Reviewers

Submitting for publication #

Part of the strength of modern academic publishing is that research submitted for publication undergoes peer-review. This involves editors, associate editors and (unpaid & voluntary) de-identified peers reviewing submitted articles. Typically journal editors choose reviewers from among their professional contacts, often among those with interest, knowledge or expertise related to the research itself. Nonetheless it is largely an opaque process for authors, sometimes making for an arbitary, kafkaesque experience.

Given the significant amount of unpaid, voluntary work contributed by researchers, authors and reviewers alike, this protacted and circular process achieved little for this particular paper – other than delaying its publication and discussion of its conclusions. While much of the reviewer feedback was helpful and incorporated into the (many) revisions, the multiple revise–submit–respond cycles simply lead to a continuing shifting of the ‘finish-line’.

Review delay spiral #

Over the 16+ month submission and review cycle, the paper was reviewed by no less than five referees plus associate editor(s). In an unusual move for academic publishing, after the paper had been rewritten twice and original reviewers had “confirmed that the requested amendments had been incorporated”, the editorial team felt it was "…essential that additional opinions be sought [referees 3 and 5]".

Unsurprisingly both new reviewers, Referee 3 and Referee 5, were critical of the paper and it was, again, not accepted in its submitted form.

“The issue[s] that are discussed in this paper are very important. The data is new and worth sharing. Unfortunately, the way that the discussion is written conveys to the reader that the authors are pushing an agenda, possibly a worthy agenda. My concern is that this paper unfairly maligns RANZCOG…” – Referee 3. [emphasis added]

The submitted journal, ANZJOG (The Australian and New Zealand Journal of Obstetrics and Gynaecology) is an "…editorially independent publication owned by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the RANZCOG Research foundation".

The primary author withdrew the article from consideration for publication in October 2020.

Reviewer’s comments #

In the interests of peer review and transparency, below is the unedited, original Reviewer feedback [all sic] along with Author responses.

June 2019 #

Referee: 1 #

Comments to the Author

Consider focusing your paper on the Australian and New Zealand O&G landscape overall, rather than specifically at RANZCOG and make the qualitative component the focus of your manuscript as its assessment. Examination of the barriers to equity are most likely to be the value add of your project.  The quantitative data you present for RANZCOG leadership positions is older than in other publications and does not appear to represent new information.  The term RANZCOG-affiliated organisations implies that RANZCOG exerts some control over these organisations in terms of leadership structure/positions, which is not the case.

The purpose of the background section is to summarise the available literature. There are several statements in the background section of the manuscript that are not referenced. Please reference or remove these.

The purpose of the discussion section is to evaluate and expand on the results in the context of the existing literature.  It is also possible to generate new hypotheses in the discussion. Some discussion points that seem to contradict the results,  particularly around quotas and merit based approaches.  The data presented clearly supports a merit based approach and generally refutes quotas, yet the discussion seems to make an argument towards the use of quotas. Please clarify this, if it is justified by data that is not presented or existing in the literature, then please present the appropriate data or source.  There are also several discussion points that are not referenced therefore give the appearance of an opinion.  Please use appropriate citations, or if these are new hypotheses generated, please clarify this for the reader.

Please use academic grammar and language throughout the paper.

Please review: Angstmann, M. , Woods, C. and de Costa, C. M. (2019), Gender equity in obstetrics and gynaecology – where are we heading?. Aust N Z J Obstet Gynaecol, 59: 177-180. doi:10.1111/ajo.12969.

Author Reply to Referee: 1

Thank you for your comments. These have been noted and the following updates included:

• The revised manuscript now focuses on the overall Australia & New Zealand O&G landscape.
• The content related to the current RANZCOG gender leadership landscape has been removed. The authors acknowledge that when they wrote the original manuscript the article by Angstmann, M., Woods, C. and de Costa, C. M. was not yet published. This revised manuscript now references this article and its contribution to the O&G literature on gender and leadership with O&G in Australia & New Zealand.
• The references to ‘RANZCOG affiliated organisations’ have been removed.
• The background section of the revised manuscript now only reflects statements that have references and those without have been removed.
• The content of the discussion has been revised to more appropriately reflect the qualitative results.
• The discussion section of the revised manuscript now only reflects statements that have references and those without have been removed.
• Every attempt has been made to include academic grammar and language throughout the revised manuscript paper. The authors are grateful for any forwarded recommendations.

