Antenatal risk assessment and classification in maternity care: An integrative review

PROBLEM: Antenatal risk assessment and classification dominates midwifery care but may not be improving outcomes and may introduce iatrogenic harm. BACKGROUND: Midwifery-led care and birth settings promote good birth outcomes and women's experiences. In the United Kingdom increasing numbers of women are classified as having high-risk pregnancies and therefore recommended to have obstetric-led care and birth settings, restricting the number of women accessing midwife-led care. AIM: Evaluate and integrate literature on the effectiveness, justification and impact of antenatal risk assessment and classification as performed in the UK. METHODS: Integrative literature review of 16 articles from 2000 to 2025, from midwifery and obstetric perspectives. FINDINGS: Many antenatal risk assessments did not improve outcomes due to inconclusive tests, lack of treatment options and difficulties balancing risks. The assessments and proposed treatments were not clearly communicated to women and assumed benefit and acquiescence in the absence of evidence. Risk assessment processes could create physical and emotional iatrogenic harm to women. DISCUSSION: Reductive medical-model risk assessments and subsequent care pathways are not compatible with women-centred care and lead to known benefits of midwifery care being under-utilised. Biopsychosocial risk assessment could be culturally and value sensitive, better address social determinants and inequalities, offer genuine choice and control for women and increase the use of women-centred midwifery services while enhancing safety. CONCLUSION: UK antenatal risk assessment lacks efficacy in improving outcomes, risks iatrogenic harm and can negatively affect women's experiences. A shift to relational models of midwifery antenatal risk assessment could be more women-centred, personalised and culturally specific, possibly leading to better outcomes overall.