value communication, respect and understanding, and care that is tailored to their needs [12]. Reflecting on this framework, global health stakeholders in the Lancet’s Series on Midwifery stress women’s perspectives in MNC evaluation, recommending studies to “assess the views and preferences of women and families across a variety of settings about their experiences of maternal and newborn care. . .” [15]. The number of papers addressing women’s and partners’ perspectives on risk selection has increased over the years, indicating an advancing awareness in MNC about women-centred care. Further including the perspective of women in the understanding of risk selection creates room for women’s individual unique needs [159,180–183], optimizing the alignment of risk selection with women’s needs. Effective care. The contemporary understanding of risk selection holds a blind spot for overuse of care. Our analysis shows that risk selection is focused on preventing underuse of care. In the included papers, the quality of risk is evaluated by questioning timeliness of care, in terms of whether more care delivered sooner could have led to better care outcomes [24,30– 32,90,104,137,140,155]. A few papers in our review discussed the notion of a “cascade of interventions” [17,169,184], “. . . where one intervention in a labouring woman leads to another and so on” [17], warning for overuse of care. The vast majority of the studies focused on upscaling of care; referral from generalist tot sub-specialist care. The appropriateness of the referral, however, remained largely undiscussed. Although care that is provided “too little too late” [8] is a global problem, overuse of care is increasingly associated with poor quality care and preventable maternal and perinatal morbidity and mortality, also in high income countries [7,8,185]. Variation in care and rising rates of interventions without evident benefit [185] are indicators of care that is delivered “too much too soon” [8]. Our results indicate that this is particularly related to intermediate levels of risk, also referred to as the “grey zone" [186–195]. According to Brownlee and colleagues [185], most health care services fall into the grey zone— which include services that offer little health benefit, those for which the balance between benefits and harms differs amongst individuals, and the numerous services that are backed by little or no scientific evidence. Excluding the notion of overuse of care and downscaling of care services in the understanding of risk selection undermines the purpose of risk selection and impedes enhancing the effectivity of risk selection [8]. The challenge is finding the right balance in effective delivery of care, striving for risk selection that is not only effective in terms of preventing harm due to underuse of care, but also avoiding overuse of care. Strengths and limitations To our knowledge, this is the first study to review the concept of risk selection in MNC. The search was systematically conducted with the help of an information specialist and was updated to include recent publications. We made an effort to include a wide and comprehensive range of terms in the literature search strategy. Our broad search strategy, the search update and the inductive thematic data synthesis approach enabled us to obtain a broad and deep view of the operationalisation of risk selection across the full scope of MNC during the past four decades. Due to the vast number of included papers, we restricted the search strategy to four databases that usually cover MNC literature, we only included papers in English and Dutch, and we did not apply the snowball method to extend the search. Furthermore, we only included studies conducted in high-income countries, including studies from 24 countries. Not all countries were evenly represented in our results, and some countries were not represented at all. We can only speculate on the underlying reasons, including that our search did not identify all relevant studies, for example because papers may have been published in local —non-English—journals, which are not clearly indexed within the scientific databases. However, we did reach data saturation. ONE Risk selection in maternal and newborn care | June 8, 2020 11 / 22 79 3 TOWARDS A BETTER UNDERSTANDING OF RISK SELECTION