---
title: "Revolutionizing Antenatal Care with the Inverted Pyramid Model"
id: "plos-medicine-1-the-inverted-pyramid-of-care-in-modern-day-obstetrics"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-1-the-inverted-pyramid-of-care-in-modern-day-obstetrics"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255"
published_at: "2026-09-28T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Revolutionizing Antenatal Care with the Inverted Pyramid Model
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-1-the-inverted-pyramid-of-care-in-modern-day-obstetrics
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255)
- **Published At:** 2026-09-28T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The `inverted pyramid of care` in obstetrics emphasizes early pregnancy risk assessment. - Unlike traditional methods that increase visits towards the end of pregnancy, this model suggests early identification and management of risks. - Early screening allows for the prediction of conditions like pre-eclampsia and fetal chromosome abnormalities. - Updated strategies for antenatal care incorporate personalized surveillance and intervention pathways. - Advances in technology and artificial intelligence are anticipated to improve diagnostics and treatment in obstetrics.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1005255) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#citedHeader) * 16 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255#discussedHeader) Open Access Policy Forum Policy Forum articles provide a platform for health policy makers from around the world to discuss the challenges and opportunities in improving health care to their constituencies. [See all article types » ](https://journals.plos.org/plosmedicine/s/other-article-types) # The inverted pyramid of care in modern-day obstetrics * Laura A. Magee , Roles Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing * E-mail: laura.a.magee@kcl.ac.uk Affiliation Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-1355-610X ](https://orcid.org/0000-0002-1355-610X "ORCID Registry") ⨯ * Peter von Dadelszen, Roles Methodology, Visualization, Writing – review & editing Affiliation Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-4136-3070 ](https://orcid.org/0000-0003-4136-3070 "ORCID Registry") ⨯ * Kypros H. Nicolaides Roles Conceptualization, Visualization, Writing – review & editing Affiliation Fetal Medicine Research Institute, King’s College Hospital, London, United Kingdom ⨯ # The inverted pyramid of care in modern-day obstetrics * Laura A. Magee, * Peter von Dadelszen, * Kypros H. Nicolaides ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 28, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1005255) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005255) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005255) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1005255) * [Summary points](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#abstract0) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec001) * [Designing and implementing screening programmes](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec002) * [Fetal chromosomal abnormalities and other first trimester diagnostics](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec003) * [Placental structure, cord insertion, and fetal anomalies](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec004) * [Placental dysfunction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec005) * [Large-for-gestational age infants](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec009) * [Gestational diabetes mellitus](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec010) * [Preterm birth](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec011) * [Long-term maternal cardio-renal-metabolic risk](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec012) * [Conclusions and future directions](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#sec013) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005255) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255) [?](https://journals.plos.org/plosmedicine/s/accepted-manuscripts#loc-early-version) ## This is an uncorrected proof. ## 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. ## Figures ![Fig 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.g001) ![Table 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t001) ![Table 2](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t002) ![Fig 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.g001) ![Table 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t001) ![Table 2](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t002) ![Fig 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.g001) ![Table 1](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t001) ![Table 2](https://journals.plos.org/plosmedicine/article/figure/image?size=inline&id=10.1371/journal.pmed.1005255.t002) **Citation:** Magee LA, von Dadelszen P, Nicolaides KH (2026) The inverted pyramid of care in modern-day obstetrics. PLoS Med 23(9): e1005255. https://doi.org/10.1371/journal.pmed.1005255 **Published:** September 28, 2026 **Copyright:** © 2026 Magee et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Funding:** The authors received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. **Abbreviations:** AI, artificial intelligence; EFW, estimated fetal weight; FMF, Fetal Medicine Foundation; GDM, Gestational diabetes mellitus; LGA, large-for-gestational age; MAP, mean arterial pressure; PAS, Placenta accreta spectrum; PlGF, placental growth factor; SGA, small-for-gestational age ## Introduction Before 1900, maternity care focused on attendance at birth of the wealthy, by those of variable skill. Maternal mortality was very high (400–500 per 100,000 births) and this continued into the 20th century [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#pmed.1005255.ref001)]. In 1929, the UK Government introduced universal antenatal care, based on timely detection and intervention for maternal and fetal complications [[2](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#pmed.1005255.ref002)]. Universal antenatal care was based on visit frequency, with more visits in late pregnancy when complications most commonly occur. Maternal mortality—due largely to sepsis, haemorrhage, and pre-eclampsia—declined rapidly during the 1930s, reaching 99% for trisomy 21, at SPR £200 in the UK), other countries offer contingent screening to reduce costs; those who screen positive with traditional screening, are offered cfDNA testing, achieving a DR of 96% for trisomy 21, at a risk cut-off of 1:1,000 (at SPR = 13%). Other first trimester diagnostics in practice include serology for infectious disease ([Fig 1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#pmed-1005255-g001)), with the aim of reducing mother-to-child transmission of human immunodeficiency virus or Hepatitis B to <1% [[12](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#pmed.1005255.ref012),[13](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005255#pmed.1005255.ref013)]. Serology is also used for the detection of haemoglobinopathies. Universal testing (e.g., haemoglobin electrophoresis) identifies maternal carriers for sickle cell, thalassaemia, and other haemoglobin variants. This enables partner testing a
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