Referee: 2 #

Comments to the Author

This is an interesting paper which adds to the literature in the Australian and NZ context. Please consider this is an Australian and NZ College and change australia to new zealand and australia where applicable through the document e.g. line 23 page 3

There is an additional , after 50+ line 17 pg18 line 28 pg 19

If you are going to state which country the free comments come from I think you should state it on all of them. I would not use the term federal/state council it excludes NZ or if that was used in the survey be clear about that. The low response rate and potential bias in responders should be noted in the discussion.

Author Reply to Referee: 2

Thank you for your comments. These have been noted and the following updates included:

• In the revised manuscript all references now include Australia and New Zealand.
• The identified additional comma has been removed in the revised manuscript.
• All free text comments now include a reference to a country within the revised manuscript.
• Federal and state councils were included in the survey and this has been noted in the content of the revised manuscript.
• The survey response rate is consistent with average internal online response rates of 30-40%, and higher than median survey response rates of 26% across all online survey types. Specifically for RANZCOG membership surveys, our response rate was higher than average.
• We consider that respondent bias is not relevant as the survey was subjective research by design, with respondents being asked specifically for their opinions and experiences in relation to the research subject matter.

Associate Editor #

Comments to the Author:

Thank you for your manuscript which addresses an important issue. In addition to the comments from the reviewers, I request that the authors address the following points:

1. While the paper provides a broader look at leadership within the field of O&G within Aust/NZ the RANZCOG leadership data is not up to date, nor is a recent relevant publication cited (Angstmann et al 2019) included. The value with this paper is that data were collected from hospitals and universities but it is misleading to call them RANZCOG affiliated as this implies that RANZCOG has some influence over the leadership processes in these various organisations. Most valuable is the qualitative component which makes a novel attempt to understand the barriers experienced by women in achieving leadership positions.

2. The abstract contains multiple syntax errors (please adhere to Australian spelling) and acronyms can only be used once the full name has been included

3. The introduction flows poorly with small disjointed paragraphs and sentences reflecting opinion that are  not referenced. eg

“The current disparity between the gender representation of the RANZCOG board and membership threatens the authentic credibility of its leadership.”

“Outcomes for RANZCOG members may thus be less than optimal, further translating into diminished outcomes for the health of women in the community.”

The background section should largely be a review of the current available literature.

There are also syntax errors throughout and abbreviations need to be firstly written in full  eg Royal Australian and New Zealand College of Obstetricians and Gynaecologists before the acronym can be used. Please use Australian spelling throughout.

4. Methods:  Explain how data were collected from the hospitals and universities

5. The discussion and conclusion needs to align with the findings and please take care to use language that is not overly subjective in the discussion. There are several statements where the authors have drawn their own conclusion without justification from other data or sources. For example

" This may simply be an expression of satisfaction with leadership attained and no desire for additional leadership roles."

“It is interesting that arguments of ‘merit’ are mostly made to oppose changes to leadership pathways that threaten the status quo, than to advocate for improving existing systems to become more merit based.”

Author Reply to Associate editor:

• The revised manuscript now focuses on the overall Australia & New Zealand O&G landscape. References to RANZCOG affiliated organisations have been removed in the revised manuscript.
• Syntax errors in the revised manuscript abstract and background section have been removed and acronyms have been used only once the full name has been included.
• The revised manuscript introduction has been updated and sentences reflecting opinion are either referenced or removed.
• The revised manuscript methods section contains details on the collection of data from hospitals and universities.
• The revised manuscript discussion has been updated to better reflect the findings.

September 2019 #

Referee: 1 #

Comments to the Author

I would prefer the term abortion to TOP as most legislation is abortion law

I recommend not starting a sentence with a numeral number. mCI should be added to the written answers espeiailly those that cross and are difficult to see on the graph.

