The journal of the american medical association turned this study down

Oh, that makes me sad that they didn't think their audience would be interested. Their audience ought to be interested, for Pete's sake. I am chewing on another home birth post...

Of course their audience wouldn't be interested--because their audience is making $$$$$$$$ doing hospital births. Why would they possibly be interested in only making $$$$$$ when they could be making $$$$$$$$? :-)

Hi there. Couple of questions.

1. How do you know this paper was submitted to JAMA?

2. For the purposes of this discussion lets assume it actually was, and was rejected.

2a. Do you actually know that the editors rejected it because they felt it would not be of much interest to their readership? How? (Do you have the rejection letter?)

3. We will assume that is indeed what happened.

3a. Why do you think that decision is unreasonable?

JAMA is one of the world's leading clinical journals. It's readership is mainly US and Commonwealth general internal medicine and specialist doctors (not OB/gyns or "women's health" doctors). Each week, JAMA receives a HUGE number of submissions, and they reject 80-90% of them. There is no space to publish everything, so they only chose the best and most relevant papers they get.

Why is that wrong?

4. This study is far from top flight work. It was not even a controlled trial; we will not even talk about Level I evidence.

But more important than that, it also is not original, there have been scores of this type of cohort studies, usually done by midwife groups who are themselves keen on pushing a certain view of pregnancy and birth. Nothing wrong with that of course, its just good to bear the obvious biases in mind.

In view of the fact that this study is nowhere near the type of high quality submissions JAMA is accustomed to getting, why do people seem to read ulterior motives in the decision to reject? Is the sense of self-importance and entitlement so high that it is felt even lower quality studies must always be published in a JAMA standard journal as long as it is a study in this area?

5. Finally and most importantly, it must be borne in mind that the paper was published in **BMJ**. Seriously, people are complaining about this? The BMJ is one of the "Big Five"!! If you ask me, the authors should be *mighty* pleased they got this thing published there.

Jane, you're absolutely right.

Doctors have no interest in the health and well being of their patients. Their only concern is, as you put it, "$$$$$$$". There is no altruism in medicine. No nobility. Doctors don't even have the normal regard humans have for each other as humans. All they care about is, "$$$$$$$".

Doctors are eeeevil.

1-3. I was told this in a conversation with one of the authors of the study. I relied upon this word of mouth.
I don't think the decision was unreasonable, I just found it intriguing as a picture into a mindset. It is always the editor's choice to accept or reject any submission, (along with the input of the reviewers) - and I am not being hospital in making the observation I did. I find it entirely believable that the majority of physicians in the USA would be totally bored by the topic of place of birth - given that most physicians have little or nothing to do with pregnancy and/or childbirth. Journal real estate is valuable, and editors have to make judgement calls. Personally, I am totally bored by 90% of the content of the NEJM, but I still subscribe to the table of contents via email.
4. Of course there is an inherent bias - there is an inherent bias in just about every research study that is done or published. What is interesting to me is that clinical decisions are often made based on level 2 or 3 data that contradicts prior studies with a the same level of credibility - for example the see-saw on 'allowing' VBAC trials of labor.
As for original - what is unique about this cohort study is that it was designed as a prospective study based upon the intent of the pregnant mom to give birth at home, and enrollment was done at the point of contact with the care provider. This factor does control for some of the statistical issues in prior studies of outcomes related to place of birth - many studies that purport to show worse outcomes for home births include the unanticipated or unattended birth (teenager with concealed pregnancy, premie born in the bathroom, etc) with planned births attended by trained assistants. In others, there has been a suspicion that good outcome statistics may have been inflated by ignoring the antepartum transfers. Collecting data prospectively can help to really track what does happen.
I don't think it would be possible to do an RCT on place of birth in this country. I think that women and their providers are heavily invested in being able to choose. The USA started a massive uncontrolled trial of taking birth out of the home and putting it into the hospital starting over 100 years ago, and only in the last 40 years or so have any studies been done that even begin to question the assumptions behind that action.
5. Nothing wrong with the BMJ at all -I just think it is interesting that an American journal rejected a study from an American group. The BMJ is an excellent journal - but it isn't one that is regularly read by most North American OBs or Family Practice docs, at least not the ones with whom I have regular contact.

Thank you for your provocative questions and comments.