Discussion
To the best of our knowledge, this is the primer review that systematically evaluates the quality of recently published CPGs of SCD in pregnancy using the AGREE II instrument.
Four CPGs addressing the management of pregnant women with SCD were assessed using the AGREE II instrument. This AGREE II assessment highlighted several areas of improvement in the methodological rigor of the included CPGs. One CPG (ACOG) had significant gaps in its rigor of development (Domain 3), which is the largest and core domain, and three CPGs demonstrated areas for improvement in their applicability (Domain 5). The weight of these two domains has been emphasized. The NICE CPG received the highest reviewer agreement ratings.22 All of the four included CPGs had commonalities and differences in their clinical recommendations and are summarized in Table 5. Commonalities included genetic screening (ACOG, RCOG), genetic diagnosis (ACOG, NHLBI, RCOG), counselling during pregnancy (all four CPGs), transfusion or prophylactic exchange transfusion (ACOG, NICE, RCOG), fetal surveillance (ACOG, NHLBI, RCOG), and contraception (NHLBI, RCOG).
One Discrepancy was observed in the form of a lack of clearly articulated recommendations for vaccination status updated pre-pregnancy in three CPGs (ACOG, NHLBI, NICE) where it was addressed in the RCOG CPG only. PRISMA checklist was reported in Table 7.
Two CPGs (ACOG and RCOG) were more specific on pregnancy compared to the other two CPGs that contained general recommendations on SCD with smaller sections focused on pregnancy. Out of the two specific CPGs, RCOG consistently scored higher in all domains of our assessment. This systematic and objective assessment of the available CPGs is beneficial to support the decision to adopt or adapt CPGs in clinical practice. After reviewing these CPGs and given the appropriate rigor and consistently high scores with RCOG and its relevance clinically, we decided to adopt all the recommendations of this CPG in our clinical practice.
The findings of our study revealed that the CPG assessment was accurate. There was excellent/ very good inter-rater agreement between the four assessors who evaluated the eligible four CPGs using AGREE II. In our results, we were able to show that our proposed approach for quality assessment could be seen as a significant example of similar systematic reviews and assessments of CPGs.
Furthermore, our statistical analysis illustrates the practicability of the AGREE II instrument as a valuable tool in the critical appraisal of CPGs, without compromising quality. We trust in the experience of our raters who participated in the inter-observer agreement. Conceivably, inexperienced staff or non-professional reviewers would not have been able to have similar agreement on clinical decision features or characteristics in CPGs that could impact the judgement related to the provision of care to pregnant women with SCD.
In the first half of 2019 only, more than eight systematic critical appraisals of CPGs in obstetrics and gynecology have been published using the AGREE II instrument. These included high priority health topics like; induction of labor32, planned caesarean section33, recurrent pregnancy loss34, packed red cells versus whole blood transfusion for severe pregnancy‐related anemia and obstetric bleeding35, gestational diabetes mellitus36-38, and bladder pain syndrome/interstitial cystitis39. The studies mentioned above studies have identified several gaps in the included CPGs, including differences, discrepancies, lack of evidence-base, and inconsistencies in some clinical recommendations in addition to commonalities and similarities in other recommendations with future advice to improve these variabilities in CPGs.32-39