Referee: 2 #

Comments to the Author

Please re-consider your use of the term RANZCOG.  This research is not assessing RANZCOG as an organisation.  It is more appropriate to refer to survey participants as RANZCOG fellows (or diplomates or trainees etc), and describe the research findings as a description of obstetrics and gynaecology within Australia and New Zealand.  This has been partially done, but needs to be consistent throughout the paper.

Please use consistency when describing the hospital “RANZCOG accredited core training hospitals” is an appropriate term.  Please consider using this throughout the manuscript and avoid “RANZCOG affiliated hospitals” or other descriptions.

RANZCOG acronym is appropriately described in its first use, please do the same for O&G (i.e. write out “Obstetric and Gynaecology”)

Please clearly identify aims.

The qualitative component requires further description. The opinion of the majority has been well described in a qualitative manner. Qualitative research papers should use quotes that represent the majority view to demonstrate the points, but also some quotes to demonstrate the outlier views.

Associate Editor #

Comments to the Author:

Thank you for making some changes. Please address the suggestions of the two reviewers. Please also attend to the significant issues I have identified below.

Abstract:

Please use the full name of RANZCOG before using the acronym and the same for O &G. Methods

Change the first line to read “This study comprised an audit of leadership roles in hospitals and universities and a survey of RANZCOG fellows with structured and unstructured components”. The first part of the study really describes an audit of leadership across hospitals and universities in Australia.

The second part is a questionnaire which had open ended questions is not strictly qualitative research- therefore the claim of mixed methods is not correct

Results

More detail on the findings is required. What was the proportion in the leadership?

What proportion of men and women experience gender bias.

What proportion of males and females desired additional and future leadership (and does that mean current and future?).

What was the most commonly cited barrier?

Conclusion

This study purports to be about “gender equity in leadership” yet the conclusion is broader than that separating out gender bias – which may take many forms- from leadership barriers. This requires greater clarify. Consider changing the last line to that in the main text conclusion “Although obstetrics and gynaecology in Australia and New Zealand holds a well identified gender leadership gap, this study has reassuringly found a strong desire for leadership diversity and identified many constructive solutions from our members.”

Introduction

The introduction is still a little disjointed and locally focused. Please merge paragraphs two and three and delete references to individuals the last sentence about the challenge that RANZCOG should rise to meet. Paragraph 4 please try and make the issue broader than O and g in Australia

Paragraph 5. This paragraph should state the aims not what was done

Methods

As above, the questionnaire which had open ended questions is not strictly qualitative research- therefore the claim of mixed methods is not correct. It would be better to state as I have suggested in the abstract exactly what was done. Data analysis

Change “qualitative data” to responses to open ended questions.

Results.

Under the section “O&G leadership”  include the numbers and % as well as the p value.

Gender bias section: there is data missing on line 50-52

Discussion

The discussion should first present the key findings. The first paragraph thus needs to be swapped with the second.

Combine the two paragraphs dealing with “quota versus merit” into one and make it more academic argument with references to other medical organisations that have grappled with this.

At this point the actual was rewritten and resubmitted. #

August 2020 #

Referee: 1 #

Comments to the Author

medical craft groups is an odd description which I don’t recognise as standard terminology There are a few places where I would use a plural were not was I would be consistent through the document with membership or fellows and trainees I prefer the later because it is more accurate but for less words you could define membership at the beginning .

I would amend line 22 and down to read Medicine has long been a male-dominated field, and historically the RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologist), held a significant male membership majority. Angstmann, Woods and de Costa recently (YEAR) outlined, women now comprise 50% of RANZCOG specialists and 83% of RANZCOG trainees.

Author Reply to Referee 1

Thank you for your feedback.

• I have updated medical ‘craft group’ to ‘medical specialties’.
• I have reviewed the article, and as identified (without specific paragraphs), updated several uses of the plural ‘were’ to ‘was’.
• I have updated your suggestion and defined ‘membership’.
• I have updated line 22 as recommended.

Thank you.

