Posts Tagged ‘bias’

Much ado about “levator microtrauma”: Do epidurals protect the pelvic floor?

September 3rd, 2010 by avatar
Levator Ani

The levator ani is a muscle, not a clinical outcome.

Ok, ok, I’ve heard from enough of you about the study purportedly showing that epidurals protect the pelvic floor, I suppose it’s time to write up what I think about it.  First, a little about the study from the (overzealous) journal press release. I couldn’t resist doing a little bit of [line editing] on it:

Researchers from Australia undertook a prospective study of 488 women undergoing their first pregnancy between May 2005 and February 2008. The object of the study was [to determine predictors of delivery mode, but since they had enrolled all of those pregnant women they designed some other studies, too. In one, the researchers invited those 488 women to return for follow up at 3-4 months and retrospectively analyzed data on the 367 women who did] to determine if there are any risk factors during birth which may result in levator trauma including macrotrauma (large scale avulsion – tearing) and microtrauma (damage to the muscle tissues such as irreversible overdistention of the pelvic floor opening). Researchers believed that the findings from their study may help modify obstetric practice to help prevent levator injury…

No levator avulsion was recorded in the women who had a caesarean section. Levator avulsion was diagnosed in 13% of women who had a vaginal birth (9% of whom had had a vacuum delivery and 35% of whom had had a forceps delivery). Researchers found that forceps delivery was associated with a three to four-fold increase in levator avulsion. [They excluded the 13% of vaginal births in which levator avulsion was diagnosed and evaluated the rest of the women for “microtrauma”. We put “microtrauma” in quotes because no one has ever defined or determined the prevalence of this “condition”. The researchers invented it themselves! But anyway,…] Postbirth assessment showed that the longer the 2nd stage of labour, the higher the likelihood of microtrauma. Women who had an intrapartum epidural were found to have had a lower incidence of microtrauma. The researchers suggest that epidurals, because they relax the muscles through paralysis, may be beneficial in preventing levator trauma.

There are multiple problems with the press release and, for that matter, with the study itself. Christine Kent at Whole Woman Village Post does a nice job of reviewing some of them, including the fact that one of the study authors receives money from incontinence surgical device companies and ultrasound companies. But I’d like to focus on the use of “levator microtrauma” as the outcome reported.

Levator microtrauma is an example of a surrogate outcome (sometimes referred to as a surrogate endpoint). As defined by Temple (1995):

A surrogate endpoint of a clinical trial is a laboratory measurement or a physical sign used as a substitute for a clinically meaningful endpoint that measures directly how a patient feels, functions or survives. Changes induced by a therapy on a surrogate endpoint are expected to reflect changes in a clinically meaningful endpoint. [emphasis mine]

But as D’Agostino (2000) argues, some surrogate outcomes are extremely poor predictors of actual outcomes, and changing clinical practice based on studies that report only surrogate outcomes can be a major threat to patient safety if the therapy introduces other risks. So the questions we should ask ourselves when we see a study reporting a surrogate outcome are:

  • is the surrogate outcome a good predictor of a clinically important outcome (i.e., “how a patient feels, functions or survives”)?
  • does the treatment pose any excess risks over other alternatives to achieving that clinically important outcome?

In the case of “levator microtrauma,” there is absolutely no data whatsoever linking the author’s definition of microtrauma to pelvic organ prolapse or other important pelvic floor problems such as incontinence or sexual dysfunction. The aforementioned corporate-sponsored researcher showed in an earlier study that macrotrauma (aka levator avulsion) is an appropriate surrogate for pelvic organ prolapse, but remember that epidurals were not associated with macrotrauma in this study. Forceps deliveries were – and what’s the major modifiable risk factor for forceps delivery?  Epidurals!

But let’s say that microtrauma does lead to pelvic floor problems and that, therefore, epidural analgesia in labor may be a strategy for preventing those pelvic floor problems.  Is encouraging epidural analgesia in a woman who might otherwise forgo it the best strategy for preventing pelvic floor problems?  Maybe doing away with coached pushing, fundal pressure, episiotomy, and supine positioning might be the better strategy. Maybe postpartum exercises can help reverse changes associated with pregnancy and vaginal birth so they don’t turn into symptomatic pelvic floor problems.

