Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

IntroductionThis second paper in the maternal health Lancet series discusses two extremes in antenatal, intrapartum (during birth) and postnatal care associated with avoidable maternal morbidity (ill health) and mortality: ‘too little, too late’ (TLTL) and ‘too much, too soon’ (TMTS).TLTL refers to the untimely access to quality of care where workforce, capacity building, supplies, infrastructure and evidence-based standards are weak. Contrastingly, TMTS is the “routine over-medicalisation of normal pregnancy and birth” (p.1).While multiple factors influence quality of care, the authors suggest that complying with evidence-based guidelines can support facility health-care providers to avoid TLTL and TMTS.A systematic appraisal was conducted of high-quality, clinical-practice guidelines that are evidence-based.Too little, too lateTLTL is typically associated with low-income countries (LICs), particularly in sub-Saharan Africa. It also, however, affects sub-populations in wealthier countries that are disadvantaged and susceptible to maternal care inequities. Too much, too soonTMTS used to be associated with high-income countries, but is quickly spreading to other settings with the rise in facility births, particularly middle-income countries (MICs). It includes the unnecessary and excessive use of interventions which can be harmful. Inappropriate uses of interventions can be costly, particularly in settings where resources are limited. Increasing uses of practices that may be harmful, especially in the private sector, show poor regulations and low compliance to evidence-based guidelines.Caesarean section is a maternal health intervention that can be both TLTL or TMTS. Disparities exist within and across countries, and caesarean section rates are higher in private facilities and among wealthier groups. In Nigeria, for example, caesarean section at the national level is low (TLTL) but its highest coverage is with wealthier women (TMTS). MICs have the highest rates of caesarean section with rates also rising in LICs.Increasing rates are partly attributed to a lack of or low compliance to evidence-based guidelines as well as other factors like income, culture and logistics.Clinical practice guidelinesFifty-one high quality guidelines were appraised. Seventy eight interventions for antenatal, intrapartum and postnatal care were extracted and categorised as “recommended for use” and 37 “recommended against use” . The authors also explored coverage rates of six intrapartum interventions in MICs that are recommended but potentially harmful if applied excessively.DiscussionWith higher facility births and shifts in causes of maternal mortality and morbidity in LICs and MICs, TMTS is increasingly a threat to mothers and their newborns worldwide.Compliance to evidence-based guidance requires the participation of women and communities as well as reports on lessons learnt of successful and challenging approaches.Conflicting recommendations on the benefits and harms of routine interventions can devalue the use of guidelines. More efforts are needed to support LICs to develop and implement evidence-based guidelines in maternal care that are locally adapted.High quality guidelines must be consistent using similar language and report similarities in the composition and direction of recommendations. Guideline developers should use robust methods and create guidelines that are easy to follow.ConclusionAn international approach that is multi-faceted and promotes evidence-based, respectful routine procedures across the continuum of maternal care is necessary.To read the article, click here. Free subscription is required to access the full article.Miller, S., Abalos, E., Chamillard, M., Ciapponi, A., Colaci, D., Comandé, D., Diaz, V., Geller, S., Hanson, C., Langer, A., Manuelli, V., Millar, K., Morhason-Bello, I., Pileggi Castro, C., Nogueira Pileggi, V., Robinson, N., Skaer, M., Paulo Souza, J., Vogel, J.P., Althabe, F. (2016). Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet, Maternal Health Series Paper 2, (Early online publication).