How useful is what we have? Limitations of Cochrane Reviews, the case of substance treatment in pregnancy
Abstract
Aims: To describe the public health promise and methodological problems of \nCochrane reviews. \nCochrane reviews are central to evidence-based medicine. However by focusing \nexclusively on randomized controlled trials (RCTs) a large swath of the published \nliterature is excluded from their purview. Our experience conducting three of the \nfour published reviews that examined interventions for substance use in pregnancy \nhas brought particular methodological issues to light. Pregnancy is timelimited \nevent and therefore amenable to a RCT intervention. However this study \ndesign is employed mostly in academic centers serving poor inner-city women. \nHow useful then is this evidence? We begin with a brief overview of the \nCochrane Library with particular emphasis on the addiction and obstetric literature. \nThen the following methodological topics are addressed: the tensions \nbetween clinically useful, clinically expedient, and sociologically meaningful outcomes; \nthe difference between experimental and real world interventions; problems \nin external validity due to RCT recruitment in pregnancy; and confounding \nand bias in exposure assignment. We contrast our results from Cochrane \nreviews with the observational studies that were excluded from our reviews. \nFinally we argue for a more flexible design for systematic reviews that can allow \nthe inclusion of more diverse study designs. The current Cochrane software \n(RevMan 5.0) appears to offer hope for this. \n…
How strong is the evidence?
Evidence Hub reads this as a randomized trial, done in people. Its evidence level is 2 of 5 (High · randomized trial). Randomized trials of a reasonable size are the strongest single-study design.
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