Like other studies that report surrogate outcomes, this study is not useless.  It provides some data that can help us understand how epidurals affect pelvic floor muscle tone and strength and alter the process of vaginal birth, and I’ll be the first to say that we need more research in those areas. In other words, these data on a novel surrogate outcome can help us design more studies, not guide patient care.

Anyone who has even a basic understanding of clinical research should recognize that we need much more data before we can say that epidurals may help prevent future pelvic floor prolapse.  Oh wait, the editor-in-chief of a major international obstetric journal just said exactly that! In the headline of a major press release!



Temple RJ. A regulatory authority’s opinion about surrogate endpoints. Clinical Measurement in Drug Evaluation. Edited by Nimmo WS, Tucker GT. New York: Wiley; 1995.

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Becoming a Critical Reader: Bias, Bias Everywhere!

February 17th, 2010 by avatar

Pretty much everyone would agree that there is bias in research. Most people would say that bias is inherently bad. While it absolutely can be a bad thing, it can’t be completely eliminated. So what can be done about bias in research?

There are many kinds of bias:

  • Researcher bias: researcher sets out wanting to the study to prove something, and intentionally or unintentionally manipulates the study to make sure that happens
  • Sponsor bias: The organization that sponsors the study either encourages researcher bias or manipulates the publication of the data. Some studies might be completely suppressed, some might have overly inflated press releases touting minimal results.
  • Publication bias: Journals must be selective in what they publish due to space limitations, but I think it is fair to say that some journals may choose not to publish a study that might anger its audience.

But today I want to focus on READER bias:

Your first job in the critical reading of an article is to check your bias. We are all human, and so we all have bias. Sometimes it is hard to see your own biases. Take a look at the pictures below. In the first picture, we can tell that there is something there, but it is difficult to see. In this case, the letters are lined up with our angle of vision.


In this second picture, the letters are running the opposite way as our line of vision, and as you can see, suddenly that bias is crystal clear!


The same is true with our reading of the research. The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked.

Murray Enkin, author of “A Guide to Effective Care in Pregnancy and Childbirth”, said this:

Perhaps the most important bias of all resides in the (potential) reader, who determines how (or if) the results will be read and interpreted.

I would agree with him. I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

But the good news is that reader bias isn’t impossible to overcome.

The solutions? Awareness of bias and a change of perspective! As you read, consider how this research might be read and understood by someone with a completely different perspective. When you read a study that really resonates as a great study with you, play “devil’s advocate” and pick it apart. Be merciless in looking for flaws, weaknesses and the other types of bias listed above. The same is true of seeing an article you disagree with. Look for strengths and solid evidence. Have an open mind to other possibilities. Sometimes when doing this, you’ll be able to see some aspects you would never have noticed otherwise.

So, here’s an exercise for you. Take a few minutes, and write down what your biases are when it comes to research. Which kinds of research, which methods, which topics do you particularly feel drawn to? Which ones seem silly or useless? For inspiration, you may want to read a personal commentary article written by Murray Enkin (2008) where he goes through his own personal biases. The things he feels a bias for or against may not be the same for you. I know I have a disagreement with one of his stated preferences. But taking the time to carefully think through your own personal biases, to clearly acknowledge the filters through which you view the research, can only help you as you try to step back and make a critical analysis of the research.

Reference: Enkin, M. W. (2008) Biases in evaluating research: Are they all bad? Birth: Issues in Perinatal Care. 35(1). 31-32.

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Cherrypicking stats: bad form and not helpful

December 1st, 2009 by avatar

Science & Sensibility contributor, Andrea Lythgoe, has a great post up at her own blog. In The Doula Numbers Game, Andrea shows that many of us may be overestimating – and overstating – the beneficial effects of continuous support from doulas. She argues and I agree that using outdated statistics that yield “better” results could compromise our integrity. Moreover, doing so is not necessary to advocate for greater access to doulas.

