
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, categorizing 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.
This systematic review categorizes evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care as recommended, recommended only for clinical indications, and not recommended. It also presents prevalence data from middle-income countries for specific clinical practices, which demonstrate “too little too late” (care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help) and increasing “too much too soon” (unnecessary use of non-evidence-based interventions, as well as use of interventions that can be lifesaving when used appropriately, but harmful when applied routinely or overused).
Key messages
- Adherence to evidence-based guidelines could help health-care providers to avoid “too little too late” and “too much too soon.”
- “Too little too late” is found everywhere there are disparities in socio-demographic variables, including, wealth, age, and migrant status.
- “Too much too soon” is rapidly increasing everywhere, particularly as more women use facilities for childbirth. Increasing rates of potentially harmful practices, especially in the private sector, reflect weak regulatory capacity as well as little adherence to evidence-based guidelines.
- Caesarean section illustrates both “too little too late” and “too much too soon” with disparate rates between and within countries, and higher rates in private practice and higher wealth quintiles. Rates are highest in middle-income countries and rising in most low-income countries.
- Quality clinical practice guidelines need to be developed that reflect consensus among guideline developers, using similar language, similar strengths of recommendation, and agreement on direction of recommendations.
- Strategies for enhanced implementation and adherence to guidelines need multisectoral input and rigorous implementation science.
- A global approach that supports effective and sustained implementation of respectful, evidence-based care for routine antenatal, intrapartum, and postnatal care is urgently needed.