We Are Not a Risk to Be Managed
New research published in the journal Midwifery this year asks a question that should be at the centre of every conversation about maternity care in the UK right now: are the systems we've built to keep pregnant people safe actually doing that? The answer, it turns out, is more complicated — and more damning — than most of us are being told.
An integrative literature review published in 2026 in the journal Midwifery (Mackintosh et al.) examined 25 years of evidence on how antenatal risk assessment and classification (ARAC) is practised in the UK. The authors — a team of midwives and health professionals — looked at whether the risk assessments that now dominate antenatal care are actually improving outcomes for women and babies. What they found should give everyone pause.
The headline? Many antenatal risk assessments are not reliably improving outcomes. Some are actively causing harm. And the system of funnelling increasing numbers of pregnant people into obstetric-led care — based on risk classifications that are often inconclusive, poorly communicated, and built on population-wide data that may have little relevance to the individual — is stripping people of access to the model of care the evidence most consistently supports: midwife-led care.
Let's talk about what that actually means.
The risk assessment machine
We've built a maternity system in the UK in which being classified as "high risk" has become, for many people, the defining experience of their pregnancy. And the threshold for that classification keeps shifting. Between 2012 and 2023, spontaneous labour rates in the UK fell from 64% to 43%. Induction rates rose from 21% to 33%. Caesarean births climbed from 25% to 40%. These are not small numbers. These are a fundamental transformation in how birth happens in this country.
And yet — stillbirth rates fell only modestly over that same period, missing the government's own 50% reduction target. Neonatal mortality slightly increased. Maternal deaths from direct causes rose by 33% between 2016-18 and 2019-21.
So we are doing more to pregnancies than we ever have. We are classifying more people as high risk, intervening more, monitoring more. And outcomes are not improving at the rate the system has promised. In some areas they are getting worse.
The paper is direct about why. Many of the risk assessments driving these decisions have poor predictive value. They use population-level epidemiological data to assign risk categories to individuals — an approach that doesn't account for a person's own history, values, embodied knowledge, or the many protective factors in their life. In some cases, there is no meaningful intervention available for the risk identified. In others, the intervention itself carries risks that are routinely downplayed or simply not explained.
As the researchers note, risk assessments were frequently presented to women as routine and non-voluntary — simply part of what happens in pregnancy — rather than as offers, with a clear rationale, that a person could weigh up and accept or decline. Women were told they "needed" the scan. The assumption was that identifying a risk automatically meant accepting a care pathway to address it.
That is not informed consent. And it's not women-centred care.
Being told you're broken
There is something particular that happens to a person when they are told, repeatedly and in clinical language, that their pregnancy is risky, that their body requires surveillance, that the doctor is there because things might go wrong. The research is clear on this too.
Being labelled high risk led to worse psychosocial outcomes than those labelled low risk. Scans indicating a larger-than-average baby had what the researchers describe as "oppressive and disempowering effects" — reduced choice, a sense of loss of control, diminished joy. For some people it contributed to tokophobia. The "high BMI" label — a tool developed for population-level public health data, not individual clinical assessment — was found to imply moral failure and compound anxiety, actively working against the health-promoting relationship it was supposedly there to support.
And when the perceived risk was higher, people were more willing to hand over decision-making entirely to their care providers. Which is, of course, exactly when it matters most that they don't have to.
This is what the medicalisation of pregnancy does. It doesn't just change what happens at birth. It changes how people understand themselves. It tells them, over and over, that their body is the problem and that clinical expertise is the solution. That birth is something to be managed, not something they are capable of.
We'd like to offer a different view. A person who understands their options, feels genuinely supported, and approaches birth with confidence in themselves and trust in the people caring for them — that person is not a problem to be solved. They are doing exactly what the evidence shows leads to better outcomes.
The hierarchy that's holding us back
Here's what sits at the root of all of this, and the paper names it clearly: we have structured UK maternity care around an obstetric model that treats pregnancy as inherently risky, birth as normal only in retrospect, and the midwife's role as secondary to the doctor's.
The evidence does not support this structure. It never has.
The most recent Cochrane review on midwifery continuity of care showed reductions in caesarean and instrumental births, higher rates of positive experiences, lower financial costs, and equivalent fetal and neonatal outcomes. Midwife-led birth settings show significant reductions in intervention rates and enhanced maternal safety without compromising neonatal safety. Women with intermediate risk factors — who under current NHS guidelines are pushed towards obstetric-led care — have better outcomes in midwifery-led settings than in obstetric ones.
And yet the system keeps narrowing the gate. More people classified as high risk. More people funnelled away from midwife-led care. More midwives — trained as experts in physiological birth — conducting surveillance checks in a biomedical paradigm that doesn't fit their skills, their values, or, frankly, the evidence.
The paper talks about midwives who "operate in a risk-focused paradigm" in ways that leave women feeling unsupported — not because those midwives don't care, but because the system they work within has positioned risk management as the primary task. When your job is to find what's wrong, it's hard to also be the person who says: your body knows how to do this.
This is a structural problem. And it has a patriarchal architecture. The medical model that placed the doctor above the midwife, the clinical above the relational, the measurable above the experiential — that model was not built on evidence. It was built on power. The good news is that power structures can change. The less good news is that they don't change on their own.
How Doulas support birth
This is where a doula becomes particularly valuable — not as a clinical advisor, but as a consistent, informed, emotionally attuned presence who helps you understand your options before you're in the room where decisions feel urgent. A doula helps you prepare questions. Helps you understand what the evidence does and doesn't say. Helps you hold onto your own preferences when the system is pulling in other directions.
A good doula does not tell you what to do. They help you figure out what you want to do — and support you to do it.
What needs to change
The paper concludes with a call for a shift towards what the authors describe as biopsychosocial risk assessment within relational care models. In plain language: risk conversations that are led by the midwife who knows you, grounded in your values and circumstances, and approached as an ongoing dialogue rather than a checklist. Risk assessment that includes the risks of the interventions being proposed, not just the risks they're meant to address. Decision-making that genuinely rests with the woman or birthing person.
This is not a utopian vision. There are midwifery models doing this now. Caseloading practices. Continuity of carer schemes. Community-based midwifery teams. The evidence for them is robust and growing.
What we need is for the system to stop treating them as nice-to-haves and start treating them as the evidence-based standard of care they are. And what we need, as birth workers, is to keep saying clearly: the way things are is not the way they have to be.