The Lancet Maternal Health Series: “Beyond Too Little, Too Late and Too Much, Too Soon”

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By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

The Lancet Maternal Health Series published in September 2016 contains six papers highlighting the importance of improving access to high quality maternal health care for all women across the globe. In paper 2, “Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide,” Miller and colleagues examine two extremes in global obstetric care:

Too little, too late: Absent, delayed or inadequate care often linked to insufficient resources such as staff, supplies, medicines or training

Too much, too soon: Over-medicalization of pregnancy and childbirth often resulting in unnecessary interventions

The authors systematically review evidence-based guidelines for antenatal, intrapartum and postpartum care and offer recommendations. They also estimate national coverage rates of recommended practices and interventions that can be harmful if overused.

Too little, too late

Care that is “too little, too late” has generally been associated with weak health care systems and shortages of resources. Among low- and middle-income countries, the authors found wide variation in adherence to recommended practices such as breastfeeding initiation within the first hour of birth, which ranged from less than 20% of births in Serbia, Turkmenistan, Jordan and Pakistan to over 90% of births in Iran, Angola and Zambia. Large variability in facilities’ capacity to deal with obstetric emergencies also creates maternal health disparities at global, national and local levels. A study of five countries in sub-Saharan Africa, for example, found that only 10% of health facilities providing obstetric services had the capacity to perform cesarean section surgery, and most of those facilities operated without electricity or a safe water source—basic resources necessary for high quality care. Furthermore, within countries, some groups are more vulnerable to receiving too little care than others: Migrants and undocumented immigrants are at greater risk of not being able to access maternal health services, experiencing inadequate care and suffering worse outcomes, as are black women in the United States. Closing these gaps in access and quality around the globe is essential for ending preventable maternal mortality and morbidity.

Too much, too soon

Lancet MH Series Paper 2
Miller et al. Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide. 2016. The Lancet Maternal Health Series

Care that is “too much, too soon” has historically been associated with strong health systems and access to an abundance of resources and new technologies. However, the authors illustrate that the over-medicalization of childbirth is a growing problem in middle-income countries as well. In fact, the world’s highest cesarean rate is in the Dominican Republic (58.9%), followed by Brazil (56.7%) and Egypt (51.8%). Furthermore, low national cesarean rates in low-income countries often mask inequalities within populations: Cesareans tend to be more common in private hospitals and among wealthier women. In addition to cesarean sections, a number of obstetric practices can be life-saving in some situations and harmful in others, including induction of labor, augmentation of labor with oxytocin and episiotomy. Based on the most recent available data from middle-income countries, induction rates ranged from less than 5% in the Philippines, Paraguay and Kenya to 71% in Iran. In 2005, 92% of laboring women underwent episiotomies in Thailand, and in 2011, 79% of labors were augmented with oxytocin in India. Such dramatic overuse of obstetric interventions puts women at risk of developing life-threatening complications such as uterine rupture, infection and hemorrhage. According to the authors, increases in over-medicalization and unnecessary interventions may be offsetting reductions in inadequate care, thwarting progress in the fight against maternal mortality.

Moving forward

The ultimate goal of this paper is to inform and encourage efforts to create evidence-based, respectful maternity care for all women. In many countries, women are not allowed to have a birth companion during labor and delivery, and clinicians do not regularly follow best practices such as immediate skin-to-skin contact after birth and breastfeeding initiation within the first hour. Often times facilities provide care that is too little, too late and care that is too much, too soon simultaneously, further complicating the situation. A broader focus that combines efforts to promote the use of evidence-based guidelines and improve quality of care is needed to deliver safe, respectful and effective maternity care services to women across the globe.

This paper also highlights the limitations in global maternal health coverage data. Read more about the importance of strengthening health information systems and data infrastructure.

Learn more about global coverage of obstetric interventions from Countdown to 2030.

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