General introduction Pregnancy and birth are primarily physiological processes.1 The vast majority of births result in a healthy mother and newborn. However, complications can occur. The likelihood of experiencing a complication and the severity of that complication varies between countries, care settings, and women2 and their children.[1,2] To ensure women and their children receive the right care, at the right place, and at the right time, an effective system for selecting the most appropriate care and care provider is necessary.[1,2] The current selection system is informed by the type and degree of risks associated with pregnancy and birth.[1] This risk-based selection system is responsible, in part, for the reduction in maternal and perinatal mortality. And yet, over the past decade, five separate Lancet series — on Midwifery (2014), Maternal health (2016), Stillbirth (2016), Caesarean section (2018), and Miscarriage (2021) ― called attention to outcomes of maternity and newborn care (MNC) that indicate a misalignment between necessary care and delivered care: unwarranted variation in care, the underuse and overuse of medical interventions, care disparities, and disrespectful care.[3–9] Unwarranted variation is variation that cannot be explained by variation in needs of childbearing women and their children.[10,11] Underuse of care refers to care that is delivered “too little too late”, while overuse of care refers to care that is delivered “too much too soon”.[8] Care disparity refers to unwarranted variation due to institutional disadvantages and injustice.[12] Care is respectful when it is individualized, culturally and contextually appropriate, delivered with respect for people’s fundamental rights, and responsive to their changing needs.[8] MNC in the Netherlands is no different in this regard. Women in the Netherlands have reported experiencing disrespectful care, such as verbal abuse and medical interventions without consent.[13] Furthermore, studies indicate disparities in the outcomes of care offered to Dutch women, including ethnic differences in maternal and perinatal mortality.[14–16] Research has also shown increased rates of referral from midwife-led to obstetrician-led care and increased use of medical interventions in birth ― in spite of the lack of clear evidence that rising referral rates lead to better outcomes ―, and variation in care by region of the country rather than the needs of women.[17,18] Indeed, policymakers in the Netherlands have concluded that the existing system of risk selection is not effective.[19,20] 1 It has been argued that it is not correct to use the term ‘physiological’ to describe the healthy and normal nature of pregnancy and birth, because it refers to a science that deals with the ways that living things function. Therefore, it has been suggested to use the term ‘low risk’ instead.[114 p 1] However, the term ‘physiological’ should not be confused with the term ‘physiology’. Indeed, the latter refers to the scientific domain, however, the former is defined as characteristic of, or appropriate to, the health and normal functioning of an organism.[115] 2 When we use the term ‘woman’, I also refer to individuals with a uterus who are not woman identified, including trans men and non-binary individuals. 21