Proefschrift

General discussion and conclusions The objective of this dissertation is to enhance the understanding of risk selection in contemporary maternal and newborn care (MNC). Using a wide range of methods – including a systematic scoping review, interviews, document analysis, descriptive analyses of survey data, and inter-categorical regression analyses of registration data ― the five studies included offer a comprehensive examination of risk selection from conceptual, historical, organisational, and practical points of view. I begin this final chapter with a summary of the main findings. Then I discuss these findings in light of the question of optimality: how can what we learned about risk selection be used to reduce maternal and newborn morbidity and mortality? I focus explicitly on the association of risk selection with unwarranted variation in care, the underuse and overuse of care, care disparities, and care that is disrespectful. This reflection offers a deeper understanding of the strengths and limitations of risk selection and the strategies needed to optimize its use as a means to reduce maternal and newborn morbidity and mortality. Main findings Understanding risk selection We first studied the contemporary understandings of risk selection. The systematic scoping review showed that while different definitions of risk were used in the papers included in our review, overall, risk is used as a proxy for the needs of women and children, and risk generally has a negative connotation, associated with pathology. Our analysis identified three dimensions of risk selection: (1) risk selection as an organizational measure for optimally aligning women’s and children’s needs with available resources, (2) risk selection as a practice for detecting and assessing risk and making decisions about the delivery of care, and (3) risk selection as a tool for ensuring safe care. These three dimensions have three themes in common: risk selection (1) has a professional-centred focus, (2) aims to avoid the underuse of care, and (3) is viewed as both requiring and providing regulation. These findings indicate that risk selection needs indicators that capture the complexity of care, making possible cross-setting evaluation and comparison. Moreover, a comprehensive understanding of risk selection must consider disparities in access to care, women’s needs in terms other than pathology, and the problem of unnecessary medical interventions and overuse of care. The history of risk selection The system of risk selection in the Netherlands grants community-based primary care midwives the authority to autonomously assess risk and refer to specialist care. In order 159

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