and sensitive to pain than women of colour and lower-class women ― were avoiding childbirth, creating the possibility they would eventually become a minority.[96,97] With the advent of hospitals, the most common cause of maternal deaths became puerperal fever due to highly virulent strains of Streptococcus pyogenes transferred to birthing women from doctors and nurses in hospitals.[56,98] The use of the medicine Diethylstilbestrol (DES) to prevent miscarriage is another example of iatrogenesis. Between 1940 and 1970 DES was routinely prescribed until DES was shown to cause cancer and fertility problems in women who had been exposed to this medication in utero. Two current examples are the routine use of electronic fetal monitoring during birth and the routine use of ultrasonography in the third trimester, both practices that in many places have become a standard part of contemporary MNC despite a lack of evidence of their clinical effectiveness. Studies show that electronic fetal monitoring is a poor tool for identifying or predicting fetal and neonatal morbidity and mortality, and it is associated with unnecessary caesarean sections, leading to excess maternal and perinatal morbidity and mortality.[99–103] Likewise, routine ultrasonography used in the third trimester as a means to reduce adverse perinatal outcomes in low risk pregnancies does not, in fact, decrease the rate of perinatal mortality.[104] Research into ways to reduce ineffective care and care disparity point towards practices such as value based health care,[105] women-centred care,[1,106] shared decision making,[107] respectful care,[108,109] and continuity of care.[110] However, efforts to implement these practices have been stymied by the risk focused, biomedical, and technocratic discourse of the current system of selection. That system is based on the premise that risks mainly reside inside the pregnant and birthing body, and that harms can and should be predicted, detected and treated using medical interventions. Towards optimizing risk selection Contemporary MNC in high-income societies includes care during the preconceptual, prenatal, intrapartum and postnatal periods offered by many different professionals. Care is provided within a risk focused, biomedical, and technocratic discourse, where the understanding of risks related to pregnancy and birth informwhat care should be provided and who should provide it. The optimization of risk selection will require a wider lens that addresses risks that come from outside the pregnant and birthing body, and the risks induced by MNC itself. This more complete understanding of risk selection is necessary to develop an evidence base that supports optimal risk selection. The Netherlands provides a unique context to study risk selection. In most high-income countries MNC is routinized within a hospital setting and midwives have limited autonomy. 26 1 CHAPTER 1
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