international and national evidence-based multidisciplinary guidelines to direct local protocols. Research exploring unanswered questions and gaps in evidence is necessary to inform these guidelines. Multidisciplinary consensus offers insufficient support for guidelines and should be used only where evidence is lacking or remains inconclusive. Discussion In pre-modern times, MNC was limited to care during birth provided by local midwives with very few technical instruments at their disposal. Today, MNC includes care during the preconceptual, prenatal, intrapartum and postnatal periods offered by many different professionals. These professionals contribute their own expertise, using a range of medical interventions. Our scoping review showed that risk selection has been developed as a means to manage the challenge of matching the needs of women with limited resources. With regard to mortality, risk section has been effective, contributing to the lowest maternal and perinatal death rates in history.[1,2] However, the continued existence of unwarranted variation, the underuse and overuse of care, care disparities, and disrespectful care point toward the need to optimize the contemporary system of risk selection. Our research indicates that the subjectivity of, and blind spots in, risk selection limit its effectiveness. The subjectivity of risk selection Miller and colleagues (2016) examined ways to optimize the quality of MNC, linking inappropriate care to the absence of, and/or insufficient and/or inconsistent adherence to evidence-based guidelines. As a solution, they recommend improvement in the development and dissemination of clearly written guidelines, together with strategies to increase adherence.[3] Their recommendation fits within the risk focused biomedical discourse in MNC where risk is considered an objective fact that can be managed via standardization. However, our research indicates that risk selection is not an objective process because (1) risk is understood predominantly in terms of pathology, (2) risk is influenced by professionals’ beliefs and interests, and (3) risk is relative. A pathology centred conception of risk as a proxy for need In MNC, the needs of women and their children are predominantly understood in terms of pathology related to pregnancy and birth, even though pregnancy and birth are primarily physiological processes.[4] This pathology focused conception of risk fits within the biomedical and technocratic discourse of contemporary MNC. From this perspective, all women are considered at risk of complications, whether they are healthy or ill. Risk is viewed as detectable by screening and diagnostic methods. The assumption is that the more accurate the measures of risk are, the more clearly needs for care will be understood, 162 7 CHAPTER 7
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