The inverted pyramid of care in modern-day obstetrics

Summary points Traditional antenatal care consists of an accelerating frequency of visits with advancing gestational age, as the bulk of pregnancy complications occur in late pregnancy. The ‘inverted pyramid of care’ concept describes a focus on structured risk assessment in early pregnancy, to facilitate prevention and enhanced surveillance of those at increased risk of maternal, intrinsic fetal, and uteroplacental problems. Since publication of this concept in 2011, it has become clear that early pregnancy screening may be contingent, with a sub-population identified for re-screening in mid- or late pregnancy. Maternal conditions (such as pre-eclampsia), intrinsic fetal conditions (such as chromosomal abnormalities) and uteroplacental problems (such as placenta accreta spectrum) can now be predicted or identified at earlier stages. This Policy Forum advocates for building risk-stratified care pathways around early prediction, prevention, and personalised surveillance. We provide updated guidance for ‘inverted’ antenatal care, including optimal screening timepoints and the most accurate methods of screening. We also highlight recent advances in diagnostics and treatment that we anticipate will further improve antenatal care in the future, including development and integration of artificial intelligence-assisted technologies.