metrics such as underlying causes of care outcomes, unnecessary interventions, long-term outcomes and inter-professional collaboration. The contextual relativity of risk selection is a major challenge for cross-setting evaluation, complicating comparability necessary for evaluating risk selection’s quality [166–168]. One of the problems is establishing equal understandings of quality indicators [16,167]. This explains the absence of clear and shared standards for optimal risk selection in our findings. For example, we found that transfer rates used as a quality measure of risk selection were interpreted in different ways. The absence of standards makes it “difficult to assess what transfer rate provides the best outcomes of care” [65]. It also hinders meaningful evaluation of the quality of risk selection because, as Offerhaus and colleagues [169] pointed out, “high intrapartum referral rates suggest that some of the referrals. . . might have been unnecessary. . ., on the other hand, . . .achieving a low referral rate is no goal in itself”. This ambiguity impedes recommendations to improve risk selection. Only through careful, context-specific evaluation, with understanding of the reasons for variations, can cross-setting comparisons support the quest for quality improvement of risk selection. This calls for the use of composite measures for complex phenomena that capture the complexity of care, such as the interactions between cognitive, social and cultural factors [16]. A lack of contextual sensitivity in cross-setting comparisons may lead to misconceptions and erroneous policy decisions, leading to unsuccessful initiatives aiming to optimise risk selection. Furthermore, the 24 countries that are covered in this review are not represented evenly, and some countries are not represented at all, such as Switzerland, Croatia, Cyprus, Hungary and Luxembourg. Studies of risk selection in MNC from the underrepresented countries are necessary to gain insight in local practices, necessary for cross-setting learning. Blind spots of risk selection: Equitable access to care, women-centred care, and overuse of care Risk selection aims to ensure that women and children receive appropriate care, at the right place and the right time, predominantly by pursuing efficient, timely and safe care. However, to optimize risk selection, other aspects of quality of care, namely equitable access to care, women-centred and effective care [170], require further consideration. Equitable access to care. A precondition to ensure that women and their children receive the care they need is equal opportunities to access care for those with equal needs, regardless of personal characteristics,– such as gender, age, ethnicity, geographic location and socioeconomic status [170,171]. However, our results show that care provision is determined by many characteristics—often a combination, or intersection [172] of characteristics—including characteristics of health systems and care providers [173–179]. Although some salient potential barriers to care, such as geography, are considered in the papers, the notion of equity of access to care remains unaddressed. Including equitability in risk selection will contribute to creating awareness, and prioritizing the challenge of bias and social injustice in risk selection in MNC, which is necessary to optimize risk selection. Women-centred care. Care providers hold a central position in risk selection. Not only do they co-manage access to care, risk selection is viewed and assessed as providers’ conduct. The provider–woman dynamic in risk selection, and the tension that can arise when they disagree, is the focus of only one study in this review [123], and thus remains largely undiscussed. Care outcomes are measured by providers’ performance indicators; of the 210 included papers, only fourteen papers encompass women’s perspectives, and only one paper includes partners’ experience of risk selection. Renfrew and colleagues [13] developed a women-centred framework for quality MNC, as part of the Lancet series on midwifery, showing that women highly ONE Risk selection in maternal and newborn care | June 8, 2020 10 / 22 78 3 CHAPTER 3