Referee: 2 #

Comments to the Author

I think some discussion about how the numbers of women in leadership have changed over the last decade would be interesting. As more of our trainees and subsequently, specialists, are female, has there been an upward trend in women in leadership. Obviously there will be lag time between women becoming specialists and moving into roles of leadership- are we currently seeing that lag time to some extent?

Possibly comment of “limited flexibility” being overcome by zoom meeting rather than having to physically travel to Melbourne may be timely?

Author Reply to Referee 2

Thank you for your feedback.

This article is a review of RANZCOG trainee and Fellows’ views on leadership, gender bias and gender-based discrimination. A general discussion on historical and current leadership gender representation and the data on membership and leadership trends within RANZCOG has already been outlined by Angstmann, Woods, and de Costa (ANZJOG 2019). This is referenced in our article and was not the remit of this paper.

As a general member, I am unaware that RANGCOG has indicated it will engage with ‘zoom meetings’ as its primary meeting format post the COVID-19 pandemic (the current driver of ‘zoom meetings’). It would be presumptive of us to suggest this is now standard RANZCOG practice in this paper but is absolutely worthy of consideration (as suggested by survey responders).

Thank you.

Referee: 3 #

Comments to the Author

Thank you for this paper - it is a very interesting and important study.

I have a few questions after reading and I think there are a few more points you could discuss (see below):

Can you describe how the term gender bias was defined to the study population?

Please include in your discussion why you think gender bias was experienced more by trainees than consultants and again more by younger members than older members

Can you comment further on the data stating that trainees and specialists not identifying as male or female reported the highest rate of gender bias - and what these bias' were?

Author Reply to Referee 3

Thank you for your feedback.

Gender bias was not restrictively defined in the survey so as to maximize the inclusivity of respondents’ views (ie. respondents were surveyed on their perception of bias subjectively experienced by each individual as being due to their identified gender). An academic definition of gender bias has also been added to the paper.

The authors have included a new discussion paragraph summising why gender bias was experienced more by trainees than Fellows, and again more by younger responders than older responders.

Due to the low numbers of survey responders not identifying as male or female, the ‘specific biases’ they reported are not be described because it puts these respondents at risk of de-identification. The authors however note the many publications revealing higher rates of experienced bias among those identifying as LGBTQIA in many industries.

Referee: 4 #

Comments to the Author

The paper is a report on the results of a survey of RANZCOG members views on gender bias and gender-based discrimination. My overall impression is that it does not add significantly to what is already known and what has already been published. In fact, the paper references the Angstmann paper (Angstmann M, Woods C, de Costa. Gender Equity in Obstetrics and Gynaecology – where are we heading? Aust NZ J Obstet Gynaecol. 2019;59: 177-180.) but doesn’t really expand on it or provide any useful new insights or data.

One notable absence is any data on actual participation rates in leadership positions, with the exception of “one woman on the RANZCOG Board”. This is technically incorrect. There are now three women on the RANZCOG Board. There is one female Fellow on the RANZCOG Board. Out of 7 elected positions, there is one woman on the RANZCOG Board. There is no reference to the composition of RANZCOG Council (near gender parity), RANZCOG Committees (at or above gender parity in favour of females), State and New Zealand Committees (some are at, or close to, 100% female). There are no data on the leadership positions in “RANZCOG-accredited hospitals”. Without some sort of benchmark, the paper relies on generalisations.

This point is important. The gender equity issue is historical and current but it also transitional i.e. where were we then, where are we now and where are we going? Is the aim gender parity or proportional representation? Whatever the answer, the data are important and need to be current. This is a weakness in the references. If more recent data are not available then this should be referred to in the Discussion.

The discussion doesn’t offer any developed suggestions as to how to address the issues raised, other than suggesting shorter Council terms.

The paper refers to leadership positions for “departmental or unit heads within RANZCOG affiliated core O&G training hospitals, and department heads within university O&G departments in Australia and New Zealand”. However, these positions are not determined by RANZCOG. The paper does not explain this and the risk is a perception that the lack of gender equity in hospitals and universities in some way reflects RANZCOG policy or that RANZCOG has some responsibility for the inequity. There are no data on the number of actual leadership positions available or the gender distribution.

