Answer to the Letter to the Editor Regarding the Article “Obstetric Paralysis: Who is to Blame? A Systematic Literature Review”

Abstract

We appreciate your considerations to the article. Our aim was to debate how the evolving medical knowledge, now supported by the digital revolution, has challenged some long-standing, classic definitions. We discussed data from the former Medical Insurance Association of America, from January 1985 to December 2001, referring to malpractice charges to the birth attendant physician in cases of obstetric paralysis.1 Since the publication of the study by Jennett et al.,2 in 1992, we believe that publications from the last 20 years or so have been changing howbrachial plexus injury at birth is viewed; in our opinion, this is a better denomination than obstetric paralysis. Regarding the title, a systematic literature review is defined as a secondary study with the aim of grouping similar studies, published or not. It critically evaluates the methodology of these studies and, whenever possible, includes a statistical analysis, in a so-called meta-analysis. Since it synthesizes data from similar primary studies of relevant scientific quality, it is considered the best level of evidence to make therapeutic decisions and establish medical management strategies.3,4 To avoid an analysis bias in a systematic review, data selection and assessmentmethods are defined beforehand in a well-defined, rigorous process. Initially, a clinical hypothesis is elaborated to define the focus of the study. Next, a wide literature search is carried out to identify the largest possible number of studies related to the subject. Papers are selected, and then their methodological quality is assessed based on the original study.5 Therefore, we partially agree with the criticism regarding the title and classification of our study. The study was called “systematic review of literature”, and not just “systematic review”, because it uses all the elements required to make a classic systematic review, which assesses primary studies, that is, randomized clinical trials, summarizingfindings from systematic review articles alone. Thus, we used only outcomes from these systematic reviews that are important for evidence-basedmedicine, obtained from the primary studies previously evaluated by these reviews. Such (systematic) organization assures the same technical-scientific quality for our study, since several primary studies were indirectly evaluated.