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

Miller, Suellen; Abalos, Edgardo; Chamillard, Monica; Ciapponi, Agustin; Colaci, Daniela; Comandé, Daniel; Diaz, Virginia; Geller, Stacie; Hanson, Claudia; Langer, Ana; Manuelli, Victoria; Millar, Kathryn; Morhason-Bello, Imran; Castro, Cynthia Pileggi; Pileggi, Vicky Nogueira; Robinson, Nuriya; Skaer, Michelle; Souza, João Paulo; Vogel, Joshua P; Althabe, Fernando

doi:10.1016/s0140-6736(16)31472-6

Cited by 1,181Maternal and Perinatal Health InterventionsGlobal Maternal and Child HealthMaternal and fetal healthcare

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

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Miller, Suellen, Abalos, Edgardo, Chamillard, Monica, Ciapponi, Agustin, Colaci, Daniela, Comandé, Daniel, Diaz, Virginia, Geller, Stacie +12 more·2016·The Lancet

DOI 10.1016/s0140-6736(16)31472-6

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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.

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Midwives’ contribution to normal childbirth care. Cross-sectional study in public health Settings. MidconBirth Study protocol
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Accelerate Progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission
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The scale, scope, coverage, and capability of childbirth care
Campbell, O. M. R., Calvert, C., Testa, A., Strehlow, M. C., Benova, L., Keyes, E., Donnay, F., Macleod, D., Gabrysch, S., Rong, L., et al. (2016) · The Lancet · doi:10.1016/s0140-6736(16)31528-8 · Cited by 334 · see citing works
Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India
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Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India
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“In some places women and babies still die because of lack of professional care, while in others they suffer from ineffective or harmful unnecessary interventions related to the medicalization of childbirth [2].”
Background
Transforming intrapartum care: Respectful maternity care
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A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care
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Crucial Contributions
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The role of doulas in respectful care for communities of color and Medicaid recipients
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Respectful maternity care : mapping current global initiatives designed to achieve a positive experience of childbirth, reduce interventions without clinical benefit or increase access to high quality maternity care
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PROMOTING RESPECTFUL MATERNITY CARE IN LOW- AND MIDDLEINCOME COUNTRIES: WHAT DO WE NEED TO ACCELERATE PROGRESS TO MATERNAL HEALTH TARGETS OF THE SUSTAINABLE DEVELOPMENT GOALS?
Asefa, D. A., & Woldie, M. (2022) · Ethiopian Medical Journal
Respectful maternity care in low- and middle-income countries: a narrative review of evidence, implementation challenges, and future directions
Keno, B. F., Morketo, D. J., & Tashite, G. T. (2026) · Scientific Reviews · doi:10.1038/s44573-026-00024-y
Respectful maternity care needs to be the standard for all women worldwide
Denny, E. (2017) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.15055 · Cited by 14 · see citing works
Respectful Maternity Care Interventions: A Systematic Literature Review.
Namusonge, L. N., & Ngachra, J. O. (2021) · East African Journal of Health and Science · doi:10.37284/eajhs.3.1.330 · Cited by 11 · see citing works

Authors: 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., Castro, C. P., Pileggi, V. N., Robinson, N., Skaer, M., Souza, J. P., Vogel, J. P., & Althabe, F.
Affiliations: University of California, San Francisco (US)
Centro Rosarino de Estudios Perinatales (AR)
Instituto de Efectividad Clínica y Sanitaria (AR)
University of Illinois Chicago (US)
Karolinska Institutet (SE)
Harvard University (US)
University of Ibadan (NG)
Universidade de São Paulo (BR)
Harbor–UCLA Medical Center (US)
World Health Organization (CH)
Corresponding author: Miller, Suellen
ORCID: Miller, Suellen
Abalos, Edgardo
Comandé, Daniel
Geller, Stacie
Hanson, Claudia
Langer, Ana
Millar, Kathryn
Morhason-Bello, Imran
Pileggi, Vicky Nogueira
Robinson, Nuriya
Souza, João Paulo
Vogel, Joshua P
Althabe, Fernando
Venue: The Lancet
Publisher: Elsevier BV
Published: 2016-10
Volume: 388
Issue: 10056
Pages: 2176-2192
ISSN: 0099-5355 (ISSN-L)
0140-6736
DOI: 10.1016/s0140-6736(16)31472-6
OpenAlex: W2519393586
Cited by: 1,181
References: 137
Citations by year: 2026: 95 · 2025: 112 · 2024: 128 · 2023: 116 · 2022: 146 · 2021: 168 · 2020: 161 · 2019: 114 · 2018: 81 · 2017: 47 · 2016: 11
FWCI: 14.90
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: The Lancet (publishedVersion)
PubMed (publishedVersion)
LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
eScholarship (California Digital Library) (submittedVersion)
CONICET Digital (CONICET) (submittedVersion, cc-by-nc-sa)
Funders: Bill and Melinda Gates Foundation
John D. and Catherine T. MacArthur Foundation
World Health Organization
Karolinska Institutet
Medical Research Council (MR/K012126/1)
Topics: Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
Keywords: respectful maternity care, evidence-based clinical guidelines, prenatal care, intrapartum care, postpartum care, maternal health equity, maternal mortality, disrespect and abuse in childbirth, middle-income countries, facility births, maternity care quality
MeSH terms: Female, Humans, Maternal Health Services, Maternal Mortality, Pregnancy, Global Health, Practice Guidelines as Topic, Evidence-Based Medicine, Health Status Disparities

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

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