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Background: More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital. Methods: In April 2018 we searched five databases from 1990 onward and used R to obtain pooled estimates of effect. We stratified by study design, study settings and parity. The primary outcome is any perinatal or neonatal death after the onset of labour. The study protocol is peer-reviewed, published and registered (PROSPERO No.CRD42013004046). Findings: We identified 14 studies eligible for meta-analysis including ~500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03). Interpretation: The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital. Funding: Partial funding: Association of Ontario Midwives open peer reviewed grant. Research in Context: Evidence before this study Although there is increasing acceptance for intended home birth as a choice for birthing women, controversy about its safety persists. The varying responses of obstetrical societies to intended home birth provide evidence of contrasting views. A Cochrane review of randomised controlled trials addressing this topic included one small trial and noted that in the absence of adequately sized randomised controlled trials on the topic of intended home compared to intended hospital birth, a peer reviewed protocol be published to guide a systematic review and meta-analysis including observational studies. Reviews to date have been limited by design or methodological issues and none has used a protocol published a priori.Added value of this study Individual studies are underpowered to detect small but potentially important differences in rare outcomes. This study uses a published peer-reviewed protocol and is the largest and most comprehensive meta-analysis comparing outcomes of intended home and hospital birth. We take study design, parity and jurisdictional support for home birth into account. Our study provides much needed information to policy makers, care providers and women and families when planning for birth.Implications of all the available evidence Women who are low risk and who intend to give birth at home do not appear to have a different risk of fetal or neonatal loss compared to a population of similarly low risk women intending to give birth in hospital. Keywords: Home childbirth, Low risk birth, Perinatal mortality, Neonatal mortality, Systematic review

Background: We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital. Methods: We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity). Findings: 16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems. Interpretation: Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births. Funding: Partial funding: Association of Ontario Midwives open peer reviewed grant. Keywords: Home delivery, Home birth, Home childbirth, Maternal mortality, Obstetrical intervention, Systematic review

Big data promises to spark new discoveries but may also distort clinical research. Large datasets that permit numerous analyses could increase the number of spurious findings and threaten the reproducibility and validity of clinical research. The publication of unreproducible research is incentivized by a scientific culture that rewards novelty over rigor. Introducing preprint publication to clinical research could change the culture. The first clinical preprint platform, medRxiv, allows researchers to publish working papers in advance of peer-review to more easily share preliminary findings. Preprint publishing aims to be fast and frictionless, which fundamentally changes the incentive structure of academic publishing. Preprints offer a relatively weak reward (a preprint publication) for substantially less effort than peer-review publication. By reducing barriers to publication, preprints may help encourage scientists to publish null findings, which could mitigate publication bias. By enabling scientists to share preliminary work and publish evolving versions of manuscripts, preprints may also facilitate "workshopping" of ideas and detailed methodological review. This would better reflect the iterative nature of observational research than peer-reviewed publications, which immutably document the "final" results of a study. Preprint platforms are a timely innovation that may buffer the undesired effects of big data on clinical research.

S cientific peer review is imperfect, and efforts to improve the process have had limited impact. For example, concealing reviewer or author identity, using a statistical checklist, or training referees has yielded mixed results at best. However, until new approaches (e.g. post-publication review) are tried and evaluated, peer review remains the scientific community’s primarymechanism for ensuring editorial quality and principal bulwark against error. JGIM’s approach to editorial review is not dissimilar from that employed by our peer publications. We use a three-stage process, and at each stage we ask of the research, Bis it new, is it true, and will it change practice.^ First, the co-editors in chief and senior associate editor evaluate manuscripts for fit and potential impact. Manuscripts that pass this initial bar are sent to a deputy editor for a secondary, in-depth review. A subset of these manuscripts are sent on for peer review. We ask peer reviewers to do three things: first, identify scientific strengths and deficiencies; second, assess impact on the field of general internal medicine; and third, help authors convey their ideas with greater clarity. We are biased, of course, but we think that as a group, JGIM peer reviewers are exceptionally conscientious at accomplishing these tasks. While we ask reviewers to make recommendations regarding acceptance, we are mindful of the unreliability of this process and use these recommendations as only one element in what is ultimately an editorial decision. Many good papers are returned to authors with regrets, and no doubt we reject some potentially important and impactful work. Peer reviewers, editors, and the editorial process are all fallible.We are grateful to authors who continue to submit to the journal, hoping that we finally get it right. JGIM would like to thank the many talented people who have volunteered their time to serve as peer reviewers for the journal over the past 12 months. In 2015–2016, 795 reviewers provided a total of 957 reviews with a mean quality score of 4.4 on a scale of 1–6 (as judged by our JGIM deputy editors). Of these, 154 provided at least two reviews, and 8 provided three or more. We are indebted to them for their service. Among this group of dedicated peer reviewers, there is a group that stands out. These top peer reviewers performed at least two reviews between July 2015 and June 2016, returned all reviews within 30 days, and received a quality score of 4 or greater (out of a maximum score of 6) on all reviews. An asterisk identifies the 88 reviewers who meet these criteria. We congratulate them on their service to the academic community and thank them for their efforts on behalf of the journal.

The PAEA End of Rotation™ exams were developed to assess medical knowledge of the 7 core supervised clinical practice experiences, including Emergency Medicine, Family Medicine, Internal Medicine, General Surgery, Pediatrics, Women's Health, and Psychiatry and Behavioral Health. The examinations were created by experienced PA educators and national exam experts with continual review and content updates. This paper summarizes changes since the inception of the exam program, including test construction and development, reliability, validity, and scale scoring. They are built using content blueprints and topic lists that were developed by experienced PA educators and national examination experts. All examination items are peer reviewed by PA educators and statistically validated for accuracy and consistency by psychometricians who specialize in examination development. This article will review the changes since the inception of the exam program including test construction and development, reliability, validity and scale scoring. Also addressed is an update on the PAEA End of Curriculum™ examination.

In this paper we review several novel approaches for research evaluation. We start with a brief overview of the peer review, its controversies, and metrics for assessing efficiency and overall quality of the peer review. We then discuss five approaches, including reputation-based ones, that come out of the research carried out by the LiquidPub project and research groups collaborated with LiquidPub. Those approaches are alternative or complementary to traditional peer review. We discuss pros and cons of the proposed approaches and conclude with a vision for the future of the research evaluation, arguing that no single system can suit all stakeholders in various communities., This work has been supported by the EU ICT project LiquidPublication. The LiquidPub project acknowledges the financial support of the Future and Emerging Technologies (FET) programme within the Seventh Framework Programme for Research of the European Commission, under FET-Open grant number: 213360.