Background: Qualitative-evidence syntheses published in the Cochrane Library provide evidence that can inform or complement effectiveness reviews. The GRADE-CERQual approach assesses confidence in the evidence generated from these syntheses, based on 4 key components: methodological limitations of studies contributing to a review finding; coherence of the review finding; adequacy of the data contributing to a review finding; and, relevance of the included studies to the review question. Several syntheses published in the Cochrane Library have now utilised this approach. These experiences provide opportunities for learning and further development of GRADE-CERQual.
Objectives:To discuss our experience of applying GRADE-CERQual to the synthesis: ‘Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low-and middle-income countries’.
Methods: As part of the analysis of the qualitative evidence synthesis, one review author applied the 4 components of GRADE-CERQual, and made a judgement about the overall confidence in each review finding. Discussions were held with one or two other co-reviewers to refine the GRADE-CERQual assessment. We judged our confidence as high, moderate, low or very low.
Results: Of 51 findings, we graded 2 as high confidence, 16 as moderate confidence, and the remaining findings as low or very low confidence. The synthesis included descriptive and complex findings with varying degrees of transformation. Application of GRADE-CERQual to such complex findings presented unique challenges. For instance, more transformed findings often led to concerns about coherence and the review team had to choose between more descriptive and less-transformed findings to increase level of confidence in the finding; or opt for more transformed findings that were potentially more helpful to decision makers. We will also describe the unique challenges that arose in relation to our framing of the overall assessment of confidence and in creating summaries of the findings.
Conclusions: Our experiences in applying GRADE-CERQual provide useful insights for further development of the approach.