Assessment of Grades of Recommendations and Applicability of Royal College of Obstetricians and Gynaecologists Green‐Top Guidelines: A Cross‐Sectional Study

BACKGROUND: Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guidelines (GTGs) 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 reflected in study design. OBJECTIVES: To determine distribution of recommendation grades across obstetric GTGs. For Grade A recommendations, to evaluate if supporting studies reported equity-relevant design features and methodological robustness. DESIGN: Review of RCOG obstetric GTGs. SETTING: United Kingdom. SAMPLE: All RCOG non-archived obstetrics GTGs published up to 20 April 2025. METHODS: Frequencies of Grade A-D recommendations and Good Practice Points were recorded. For Grade A recommendations, underpinning studies were assessed for health equity and generalisability. All primary studies underpinning every Grade A recommendation were included; where a single study supported multiple recommendations, it was included every time and mapped to each relevant recommendation. The median health equity and generalisability score for each recommendation (if > 1 supporting studies) and a median score of all Grade A recommendations per guideline was calculated. MAIN MEASURE OUTCOMES: Distribution of recommendation grades: health equity and methodological robustness scores for studies underpinning Grade A recommendations. RESULTS: Variable frequencies of Grade A, B, C, D recommendations and GPP from 37 eligible guidelines were noted. Only 28 GTGs had Grade A recommendations, with median health equity and generalisability scores of 1 of 13 and 6 of 10 respectively across those recommendations. CONCLUSIONS: Twenty-four percent of obstetric GTGs have no Grade A recommendations. Of those that do, consideration of health equity and generalisability in associated studies is limited. These design and reporting features should be considered in future research to improve applicability of clinical guidance to all patient groups.