One last suggestion (which the authors may rightly say is not relevant to their paper but may be interesting nonetheless). RANZCOG has a female CEO and predominantly female staff, including in leadership positions.

Two typos:

[This the] lack of women in top medical leadership roles well known

Rayburn WF. The Obstetrician-Gynecologist Workforce in the United States. Facts, [Figues], and Implications. 2017. Available from:

Comment to Referee 4

Thank you for your feedback.

The authors are unaware of any previous publication of RANZCOG Fellow and trainee experiences of gender bias, and so this paper clearly adds significant and unique data to our understanding of gender issues in Australia and New Zealand obstetrics and gynaecology.

The authors agree that the article by Angstmann M, Woods C, de Costa is an excellent overview of the changing gender representation in our speciality. This article however does not contain Fellow and trainee views of gender bias or gender-based discrimination.

Publishing the data on RANZCOG council composition is not the aim of this paper. This is widely available data on the college website and is contained with the 2019 RANZCOG Gender Equity and Diversity report. Information on this was also contained in the fore-mentioned Angstmann M, Woods C, de Costa article.

The data on leadership positions in “RANZCOG-accredited hospitals in 2017” was disclosed at the 2018 ASM, was published in the primary author’s Master’s thesis in 2018 (with a copy held by RANZCOG) and is contained and referenced in the 2019 RANZCOG Gender Equity and Diversity report. This data was also presented and discussed in the original submission of this paper but removed after advice by the journal’s Referees and Editors because it was considered too duplicative of the Angstmann M, Woods C, de Costa paper.

The aim of this article was to publish RANZCOG member views of gender bias and gender-based discrimination collected via a 2017 survey. This timeline is clearly discussed. Discussion of the greater issues of gender equity was not the remit of this article. This however has been the remit of RANZCOG’s Gender Equity and Diversity Working Group, of which both authors have participated in. Again, the 2019 RANZCOG Gender Equity and Diversity report, co-authored by both authors of this paper, includes potential solutions.

The two typos have been corrected.

The authors have noted your identification of our RANZCOG female CEO and predominantly female staff. This will not be included in our paper for the following reasons:

• It is not relevant to our discussion of Fellow and trainee views, nor to discussion of O&G clinical leadership roles.
• Women have been and remain the gender majority in ‘administrative’ positions in most departments and institutions, just as males have and remain the gender majority in medical leadership positions. Literature on gender and careers reveals this is not because one gender is more capable or desiring of these roles, but instead due to long standing cultural and institutional gender bias on careers and top-level leadership. This issue is outside the remit of this paper.
• Our current female CEO considered against a long history of male RANZCOG CEO’s does not demonstrate that RANZCOG has achieved gender parity in CEO leadership.

Thank you

Associate Editor #

Comments to the Author:

There are some major concerns expressed by Reviewer 4, and more minor ones from the other reviewers, that need to be addressed by the authors before the paper can be considered for ANZJOG.

The actual current situation for the RANZCOG Board and the various committees need to be spelt out and the transitional nature of the gender balance on these explained. It is also important to explain that leadership positions in universities and public and private hospitals are not the responsibility of RANZCOG.

If possible, more data should be provided about senior university roles in 2020 which may have changed since some of your original research was done. Please address all these issues and resubmit your manuscript.

Author Reply to the Associate Editor

Thank you for your feedback.

The authors have addressed reviewers’ comments, in particular the concerns of reviewer 4.

The current situation of the RANZCOG board and various committees has been previously outlined by Angstmann, Woods, and de Costa (ANZJOG 2019). This is referenced in our article. Spelling out the current situation of the RANZCOG Board and various committees is not the aim of this paper.

The authors note that this article was submitted prior to the RANZCOG board releasing its transitional tool for board gender and council equity. This could not and should not have been included at that time.

