title: Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
abstract: On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA. Electronic address: suellen.miller@ucsf.edu.
authors.forename: Suellen
authors.initials: S
authors.lastname: Miller
authors.affiliation: Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina.
authors.forename: Edgardo
authors.initials: E
authors.lastname: Abalos
authors.affiliation: Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina.
authors.forename: Monica
authors.initials: M
authors.lastname: Chamillard
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
authors.forename: Agustin
authors.initials: A
authors.lastname: Ciapponi
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
authors.forename: Daniela
authors.initials: D
authors.lastname: Colaci
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
authors.forename: Daniel
authors.initials: D
authors.lastname: Comandé
authors.affiliation: Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina.
authors.forename: Virginia
authors.initials: V
authors.lastname: Diaz
authors.affiliation: Center for Research on Women and Gender, University of Illinois, Chicago, IL, USA.
authors.forename: Stacie
authors.initials: S
authors.lastname: Geller
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Claudia
authors.initials: C
authors.lastname: Hanson
authors.affiliation: Maternal Health Task Force, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Langer
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA.
authors.forename: Victoria
authors.initials: V
authors.lastname: Manuelli
authors.affiliation: Maternal Health Task Force, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Millar
authors.affiliation: University of Ibadan, Ibadan, Nigeria; London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Imran
authors.initials: I
authors.lastname: Morhason-Bello
authors.affiliation: GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil; Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
authors.forename: Cynthia Pileggi
authors.initials: CP
authors.lastname: Castro
authors.affiliation: GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil; Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
authors.forename: Vicky Nogueira
authors.initials: VN
authors.lastname: Pileggi
authors.affiliation: Harbor-UCLA Medical Center, Los Angeles, CA, USA.
authors.forename: Nuriya
authors.initials: N
authors.lastname: Robinson
authors.affiliation: Safe Motherhood Program, San Francisco, CA, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Skaer
authors.affiliation: GLIDE Technical Cooperation and Research, Ribeirão Preto, SP, Brazil; Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
authors.forename: João Paulo
authors.initials: JP
authors.lastname: Souza
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
mesh_terms: D019317:Evidence-Based Medicine / Q000379:methods* / Q000592:standards; D005260:Female; D014943:Global Health; D054624:Health Status Disparities; D006801:Humans; D008427:Maternal Health Services / Q000191:economics / Q000592:standards* / Q000600:supply & distribution; D008428:Maternal Mortality; D017410:Practice Guidelines as Topic / Q000592:standards*; D011247:Pregnancy