Data from the Cochrane Systematic Review show more modest effects of doula support, but they still add up to “clinically significant” benefits, greater satisfacation, and no evidence of harm. Maternal-fetal medicine researchers who evaluated the evidence for a variety of obstetric interventions in the November 2008 issue of the American Journal of Obstetrics and Gynecology called doula support “one of the most effective interventions” (p. 446) for improving outcomes. And they did so without being wowed by the inflated early statistics. (They stuck to the Cochrane.)

It can be extremely difficult to look at research objectively. It is human nature to want to cherrypick the research that furthers our cause the most. We may try to find fault with statistics we don’t like and subconsciously ignore problems or limitations of statistics we do. But improving the safety and effectiveness of maternity care requires that we critically analyze the research, which means recognizing limitations and flaws in the studies we agree with and standing behind solid research even when we don’t like the conclusions. We need not worry. Even with a critical lens, research points to a need to radically reform our system to make it more mother-friendly.

Andrea finishes each post in her Understanding Research series with a familiar plea to practice, practice, practice finding and reading research literature. One of the skills we all should practice is to read the studies that seem to contradict our beliefs or biases. Often, these studies are flawed, and spending time reading them helps us hone our ability to spot methodological problems and logical inconsistencies in other research. Other times the research is valid, and we see circumstances where technology and medicine do in fact improve outcomes. Reading these studies can also shed light on important unanswered research questions.

I highly recommend that readers take a look at Andrea’s post for an example of thoughtful critical analysis of statistics on doula support in labor. It is hard to update our long-held beliefs or alter the ways we teach and practice. But this is just what we’re asking of our “medical model” counterparts. We should lead by example.

By the way, Andrea wrote her post for the upcoming Healthy Birth Blog Carnival.  There are so many other great contributions, too. I will have the Carnival up in the next 48 hours – promise!

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Disputed Territory: A doctor reviews “Birth Territory and Midwifery Guardianship: Theory for practice, education, and research”

November 16th, 2009 by avatar

This is a guest contribution from Katharine Hikel, MD. Dr. Hikel is a writer on women’s health for Medscape/WebMD. Peer-trained in feminist women’s health clinics, she is also a graduate of Harvard and the University of Vermont College of Medicine. She lives in northern Vermont with her family.

Birth TerritoryReview:
Birth Territory and Midwifery Guardianship: Theory for practice, education, and research
Edited by Kathleen Fahy, Maralyn Foureur, Carolyn Hastie.
Butterworth Heinemann (Elsivier): Books for Midwives. 2008

The next vital revolution in maternity care may well be the overhaul and redesign of the birthplace. In “Birth Territory and Midwifery Guardianship,” writers describe the relationship of the birth setting to the emotional-physiological state of laboring women.  In this regard, ‘Birth Territory’ encompasses not only physical space, but also personal relationships, power structures, and access to knowledge.

Maternity care as we know it has evolved along divergent roads: the midwifery, expectant-management ‘natural’ approach; and the obstetric, interventive, ‘actively-managed’  model.  Midwifery care is a woman-centered approach; it relies on relationships which support women’s natural abilities to give birth. The obstetric model, designed by and for doctors, operates on  principles of academic exclusiveness, described by Louis Menand:

It is a self-governing and largely closed community of practitioners who have an almost absolute power to determine the standards for entry, promotion, and dismissal in their fields. The discipline relies on the principle of disinterestedness, according to which the production of new knowledge is regulated by measuring it against existing scholarship through a process of peer review, rather than by the extent to which it meets the needs of interests external to the field…

[T]he most important function of the system is not the production of knowledge. It is the reproduction of the system. To put it another way, the most important function of the system, both for purposes of its continued survival and for purposes of controlling the market for its products, is the production of the producers

Academic obstetrics is impervious to knowledge and input from other disciplines; it exists in a closed, parallel world; it exists not for the purpose of taking care of women, but for the purpose of taking care of itself. The chief concern of any obstetrical unit is the viability of the department, of the program; if outcomes figure into that, well and good; but women’s actual experiences and opinions, because they are not part of the published literature, are of no concern.  Small wonder, then, that so little thought has been given to the environment of hospital birth, other than for the convenience of hospital practitioners.