The focus of this article is the publication of members views and experiences, not RANZCOG’s gender equity tools or possible solutions. These areas are deserving of their own articles given the complexities and many stakeholders. RANZCOG’s gender equity tools and solutions are clearly outlined in the RANZCOG Gender Equity and Diversity report, co-authored by this paper’s authors. The authors do not think there is benefit in duplicating this already publicly available work.

The authors would argue that it is incorrect to assert that all leadership positions in universities and public and private hospitals are not the responsibility of RANZCOG. As an example, ITP coordinators fall under RANZCOG regulations. RANZCOG has considerable power available to guide.

To ensure that no misinterpretation on the responsibility of leadership, the following paragraph has been updated:

‘Leadership was defined as holding a professional ‘position of leadership’, including departmental or unit heads within RANZCOG affiliated core O&G training hospitals, and department heads within university O&G departments in Australia and New Zealand’. These positions are commonly independent from formal RANZCOG governance.

We have not included any data on University positions after ANZJOG editorial feedback to the authors’ first submission of this paper. The current article does not contain any data on university leadership. Including and/or updating this data is not relevant to the paper’s focus.

The authors strongly believe that if ANZJOG genuinely values members views and experiences as presented in this article, then this paper should be judged on its relevance and importance, resisting any bias toward the subject matter.

October 2020 #

Associate Editor Pre-amble #

[emphasis added]

I regret to inform you that after editorial assessment and external peer review, I am not able to accept it for publication.

Your revised article was returned to the original reviewers, who confirmed that the requested amendments had been incorporated. However, the editorial team felt it to be essential that additional opinions be sought [referees 3 and 5] and these reviews are included below. Associate Editor comments are also provided.

I note one of the reviewers suggested that the manuscript may be better suited as a ‘Short Communication’. We would consider a new submission, meeting the Short Communication requirements outlined in the ANZJOG Author Guidelines, on its own merits should you wish to pursue that option.

I appreciate the effort that goes into the preparation of a manuscript and the disappointment when it is not accepted. Thank you for submitting your work to The Australian and New Zealand Journal of Obstetrics and Gynaecology, and I look forward to future contributions from you.

Referee: 3 #

Comments to the Author

The issue that are discussed in this paper are very important. The data is new and worth sharing. Unfortunately, the way that the discussion is written conveys to the reader that the authors are pushing an agenda, possibly a worthy agenda. My concern is that this paper unfairly maligns RANZCOG and places an unreasonable burden on RANZCOG to influence leadership positions that are outside the College’s remit, while failing to adequately discuss the leadership positions that are clearly within the College’s control i.e. President, Board, Council and subcommittees. Simply referencing the Angstmann paper is insufficient. The use of the term “RANZCOG associated environments” is misleading. The authors suggest that RANZCOG carries responsibility for the culture in all tertiary obstetric units or teaching facilities where RANZCOG trainees are present. They make no mention of the Diploma candidates, who also fall under RANZCOG’s remit. Furthermore, while the respondents identified circumstances that reflect broader social paradigms e.g. available time, family commitments and personal energy, the authors concentrate on RANZCOG, not discussing the need for broader societal changes.

In their response to the first review, they stated that “Publishing the data on RANZCOG council composition is not the aim of this paper” but they have still commented on Council composition and RANZCOG-specific leadership positions “Our survey responses identified many additional leadership barriers to those previously discussed, including the ‘limited flexibility’ of council commitments, the lack of formalised ‘leadership training’ and ‘succession planning’, and the need for a ‘changing of the guard’, encouraging shorter leadership terms. Prioritising these areas for both males and females will improve gender leadership equity within RANZCOG, and many of these are already actioned recommendations from RANZCOG’s 2019 Gender Equity and Diversity Report”. This creates confusion - is the paper about leadership positions within the College, or in other settings? If it’s about both, then data on both should be provided. If the paper is exclusively about leadership in hospitals, then this should be explicit, and the connection of leadership positions and RANZCOG should be more clearly defined.

