following and paraphrasing.

But at least there's an admission in your post that there is no concrete data on CPM outcomes.  So the anti-homebirthers bringing their ceaseless crusade to MDC have no business citing CDC and Wisconsin data on "other midwives" to make their case.
 

[Kanna]

Originally Posted by Turquesa 

Fair questions, but don't always be putting the burden solely on midwives.  Sorry to resort to tu quoque, but there are GRAVE problems with how physician negligence is handled in the U.S.: http://www.citizen.org/documents/1937.pdf

Wow.....that system has flaws like swiss cheese. To quote (for people who don't want to read the whole thing):

peer-reviewed clinical privilege sanction

hospitals may not be sending such reports to all of the appropriate state licensure board(s) where the doctor is known to be licensed

94% of these 220 physicians who constituted an “Immediate Threat to Health or Safety,” the hospital took one of the very serious actions cited above…..However….state boards did not take any action against any of the 209 physicians that were considered such a threat

Furthermore, if a physician gives up his/her medical license during a medical board

investigation, it is still a reportable action to the National Practitioner Data Bank as a

“voluntary surrender.” Such medical board actions, if they were properly reported to the

NPDB, would have been taken into account in our analysis; i.e., they were counted as a

licensure action and excluded from our analysis.

Conclusion

Our analysis of physicians with one or more clinical privilege reports but no licensure

report raises serious questions about whether state medical boards are responding

adequately to hospital peer review determinations of substandard care or conduct, and,

secondarily, whether state boards are getting copies of hospital reports to the NPDB.

How does the midwifery model of reporting and sanctioning negligence work by comparison?