Meanwhile, midwives have continually concerned themselves with what the authors of Birth Territory and Midwifery Guardianship call ‘the elements in the geography, architecture, and metaphysics of birth spaces to which women will consciously and unconsciously respond.’

In their book, the writers – midwives, and an architect of birth spaces – asked women what they wanted in their birthing places. Responses included:

  • A pleasant place to walk
  • Sufficient pillows, floor mats, bean bags
  • Availability of snacks and drinks
  • En suite toilet, shower, bath; a birth pool
  • Comfortable accommodations for companions and families
  • A homey, non-clinical environment
  • Control over temperature
  • Control over brightness of light
  • Privacy; not being overheard by others
  • Not being watched
  • Control over who comes into the room

The majority of birthing women surveyed did not have these options. The authors argue that lack of a woman-centered birthing environment, and little control over that environment, are reasons for high rates of obstetric intervention. Labor and birth are whole-being experiences; the autonomic nervous system will shut the whole process down if the woman perceives stress, threat, or danger.  In typical hospital settings, with shift changes, strangers walking in and out, bright lights, confinement to bed and monitor, and restricted oral intake, it is no wonder that the process doesn’t go as smoothly as it could. “Failure to progress” – the diagnostic reason given for 50% or more cesareans – is largely an environmental issue.

Katharine Hikel, MD

Katharine Hikel, MD

Birth territory is also defined by relationships; yet medical obstetrics has constantly worked to sequester birthing women away from all sources of comfort, including non-medical practitioners; only in the 1960s were fathers and partners invited into hospital delivery rooms; and only lately, with the advent of doula practices, has one-to-one attendance – the cornerstone of midwifery – become recognized as a significant predictor of good outcome.  But few hospital practices are relationship-centered. Prenatal visits are fifteen or twenty minutes long, mainly focused on weight gain and lab work. There’s usually a team of doctors and midwives; the person who’s available at the time of one’s birth is not a matter of preference, but of the practice’s call schedule.

Obstetrics is statistics-based, not relationship-based; obstetricians know that the average due date is 40 weeks from the last menstrual period; they know that if a woman is laboring (in a hospital) with waters broken for over 12 hours, her chance of infection skyrockets; they know that the Friedman labor curve shows that the average progression of dilation is one centimeter per hour; they know that the average pushing phase is under two hours. They are under pressure to make everyone fit those statistical norms, and they have the tools to make it so; and that’s what they do.

The best birth territory requires the best attendants. Fahy and her coauthors argue that birth is a reflection of relationships – with oneself, and with others; that relationships depend on love, and spiritual development (words you will never see in any obstetrical textbook).  In developing the best birth attendants, they see open-heartedness as a requirement for good practice; they describe the characteristics of a good practitioner in Buddhist terms of ‘right relationship’: empathy; ethical behavior; self-awareness; capacity for love. In a chapter called “Reclaiming the sacred in birth,” they describe the conditions for nurturing ideal midwives: ‘to know and nurture themselves within their own families and communities,’ and emphasizes working on personal development, as well as clinical skills, with a supervisor or professional partner. The training environment of midwives should encourage the development of nurturing and intimate, though professional, relationships with her clients; it is that relationship that forms a necessary part of optimal birth territory.

The territory of obstetrics residents is largely devoid of patient-relationship considerations; it is rather consumed with concerns about on-call hours, clinical rotations, numbers of procedures, and one’s place in the departmental hierarchy. The knowledge itself is based in pathology – ‘problem-oriented’ – a diagnostic/treatment approach that assumes there’s trouble, and goes about finding it. This works well in the rest of medicine, which is really about disease; but colors the teaching approach to the normal, healthy event of childbirth.  The knowledge that’s important – taught and practiced – is all within the limits of academic obstetrics, which ignores, if not devalues, ‘nonscientific’ knowledge. The ‘permitted’ knowledge supports what the authors call the ‘metanarrative’ of academic medicine: the postmodern myth that the safest and best place to give birth is under obstetric management. Any knowledge that counters that myth is disputed or ignored.