Finally, since the paper refers to actions from the 2019 Gender Equity and Diversity Report, it would be constructive if the authors expanded on what those changes are and how they address (or not) the concerns identified in their study. I think that it is disingenuous to state “The focus of this article is the publication of members views and experiences, not RANZCOG’s gender equity tools or possible solutions.” but the tone of this paper is, in my opinion, overtly critical of RANZCOG, without acknowledgement of the changes that have occurred, or suggestions for change. In my opinion, it is not simply a report of a survey. Rather, it is an opinion article. Without adequate analysis and discussion, it conveys a biased, rather than balanced, position.

Referee: 5 #

Comments to the Author

The subject matter of this paper is indeed interesting and relevant to current O&G practice.  Following prior revision, the manuscript is grammatically and sequentially sound. However there are important methodological issues to be addressed before it would be suitable for publication.

What is the study hypothesis or aim? Are you assuming gender bias is prevalent in Aust and NZ because it is documented elsewhere and that you are wanting to understand trainee perspectives on bias? Your quantitative findings suggest that you are firstly demonstrating that bias is present (Figure 1).  Please clarify the study aim in the introduction.

With regards to the quantitative data, were all the questions in Table 1 free response or were they more prescriptive e.g. question 1 ‘yes’ ‘no’ ‘unsure’ selection, and question 2 a list of gender bias categories to choose from? Or did the items listed in Figure 3 arise from thematic analysis of the responses? It would be clearer for the reader to qualify this.  In addition to the questions in Table 1, it appears you sought information on training level (fellow vs trainee), age and sex (male or female) of the respondent—again not clearly outlined in the methods.  What about training location (rural or metropolitan), and respondent ethnicity?  These would likely impact on the respondents perception of bias in the workplace as alluded to in the first part of the discussion.  Whilst the paper focuses on gender bias, these other factors are important confounders and need to be addressed in your methodology.

Unfortunately the qualitative analysis is superficial and some of the conclusions drawn are presumptive. Firstly there is no exploration of what gender bias means to the respondents and it is likely this would differ based on other individual respondent factors that have not been inquired about in your study e.g. ethnicity, experiences from other work-place settings (e.g. careers prior to medicine and O&G).  Before any conclusions can be made about whether respondents experience bias, and which types of bias, the definition of bias among the cohort needs to be characterised.  Analysing differences in perception of gender bias is crucial to outlining the remainder of your argument as your quantitative findings point towards a difference between self-versus others perceived biases (Figure 3). Of equal importance is the setting in which the respondents are training or practicing; there is no mention of regional exposure versus metropolitan exposure and how perceptions of bias and training opportunities are impacted by location and institutional expectations. To draw meaningful conclusions on such a layered topic, the analysis requires use of more formal qualitative methodologies via anonymous in-depth interviews and a more comprehensive sub-theme analysis using grounded-theory or narrative analysis.

Perhaps the manuscript would be better prepared as a short communication of the quantitative findings gathered from the first 2 questions in each survey category.  This would then allow you to focus on the fact that gender bias is recognised and experienced by respondents and that it appears to impact on clinical opportunities for male trainees, and leadership positions and advanced surgical experience for female Fellows. Illuminating the implications of bias on training quality is more likely to result in a structured/objective approach for improvement.

Associate Editor #

Comments to the Author:

This manuscript addresses an important issue but due to a significant lack of alignment throughout the paper about the aims,  a lack clarity in the methods and a discussion that requires further consideration, it is not suitable for publication.

In addition to the reviewers comments, my suggestions for consideration are

Abstract

The background section focuses on leadership yet the title and the main aim is about gender equity.

The description of the methods is not accurate.

The results and conclusion are merged and no data is presented.

Introduction

The introduction is muddled – the leadership discussion should follow the discussion of gender discrimination.

Methods

The details of the survey are lacking.

Discussion

The discussion contains rhetoric and lacks rigor. There was no information about sexual diversity so the comment in the first paragraph is true but not a finding in this study. Again the primary aim as stated by the authors is to “review RANZCOG Fellow and trainee views on gender bias and gender based discrimination.” This should be the main focus of the discussion.

Final Author Response #

Dear ANZJOG team,

I am withdrawing my application for publication. I will not be resubmitting an edited version or short communication.

Regards, Kirsten

October 2020