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.

Objectives:  Pre-eclampsia is a hypertensive disorder of pregnancy which, left untreated, can cause significant foeto-maternal morbidity. Accordingly, the National Institution for Health and Care Excellence (NICE) recommends that high-risk women be prescribed daily prophylaxis with 75-150mg aspirin from twelve weeks’ gestation until delivery. NICE stratifies risk using eleven maternal risk factors; however, no secondary research has been published evaluating the diagnostic accuracy of this algorithm. This systematic review and meta-analysis evaluates the sensitivity and specificity of the NICE risk‑stratification algorithm in predicting pre‑eclampsia in pregnant women ≥16 years. Methods: Systematic searches were conducted using PubMed, Cochrane Library and SCOPUS to identify relevant papers with a CBEM Level of Evidence ≤4. A total of twenty eligible studies and 892,061 pregnancies were included in our analyses. The logit-transformed sensitivities and specificities from each study were modelled as a bivariate distribution with random effects in order to generate maximum-likelihood estimates (MLEs) for the overall sensitivity and specificity of the algorithm in predicting pre-eclampsia. Results: MLEs for the NICE algorithm’s sensitivity and specificity were 44.4% (95% CI 33.7-55.5) and 88.3% (95% CI 83.9-91.6), respectively. Significant heterogeneity was exhibited between the sensitivities  (I2=99.8%, 95% CI = 99.54-99.65) and specificities (I2=99.88%, 95% CI = 99.87-99.89) calculated by each of the included studies. Consequently, there is a low degree of certainty in these estimates. Conclusions: The NICE risk‑stratification algorithm performs remarkably poorly when used to predict pre‑eclampsia in any of three gestational categories. Clinicians should advise women that around 1 in 5 high-risk patients and 1 in 25 low-risk patients go on to develop pre‑eclampsia. However, future studies will likely alter the values of these statistics and the confidence therein. Key Words: Pre-eclampsia, High-risk Pregnancy, Sensitivity and Specificity, Predictive Value of Tests, Clinical Decision Rules.