What do we know about tocolytic effectiveness and how do we use this information in guidelines? A comparison of evidence grading.

BACKGROUND: Evidence summaries of tocolytic effectiveness assign quality levels based on a single dimension: the study design. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system takes into account several domains, including limitations of the study design and ranking the importance of outcomes. OBJECTIVES: The aim of the study was to compare the quality of evidence according to GRADE with the quality as described by existing guidelines. SEARCH STRATEGY: A practitioner survey to rank the importance of outcomes and a systematic review were conducted. For the systematic review, we searched Medline, Embase, and DARE databases from inception to December 2010 using the terms 'tocolytics' and 'threatened preterm labour', without any language restrictions. SELECTION CRITERIA: Inclusion criteria for the review were randomised controlled trials comparing tocolytics with either placebo or betamimetics. DATA COLLECTION AND ANALYSIS: The review and survey teams worked independently. Evidence ratings according to GRADE were performed. MAIN RESULTS: The majority of the survey respondents thought that it was important to use tocolytics to buy the time needed for steroids to promote fetal lung maturation and to allow in utero transfer. Nearly 80% of 'high' ratings in guidelines were downgraded as a result of deficiencies identified by GRADE. AUTHORS' CONCLUSIONS: We propose a move away from the use of evidence rating systems reliant solely on study design, as they have a propensity towards strong recommendations when the underlying evidence is weak.

Interpregnancy interval and perinatal outcomes across Latin America from 1990 to 2009: a large multi-country study

Objective: To determine the relationship of interpregnancy interval with maternal and offspring outcomes. Design: Retrospective study with data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Uruguay. Setting: Latin America, 1990-2009. Population: A cohort of 894 476 women delivering singleton infants. Methods: During 1990-2009 the Perinatal Information System database of the Latin American Centre for Perinatology identified 894 476 women with defined interpregnancy intervals: i.e. the time elapsed between the date of the previous delivery and the first day of the last normal menstrual period for the index pregnancy. Using the interval 12-23 months as the reference category, multiple logistic regression estimated adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) of the association between various interval lengths and maternal and offspring outcomes. Main outcome measures: Maternal death, pre-eclampsia, eclampsia, puerperal infection, fetal death, neonatal death, preterm birth, and low birthweight. Results: In the reference interval there was 0.05% maternal death, 1.00% postpartum haemorrhage, 2.80% pre-eclampsia, 0.15% eclampsia, 0.28% puerperal infection, 3.45% fetal death, 0.68% neonatal death, 12.33% preterm birth, and 9.73% low birthweight. Longer intervals had increased odds of pre-eclampsia (>72 months), fetal death (>108-119 months), and low birthweight (96-107 months). Short intervals of <12 months had increased odds of pre-eclampsia (aOR 0.80; 95% CI 0.76-0.85), neonatal death (aOR 1.18; 95% CI 1.08-1.28), and preterm birth (aOR 1.16; 95% CI 1.11-1.21). Statistically, the interval had no relationship with maternal death, eclampsia, and puerperal infection. Conclusions: A short interpregnancy interval of <12 months is associated with pre-eclampsia, neonatal mortality, and preterm birth, but not with other maternal or offspring outcomes. Longer intervals of >72 months are associated with pre-eclampsia, fetal death, and low birthweight, but not with other maternal or offspring outcomes. (AU)

Benchmarks of fairness for health care reform: A policy tool for developing countries

"…We report here on progress we have made toward developing the benchmarks of fairness into a policy tool that will be useful in developing countries for analyzing the overall fairness of health care reforms…"