Document Type


Publication Date

February 2006


This article has been peer-reviewed. It was published in the American Journal of Obstetrics & Gynecology (2006) 194(6):1564-75. The published version is available at Copyright is retained by Mosby, Inc.



The purpose of this study was to review the American College of Obstetricians and Gynecologists practices bulletins to quantify the type of recommendations and references and determining whether there are any differences between obstetric and gynecologic bulletins.

Study design

All practice bulletins published from June 1998 to December 2004 were reviewed. Odds ratios and 95% confidence intervals were calculated.


The 55 practice bulletins contained 438 recommendations of which 29% are level A, 33% level B, and 38% level C. The 55 bulletins cite 3953 references of which 17% are level I, 46% level II, 34% level III, and 3% others. Level A recommendations were significantly more likely among the 23 gynecologic than 32 obstetric bulletins (37% versus 23%, odds ratios 1.95, 95% confidence intervals 1.28, 2.96). The study types referenced in obstetric and gynecologic bulletins were similar (P > .05 for comparison of levels I, II, and III and meta-analysis references).


Only 29% of the American College of Obstetricians and Gynecologists recommendations are level A, based on good and consistent scientific evidence.