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      An Updated Systematic Review and Meta-Analysis of the Obstetric Consequences of Female Genital Mutilation/Cutting

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          Abstract

          In our recent systematic review in Obstetrics and Gynecology International of the association between FGM/C and obstetric harm we concluded that FGM/C significantly increases the risk of delivery complications. The findings were based on unadjusted effect estimates from both prospective and retrospective studies. To accommodate requests by critics, we aimed to validate these results through additional analyses based on adjusted estimates from prospective studies. We judged that 7 of the 28 studies included in our original systematic review were prospective. Statistical adjustments for measured confounding factors were made in eight studies, including three prospective studies. The adjusted confounders differed across studies in number and type. Results from meta-analyses based on adjusted estimates, with or without data from retrospective studies, consistently pointed in the same direction as our earlier findings. There were only small differences in the sizes or the level of statistical significance. Using GRADE, we assessed that our confidence in the effect estimates was very low or low for all outcomes. The adjusted estimates generally show similar obstetric harms from FGM/C as unadjusted estimates do. Thus, the current analyses confirm the findings from our previous systematic review. There are sufficient grounds to conclude that FGM/C, with respect to obstetric circumstances, involves harm.

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          Most cited references 58

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          GRADE guidelines: 3. Rating the quality of evidence.

          This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence. Copyright © 2011 Elsevier Inc. All rights reserved.
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            GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.

            This article is the first of a series providing guidance for use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments (HTAs), and clinical practice guidelines addressing alternative management options. The GRADE process begins with asking an explicit question, including specification of all important outcomes. After the evidence is collected and summarized, GRADE provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations are characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of the alternative management options. GRADE suggests summarizing evidence in succinct, transparent, and informative summary of findings tables that show the quality of evidence and the magnitude of relative and absolute effects for each important outcome and/or as evidence profiles that provide, in addition, detailed information about the reason for the quality of evidence rating. Subsequent articles in this series will address GRADE's approach to formulating questions, assessing quality of evidence, and developing recommendations. Copyright © 2011 Elsevier Inc. All rights reserved.
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              Evaluating non-randomised intervention studies

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                Author and article information

                Affiliations
                The Norwegian Knowledge Centre for the Health Services, P.O. Box 7004, St.Olavs Plass, 0130 Oslo, Norway
                Author notes

                Academic Editor: John R. Van Nagell

                Journal
                Obstet Gynecol Int
                Obstet Gynecol Int
                OGI
                Obstetrics and Gynecology International
                Hindawi Publishing Corporation
                1687-9589
                1687-9597
                2014
                23 November 2014
                : 2014
                25505915 4258320 10.1155/2014/542859
                Copyright © 2014 R. C. Berg et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Obstetrics & Gynecology

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