its subjective and complex character. This broader conception of risk selection centres the focus on women, and foregrounds prevention by taking into account the need to support physiology, societally-generated risks, and risks from MNC itself. Value-based health care offers a framework to facilitate this paradigm shift.[14,226] Value-based health care incorporates evidence to achieve the best outcomes while centring the individual’s values as the basis for decisionmaking and optimally and equitably using and allocating resources.[11,14,226] Value-based risk selection is grounded in the best available evidence of effective MNC with least risk of harm and the best use of resources. It protects, promotes, and supports physiologic childbirth and optimal experiences for childbearing women, invests in prevention and access to measures that strengthen women’s capabilities, and provides care that is subject to ongoing performance measurement, including underuse and overuse of care, care disparity and disrespectful care.[14,226] However, implementation of a value-based health care requires fundamental changes in systems and cultures of care.[14] This approach can be enhanced through promotion of equal partnership between professionals and women, systematic evaluation of “too much too soon” and educational efforts. In addition, attention should be paid not only to upscaling care when women need specialist care, but also to downscaling care, where women are referred back to the primary care midwife when specialist care is no longer necessary. Equal partnership in the relationship between professionals and women based on the women-foetus unit is necessary to achieve women-centred care.[136,155] Risk and safety are understood as dynamic, interpretive acts that occur between women and MNC professionals whereby women are listened to, believed, and supported to access their own inner knowing and experiential understanding.[27,131,227] Awareness and reduction of overuse of care can be enhanced by systematically evaluating decision making processes led by the question ‘Could we have done less’? This includes downscaling care if specialist care is no longer required. This prevents unnecessary use of hospital based, high-level, specialized care, freeing up resources for those women who really need it, and for investment in prevention and practices that strengthen women’s capabilities, enhance health, and protect, promote, and support physiologic pregnancy and birth. Finally, professional education can contribute to an understanding of the subjectivity of risk selection, the overuse of care, care disparity, and disrespectful care that contribute to ineffective MNC. For example, care professionals are trained in cultural competency, but often culture does not include the care provider’s own norms and values and is reduced to stereotypical, homogenous and static societies with shared meanings.[228,229] We 173 7 GENERAL DISCUSSION
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