The history of obstetrics is also viewed differently from within the specialty than without. The obstetricians’ view, reproduced in most obstetrical textbooks, is the development of one intervention after another, all by men – from forceps to vacuum extractions. The authors present a larger-scale view:

Medicine in the late 19th and early 20th centuries was composed almost entirely of men who shared the same power base as other dominant males: they were white, well-educated and from economically richer families. It was these males who owned or managed every institution of society: the army, the church, the law, the newspapers, the government, etc. These privileges, combined with an informal brotherhood of dominant men, created a powerful base for the success of the medical campaign to subordinate midwifery.

The authors describe the territory of hospital birth as disputed ground, where the biological requirements of birthing women are at odds with the design of institutions.  They provide ample evidence about how the dominance of obstetricians’ needs over women’s welfare has contaminated the culture of birth. In a wonderful section on oxytocin – the hormone of love, bonding, social interaction, birth, and lactation – they describe the effects of this natural hormone:

[T]he higher the level of Oxytocin, the more calm and social the mother; thereby stress is reduced; levels of the stress hormone cortisol drop; pain threshold is increased…  body temperature is regulated… and heart rate and blood pressure are lowered… Women’s response to stess may not be the automatic ‘fight or flight’ response seen in men, but is more likely to be the ‘calm and connection’ system integrated by Oxytocin.

These oxytocin-mediated events are most necessary during labor and birth; they are best enabled if the birth territory includes oxytocin-positive relationships.  Oxytocin is thought to be the source of women’s power to endure labor and birth; and its pathways are the most likely to be deranged by the institutional birth environment – the lack of oxytocin-facilitating relationships of trust and love, as well as the routine administration of oxytocin-blocking drugs such as epidurals and Pitocin – a form of artificial oxytocin that has never been proven safe in long-term outcome studies. Blocking oxytocin, whether through fear, disturbance, or Pitocin, leads to disrupted or painfully difficult labors.  These authors suggest that disruption of normal oxytocin pathways, and supplanting them with intrapartum Pitocin exposure, may also result in serious mental health problems on the love-and-relationship axis: schizophrenia, autism, drug dependency, suicidal tendencies, and antisocial criminal disorders. It’s not just the mother who’s affected by the birth territory.

But what is the best birth environment?  In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.”  Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman whose labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.

Why not indeed. The major obstacle to any redesign of the territory of birth is resistance from the field of obstetrics. The American Congress of Obstetricians and Gynecologists (which recently changed its name from the American College of Obstetricians and Gynecologists, reflecting a major shift in interest from academics to politics) has a 23-member lobbying arm, “OB-GYNS for Women’s Health PAC”, which describes itself on its web site:

Ob-Gyns for Women’s Health and Ob-Gyn PAC help elect individuals to the U.S. House of Representatives and Senate who support us on our most important issues. Individuals who understand the importance of our work, who care about the future of our specialty, who listen to our concerns, and who vote our way. In only a few short years, Ob-Gyn PAC has helped elect ob-gyns and other physicians to the U.S. Congress, and has become one of the largest and most influential physician PACs in America.

Only five of the 23 members are women; all ten of its board of directors are men. Current issues occupying the group are “Stopping Medicare payment cuts, ensuring performance measures work for our specialty, preserving in-office ultrasounds” (though there are still no long-term studies on the effects of ultrasound on the developing fetus, or on women, for that matter); and “winning medical liability reform,” which means limiting liability for malpractice.
Meanwhile,  the Medicaid Birth Center Reimbursement Act – Senate Bill #S.1423 (House Bill HR 2358) – is not on the list of bills that ACOG supports, even though this expansion of birth territory would probably better outcomes, and certainly cost less than the hospital OB model.

The only bad thing about “Birth Territory and Midwifery Guardianship” is that obstetricians will not read it.

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Can we improve research by crowd sourcing peer review?

October 21st, 2009 by avatar

Since we launched six months ago, Science & Sensibility has become a multidisciplinary hub for analysis of research in maternity care. I’m proud that we have a childbirth educator, a consumer advocate, and two clinicians among our regular contributors. We also regularly have consumers, childbirth educators, doulas, nurses, midwives, doctors, and researchers leave comments. Together, we shape our understanding of research, discover new ways to look at questions, and find out which research pertains to us and which doesn’t. And we do it in ways that none of us could do alone.

