Birth Small Talk

Talking about birth

Physiological CTG interpretation – I have questions

Photo by Matt Walsh on Unsplash

There are lots of different ways that we have generated “truth” though history. Our current approach is to use the scientific method to generate knowledge considered to be reliable and authoritative. There are rules to follow in how you design and conduct research. There are also rules to follow when publishing research. These involve publishing in reputable journals that use a peer review process to establish that what is being published meets scientific standards. These don’t always guarantee that mistakes or fraudulent activity don’t occur, but it does help.

Predatory journals exposed

Over the past decade, there has been growing concern about what are known as predatory journals. Predatory journals exist primarily to make easy money for the publisher, with little to no interest in the quality of the work being published. Numerous stories exist of people successfully publishing nonsense papers in predatory journals, simply to make the point that the editorial team have clearly not read the paper and no peer review was conducted. See here for one about intergalactic parasites, here is one published by fictitious cartoon characters Maggie Simpson and Edna Crabappel, and here is one written by a doctorally qualified dog about random roadside rectal examinations for prostate cancer screening (I kid you not).

When maternity care meets the predator

Most researchers who publish in predatory journals are inexperienced researchers from developing countries who appear to have done so in good faith and been caught up in a scam to separate them from their money (Xia et al, 2014). Therefore, not all research published in a predatory journal is bad research. But when I saw a paper published recently by a team of authors who are senior obstetricians and experienced researchers, it raised some questions for me about why they would choose to publish with a predatory publisher.

I’m referring to the paper by Samyraju, Ledger, and Chadraharan (2021) published in the Global Journal of Reproductive Medicine, owned by Juniper Publishers. The journal is not listed with Scopus – an authoritative listing of recognised scientific journals, and the publisher’s name appears on a listing of predatory publishers. The authors are proponents of “Physiological Interpretation of the CTG” (see here for their guideline). The first author is a senior obstetrician in the hospital where the research was conducted. The second author is the head of research and development for the UK based education company Baby Lifeline Training, who offer classes on CTG interpretation using this “physiological” approach. The third author is the creator of the concept of “Physiological Interpretation of the CTG” and is listed on the Baby Lifeline website as the course director of the Advanced CTG Masterclass. 

In the paper, the authors explain they created an approach to CTG interpretation and translated this into a tool, the HIL tool, that was then incorporated into the CTG monitoring software package at one UK based hospital. They claim that the adoption of this tool achieved what so many fetal monitoring researchers have been hoping for – a dramatic reduction in hypoxic ischaemic encephalopathy. Alongside this they describe significant cost savings and improved staff morale. 

The paper is presented in a descriptive manner, rather than set out in the format typical of new research. There is no methods section, so the reader is unable to understand precisely how they arrived at their findings. There is no section setting out how they ensured the research was ethical. The only numerical data are presented in a figure, showing a reduction in the number of cases of severe HIE from 22 in 2014-2015, to 19 in 2016-2017, and then 9 in 2018-2020. A second figure shows the same information, with the graph again showing 9 cases of HIE in 2018-2020, labelled with an arrow stating “only 6 cases in 3 years”. The text of the paper says that there were 9 cases of HIE, then in the following sentence 6 cases, in the 3 years period of 2018-2020. The number of babies born during these year blocks was not presented so it is not possible to determine the rate of HIE, and no measures of significance are provided to assist in interpretation of the change in numbers. No data are presented to verify the claims of cost savings or improved staff morale. 


I have so many questions. Why did the authors choose to publish in an unlisted journal published by a known predatory publisher? Was this simply an error on their part due to insufficient caution in selecting a journal to submit the paper? Or does it represent an opportunistic approach to deliberately mislead by publishing a poorly constructed paper in a journal where there was not going to be a peer review process to navigate? If they have managed to produce a significant improvement in outcomes, why not conduct the research in a rigorous manner, accepted as best practice, and publish in a reputable journal? 

Without the use of valid scientific approaches, we will never know whether the HIL tool works or not. I am deeply concerned that organisations like Baby Lifeline, who are committed to improving perinatal outcomes, are promoting an approach which is not yet justifiable based on the evidence, and the creators of the approach seem to be deliberately attempting to subvert scientific approaches to knowledge production. 

The history of maternity care is littered with stories of half-baked science that becomes embedded in practice and only too late is discovered to be ineffective and challenging to step away from. Please. Please. Let’s stop doing this. Evaluate the “Physiological Approach to CTG interpretation” approach properly using scientifically valid research approaches and publish it in a journal with a reputation for rigorous peer review. If it really does work – let’s find out for sure.


Samyraju, M., Ledger, S. & Chandraharan, E. (2021). Introduction of the physiological CTG interpretation and hypoxia in labour (HIL) tool, and its incorporation into a software programme: impact on perinatal outcomes. Global Journal of Reproductive Medicine, 8(3), 5556737. DOI: 10.19080/GJORM.2021.08.555737.

Xia, J., Harmon, J., Connolly, K., Donnelly, R., Anderson, M. & Howard, H. (2014). Who publishes in “predatory” journals? Journal of the Association for Information Science and Technology, 66(7), 1406-1417.

Categories: CTG, EFM, New research, Perinatal brain injury

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2 replies

  1. Who has written this?! Doesn’t show which is worrying. Maybe I have missed this as it has been sent onto ne


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