Antenatal risk assessment: Helpful tool or overused framework?
Currently in maternity care, antenatal risk assessment forms routine practice. You may have been classified as “low risk” or “high risk” and this classification will shape key aspects of your care, such as who provides care, where your birth will take place and how your pregnancy is managed.
An underlying assumption is that identifying risk early will improve outcomes, but is this assumption correct?
What does antenatal risk assessment do in practice?
The classification of risk has a fundamental role in organising maternity services. It is used to allocate women and birthing people to models of care, usually directing those labelled “high risk” towards obstetric-led pathways, with increased monitoring and intervention. Risk assessment does not simply describe the pregnancy – it actively shapes the care that follows.
What does the evidence say?
A recent integrative review on antenatal risk assessment by Melamed et al (2026), examined 25 years of research and the findings raise some important questions. The review found no consistent evidence that risk classification improves maternal or neonatal outcomes. In many cases, risk prediction was uncertain and some of the identified risks had no clear or effective intervention available.
This uncertainty will have implications, as being labelled “high risk” often leads to increased surveillance, more frequent intervention and a shift towards obstetric-led care. Whilst this is intended to improve safety, they are not without consequence. Intervention itself carries risk, yet this is not always considered alongside the risks of non-intervention.
Risk classification will influence access to different models of care. When you are labelled “high risk”, you are often moved away from midwifery-led pathways, including continuity models. This is significant, as midwifery-led care has been consistently associated with lower rates of intervention, higher rates of spontaneous birth and more positive experiences of care (Renfrew et al, 2014; Sandall et al, 2024).
Many risk assessment tools prioritise clinical and biomedical factors. However, outcomes in pregnancy and birth are also shaped by less easily measured elements such as continuity of care, relational trust, emotional wellbeing and social context. These factors are not always fully accounted for within existing risk frameworks.
The review suggests the need for a broader, biopsychosocial approach to risk that moves beyond prediction and classification and towards individualised, relational care. This does not mean abandoning risk assessment altogether, but rather reconsidering the weight it is given and how it is used in practice.
Whilst risk assessment undoubtedly has a place in maternity care, at times this can become the main focus and you as an individual are not considered. The assessment will shape the care pathway and as a midwife, I truly value the impact of the care itself and this should not be overlooked