Highlights
This cross-sectional study of Royal College of Obstetricians and Gynaecologists (RCOG) Green-Top Guidelines reveals critical gaps in evidence-based obstetric care recommendations. Among 37 eligible guidelines, 24% contained no Grade A recommendations—the highest level of evidence-based guidance. For guidelines with Grade A recommendations, supporting studies demonstrated limited health equity considerations, with a median score of only 1 out of 13 possible points, and moderate generalisability scores of 6 out of 10. These findings underscore the need for improved research design and reporting standards to enhance the applicability of clinical guidance across diverse patient populations.
Background: The Role of Evidence-Based Guidelines in Maternity Care
Clinical practice guidelines serve as essential tools for standardizing healthcare delivery and ensuring patients receive evidence-based care. The Royal College of Obstetricians and Gynaecologists (RCOG) Green-Top Guidelines (GTGs) represent the cornerstone of evidence-based recommendations in women’s health within the United Kingdom, providing clinicians with graded recommendations that reflect the strength of underlying evidence.
The grading system employed by RCOG categorizes recommendations from Grade A (based on high-quality randomized controlled trials or systematic reviews) through Grade D (based on expert opinion or case series), with Good Practice Points (GPP) representing recommended best practice based on clinical experience. This hierarchical approach theoretically ensures that the most robust evidence supports the strongest clinical recommendations.
However, a fundamental question emerges: even when evidence is considered high quality, do the underlying studies adequately reflect factors known to influence maternity outcomes across diverse populations? Health equity considerations—including representation of minority groups, socioeconomic factors, and geographic diversity—remain inconsistently addressed in clinical research. Similarly, generalisability of study findings depends heavily on sample characteristics, inclusion criteria, and methodological rigor.
This study aimed to systematically evaluate the distribution of recommendation grades across obstetric GTGs and assess whether Grade A recommendations are underpinned by studies demonstrating health equity considerations and methodological robustness.
Study Design and Methods
This cross-sectional study conducted a comprehensive review of all RCOG non-archived obstetrics Green-Top Guidelines published up to April 20, 2025. The research team evaluated guideline documents to determine the distribution of recommendation grades across different levels (A, B, C, D) and Good Practice Points.
For Grade A recommendations specifically, the investigators conducted a detailed assessment of the underpinning primary studies. The evaluation focused on two critical domains: health equity considerations and generalisability. Health equity was assessed across 13 dimensions, examining whether studies addressed factors such as race/ethnicity representation, socioeconomic status considerations, age diversity, geographic representation, and other equity-relevant design features. Generalisability was evaluated using a 10-point scoring system that assessed methodological quality, sample diversity, and external validity indicators.
The analytical approach included all primary studies supporting each Grade A recommendation, with individual studies mapped to multiple recommendations when applicable. For recommendations supported by more than one study, median scores were calculated to characterize the overall quality profile of the evidence base.
Key Findings
Of the 37 eligible obstetric Green-Top Guidelines included in the analysis, significant variability was observed in the distribution of recommendation grades. The study documented the frequencies of Grade A, B, C, D recommendations and Good Practice Points across these guidelines, revealing substantial heterogeneity in the strength of evidence supporting clinical recommendations in obstetric practice.
A striking finding was that only 28 of the 37 guidelines (76%) contained any Grade A recommendations. This means that nearly one-quarter of RCOG obstetric guidelines lack the highest level of evidence-based support, relying instead on lower-grade recommendations or Good Practice Points for clinical guidance.
For the Grade A recommendations that were identified, the assessment of health equity considerations revealed substantial deficiencies. The median health equity score was 1 out of a possible 13 points, indicating that supporting studies rarely incorporated equity-relevant design features. This finding suggests that even the highest-quality evidence underpinning RCOG recommendations may not adequately represent the full spectrum of patients encountered in clinical practice.
Generalisability scores for studies supporting Grade A recommendations showed a median of 6 out of 10 points, indicating moderate but incomplete consideration of external validity. While this represents better performance than health equity considerations, there remains considerable room for improvement in designing and reporting clinical studies to enhance their applicability to diverse patient populations.
The median scores calculated for each recommendation (where multiple studies supported the recommendation) and the aggregate median score across all Grade A recommendations per guideline provide a comprehensive picture of the current state of evidence quality in obstetric guidelines.
Expert Commentary: Implications for Clinical Practice and Research
These findings carry significant implications for clinicians, guideline developers, and health policy makers engaged in obstetric care. The limited consideration of health equity in studies supporting high-level recommendations raises concerns about the applicability of guidelines to underserved populations, ethnic minorities, and patients with complex social circumstances.
The absence of Grade A recommendations in 24% of guidelines highlights gaps in the evidence base for obstetric practice. While lower-grade recommendations and Good Practice Points remain valuable, they carry inherently greater uncertainty and may rely more heavily on expert opinion than on rigorous empirical evidence.
Methodologically, the study identifies specific areas requiring attention in future clinical research. Health equity considerations should be embedded in study design from inception, including representative sampling strategies, collection of stratified outcome data, and explicit assessment of social determinants of health. Generalisability can be enhanced through broader inclusion criteria, multi-center designs, and transparent reporting of sample characteristics.
Guideline development processes should also evolve to require documentation of equity considerations when evaluating the quality of underlying evidence. This may involve incorporating equity assessment tools into the grading framework for recommendation strength.
Limitations of the current analysis include the cross-sectional design, which captures guideline quality at a single time point, and the reliance on reported information in supporting studies, which may underestimate actual equity considerations. Future longitudinal studies could track improvements in these metrics over time as awareness of equity issues grows.
Conclusion
This comprehensive assessment of RCOG Green-Top Guidelines reveals that while the UK healthcare system benefits from a robust guideline development infrastructure, significant gaps remain in the evidence base supporting obstetric recommendations. The finding that nearly one-quarter of guidelines lack Grade A recommendations, combined with limited health equity considerations in highest-quality evidence, signals a need for transformative change in both clinical research and guideline development practices.
The median health equity score of 1 out of 13 and generalisability score of 6 out of 10 for Grade A recommendations underscore that even the strongest evidence may not adequately serve all patient groups. As maternity care increasingly recognizes the importance of personalized, culturally sensitive approaches, ensuring that clinical guidance reflects diverse populations becomes paramount.
Future research should focus on developing standardized tools for assessing equity considerations in clinical studies, implementing reporting requirements for demographic diversity, and establishing accountability mechanisms within guideline development processes. Until these improvements are realized, clinicians should exercise appropriate caution when applying guideline recommendations to patients whose characteristics may differ from study populations.
The path forward requires collaborative efforts among researchers, guideline developers, funding bodies, and clinical communities to ensure that evidence-based recommendations truly serve all patients in the diverse landscape of modern maternity care.
References
Kumar A, Cocking A, Hall M, Morris J, Sankaran S, Lovell H, Shennan A, Nicolaides K, Story L. Assessment of Grades of Recommendations and Applicability of Royal College of Obstetricians and Gynaecologists Green-Top Guidelines: A Cross-Sectional Study. BJOG : an international journal of obstetrics and gynaecology. 2026-04-01. PMID: 41918447.
Royal College of Obstetricians and Gynaecologists. Green-Top Guidelines. Available at: https://www.rcog.org.uk/guidelines