In most cases, our work begins when a study is published in a peer-reviewed journal. The journal issue is published, the press releases go out, and then the rest of us get to weigh in. With much at stake in how the evidence will be used (the findings may impact our bodies and our babies, or change the conditions in which we practice, after all), we set to work. Too often, this process reveals flaws, detects biases, or raises other red flags. But the study is peer-reviewed, so it gets to shape policies and practices – especially if the findings align with the dominant obstetric management model – while we get to air our frustrations in blogs and letters to the editor. If you need more proof of the power of a deeply flawed but nevertheless published trial, consider the rise and fall of the Term Breech Trial, and the multi-stakeholder movement for evidence-based breech birth finally taking hold nearly a decade later. (Several bloggers have covered the recent Breech Birth Conference, including Rixa Freeze, PhD, at Stand & Deliver.)

Also consider these thoughts from the editors of two of the most prominent peer reviewed journals:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine. – Marcia Angell, MD,  in Drug Companies & Doctors: A Story of Corruption

If editors were to examine [the] body of literature [on the peer review process], they would discover that evidence on the upside of peer review is sparse, while evidence on the downside is abundant. We struggle to find convincing evidence of its benefit, but we know that it is slow, expensive, largely a lottery, poor at detecting error, ineffective at diagnosing fraud, biased, and prone to abuse.  Sadly we also know — from hundreds of systematic reviews of different subjects and from studies of the methodological and statistical standards of published papers — that most of what appears in peer reviewed journals is scientifically weak. – Richard Smith, MD, former editor of BMJ in In Search of an Optimal Peer Review System

jopmToday marks the launch of a new journal, The Journal of Participatory Medicine. Participatory Medicine itself is based on the fact that all stakeholders, especially engaged, empowered consumers, are valuable assets for improving the quality and efficiency of healthcare. The Journal mirrors this philosophy. They will break most of the rules of ivory tower academic journals by inviting contributions from patients, providing free open access to anyone, asking for comments and feedback, and, perhaps most importantly, allowing anyone (yes, even you) to volunteer to be a peer reviewer.

As I have said before, maternity care advocates have much to contribute to and gain from the Participatory Medicine movement. I encourage my readers to check out the new journal. No, none of it has to do with maternity care specifically (yet), but here are a few gems that may make you realize that, when it comes to the power of being engaged and empowered and the harms of being a passive patient, it doesn’t matter if the context of care is sickness or health. [Note, free registration required to access journal articles.]

Medicine in the US has become extremely proficient at many technically advanced diagnostic and therapeutic methods. However, they are often applied — very competently — to patients who don’t need them at all. Can participatory medicine improve this situation? One way perhaps, is by facilitating actual informed consents (not merely legal rote signings) for therapeutic and diagnostic procedures, including screening tests and procedures. – George Lundberg, MD, in Why Healthcare Professionals Should Practice Participatory Medicine: Perspective of a Long-Time Medical Editor

As our bodies healed from the assaults of cancer treatment, we began to respond to the needs of others, discovering that we had something to offer, a knowledge that was hard won and deeply felt, and that somehow in that sharing we could both help and be helped. We joined groups and formed groups and sometimes organizations, moving beyond isolation to community. – Musa Mayer in A Seat at the Table: A Research Advocate’s Journey

Purchasers, in other words, understand that participatory medicine is not just about helping an individual patient better understand how to manage their own health and make important health care decisions. Participatory medicine is also about creating a broad awareness that a health system that only rewards services, that is not based on evidence, that sanctions an unaccountable professional and managerial elite to dispense and withhold services — is not just, effective, or affordable. – David Lansky, PhD, in Why Purchasers Should Care About Participatory Medicine

Participation means that we as patients, we as providers and we as health care system managers must be willing to acknowledge our interdependence and meet on a level if changing environment. To do otherwise is dangerous and will lead to poor outcomes. We have no choice. – Kate Lorig in What it Will Take to Embrace Participatory Medicine: One Patient’s View

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