Assessment of Grades of Recommendations and Applicability of Royal College of Obstetricians and Gynaecologists Green-top Guidelines: implications for clinical practice

Background: Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guidelines (GTGs) aim to provide evidence-based recommendations in women’s health. Even where evidence is considered high quality; it is uncertain whether factors, known to influence maternity outcomes, are accounted for in study design. Objectives: 1. To evaluate obstetric GTGs to determine the distribution of grades of recommendations. 2. For Grade A recommendations, to evaluate if supporting studies accounted for health equity and generalisability. Search Strategy Review of RCOG obstetric GTGs (20 April 2025). Methods: Frequencies of Grade A–D recommendations and Good Practice Points were recorded for obstetric GTGs. For Grade A recommendations, underpinning studies were assessed for health equity based on priorities identified from MBBRACE 2024 and two global equity frameworks (scored 0-13) and generalisability using a previously validated framework (scored 0-10). The median health equity and generalisability score for each recommendation and a total score of all Grade A recommendations was calculated. Main Results Frequencies of Grade A, B, C, D recommendations and GPP from 37 eligible guidelines were 5.3%, 11.2%, 14.8%, 25.4% and 43.2% respectively. Ninety-nine Grade A recommendations were made in 28 GTGs based on 189 studies. Median health equity and generalisability scores were 1 (range 0-4) and 6 (range 0-9) respectively. Conclusions: Twenty-four percent of obstetric GTGs have no recommendations based on high level evidence. Of those that do, consideration of health equity and generalisability in associated studies is limited. These should be considered in future research to ensure clinical guidance is translatable to all patient groups.