By Anne Wolf
A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed, according to researchers in a paper published today (Sept. 15) in The Lancet.
The paper is part of the Lancet Maternal Health Series, the first since 2006. This series is unique in that it not only addresses maternal health in low and middle-income countries, but also in high-income countries, including the US, where maternal mortality rates are rising.
In “Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide,” lead author Suellen Miller PhD, CNM, MHA, and international colleagues write that two extreme situations exist on the continuum of maternal healthcare: too little, too late (TLTL) and too much, too soon (TMTS).
Miller is professor of Obstetrics, Gynecology and Reproductive Sciences at UCSF and director of the Safe Motherhood Program at the UCSF Bixby Center for Global Reproductive Health. Professor Miller works closely with UCSF Global Health Sciences as a faculty affiliate, mentoring students and providing capstone project opportunities with her global safe motherhood projects.
TLTL – care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help – is an underlying problem associated with high maternal mortality and morbidity. It occurs everywhere there are disparities in socio-demographic variables, including wealth, age, and migrant status.
TMTS describes the routine over-medicalization of normal pregnancy and birth, including 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. TMTS practices are rapidly increasing as facility-based births increase, causing harm and increasing health costs.
Although TMTS is typically associated with high-income countries and TLTL with low-income and middle-income ones, these extremes coexist in many countries due to social and health inequities.
Caesarean section is an example of both TLTL and TMTS, with rates highest in middle-income countries and rising in most low-income countries. Low caesarian section rates, an indication of TLTL, have been associated with increased maternal and perinatal mortality and morbidity, while overuse of caesarian section for non-medical indications—TMTS—has been associated with increased rates of adverse outcomes for mothers and newborns.
The authors recommend developing evidence-based clinical practice guidelines to help healthcare providers avoid TLTL and TMTS. They present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, identifying 78 recommended interventions and 37 not-recommended interventions.
They also note that guidelines cannot exist in a vacuum. “The implementation of high-quality care, with respect and dignity for every mother and every newborn, must be part of evidence-based maternal healthcare everywhere,” Miller said.
The Maternal Health Series will be launched this week at the United Nations General Assembly in New York, where Miller will discuss her paper and the findings of the rest of the Series.