Strengths and limitations
We identified several strengths in our study to share. Firstly, the
appraisal conducted in this review was performed by an expert
specialized clinical team of obstetricians and gynaecologists,
internists, and hematologists guided by an expert CPG methodologist,
which adds a layer of strength to the AGREE II assessment.
An additional implication for clinical practice is to encourage care
providers for pregnant women with SCD to adopt principles of
’evidence-based’ and ’eminence-based’ healthcare together in their daily
practice through continuous training and education on standards of
high-quality CPG and their appraisal tools.27-31
Furthermore, the results of this review can be used as a basis for CPG
development or adaptation projects for pregnant women with SCD.
Furthermore, they highlight the importance of inclusion of the AGREE II
criteria in the capacity building for clinicians to guide their
identification and adoption of CPGs for use in their daily practice.
The study methodology has several strengths as well; (i) the use of an
international, rigorously structured, and validated CPG appraisal tool:
the AGREE II instrument, (ii) appraisal of each CPG by four raters
including four clinical topic experts and a CPG methodologist, (iii) a
comprehensive search within several databases, (iv) interrater
differences were statistically assessed.
Our study also has several limitations. First, the AGREE II instrument
has several updates and different versions. Some of the disadvantages of
AGREE II have been addressed in the recently developed ’AGREE-REX’
(Recommendation EXcellence) tool that addresses clinical credibility of
the CPG recommendations. AGREE-REX has been validated and shared
publicly on the wesbite.26
The selection of 70% as a cut-off point for standard domain ratings is
another potential limitation as the original AGREE II does not mandate
such a cut- off but similar studies have suggested so as
well.25
Other limitations include, apart from those imposed by the AGREE II, the
following; (i) English language CPGs may have resulted in the exclusion
of relevant CPGs intended for use in non-English speaking healthcare
settings; (ii) this review mainly focused on CPGs for management of
pregnant women with SCD, due to its known burden and priority for
maternity health, and did not evaluate other subcategories of the sickle
cell as it was out of the scope of this study; (iii) The included CPGs
belong to two different healthcare systems (i.e. US-based and UK-based)