References Supporting Recommendations in Obstetrical Green Top Guidelines: An Overview of RCOG Clinical Guidelines

Abstract

Objective

Green-top Guidelines (GTGs) by the Royal College of Obstetrics and Gynecology (RCOG) guide clinical practices similar to Practice Bulletins (PBs) by the American College of Obstetrics and Gynecology (ACOG). Previous analyses reveal that most recommendations lack Grade A evidence and are not based on randomized clinical trials (RCTs). This descriptive study evaluates the quality of evidence supporting RCOG Obstetrical recommendations.

Study Design

We reviewed obstetrical RCOG GTGs available as of September 2024, checking each citation in PubMed for RCT status. Quality assessments were not made independently. The senior author verified a random 10% of the data (B.J.F.H.). Data were recorded and summarized in Excel.

Results

RCOG lists 37 obstetrical GTGs with 1,861 recommendations. About 1,288 (69%) of recommendations are supported by 3,674 references. A total of 43% of GTGs rely on consensus and expert opinion. When omitting recommendations based on expert opinion, 98 (9%) of RCOG recommendations are Grade A (based on high-quality evidence), and of the cited references, 5% of GTGs are Evidence Level 1 + + (highest quality), while 7% are RCTs.

Conclusion

Among the recommendations, 69% of GTGs have identifiable references. However, 43% of GTG references are nonanalytical studies or expert opinions. Our findings highlight the need for more high-quality evidence in guidelines and suggest further research in evidence-based obstetrical care.

Key Points

• Of 1,861 obstetrical recommendations, 69% cite references, but 43% rely on expert opinion.

• Only 9% of the GTGs meet Grade A standards, showing limited high-quality references.

• About 43% of the guidelines are based on clinical experience, with 5% having the highest evidence strength.

• Only 7% of references come from RCTs.

• The research highlights the need for stronger, evidence-based guidelines.

Keywords

Green-top Guidelines - evidence-based medicine - quality of evidence - expert opinion in guidelines

Authors' Contributions

• H.M.S.: Data extraction, formal analysis, writing—original draft.

• H.M-F.: Methodology, writing—review and editing.

• S.P.C.: Conceptualization, methodology, writing—review and editing.

• B.J.F.H.: Conceptualization, methodology, project administration, data audit, writing—review and editing.

Ethical Approval

Not applicable (no medical records, procedures, or involvement of human or animal subjects).

Publication History

Received: 11 March 2025

Accepted: 06 May 2025

Accepted Manuscript online:
07 May 2025

Article published online:
21 May 2025

• References

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