“Controlling risk is not the same thing as enhancing safety.”
That was one of the conclusions from month’s article, “Antenatal risk assessment and classification in maternity care: An integrative review” (Melamed et al., 2026).
This integrative review sought to find out if the UK’s approach to antenatal risk assessment and classification was achieving its goals of reducing stillbirth by identifying potential problems with the pregnancy before they developed into actual issues. By using various screening tools and tests, women who have results that vary from established population-level norms are identified as being “at-risk” for developing a complication. The premise is that early intervention would improve the health outcome for the mother or baby.
Once identified as being at-risk, the approach was most often to move them from midwifery care, which is proven to produce better outcomes, to obstetrical care, which includes more interventions with no better results - and often worse results.
Remember, we are not talking about women with established medical conditions that benefit from the skills of a highly trained surgeon, but rather screening and test results that vary outside of population-level established norms. And this approach to risk screening and classification is carried out in most places that have adopted the medical model of maternity services (everywhere).
Once the NHS (UK’s medical services) adopted increased screening and surveillance to identify these supposed at-risk pregnancies, between 2012 and 2023:
spontaneous labour rates declined from 64% to 43%
inductions rose from 21% to 33%
caesarean surgeries increased from 25% to 40%
stillbirth declined from 0.48% of all births to 0.39%
neonatal mortality rose from 0.25% to 0.3%
What was cited only once in this paper was that MATERNAL DEATH FROM DIRECT CAUSES ROSE 33% IN 3 YEARS.
The value of any screening tool is whether or not it is predictive of a likely adverse outcome and whether the intervention provides a benefit over doing nothing. And by doing nothing, we are including a total absence of salutogenic care, meaning considering the root cause and providing care that addresses the reason for less-than-optimal health, like adequate nutrition, domestic violence, poor living conditions, etc.
This review found that many tests led to inconclusive findings, lacked sensitivity, specificity, and predictive value and relied on expert opinion and socio-demographic traits rather than the condition of the woman in front of them. Further, many of the interventions were limited to termination, induction of labour, and caesarean surgery. For example, the only statistical “improved” outcomes with ultrasound came from termination because fewer compromised babies were born.
The real-life consequence of this over-focus on risk assessment is that more women end up in hospital-based obstetrical services resulting in more iatrogenic harm and worse birth experiences.
A relationship-based model of care where the one providing birth services listens to the mother, engages with her innate knowledge of her own body and circumstances, and works alongside her to take measurable steps to improve her holistic wellness is the suggested approach to actually improving outcomes for mothers and babies.
That’s the model the traditional birth companion takes. One must wonder why regulatory agencies want to $uppress this approach?