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Too much, too soon

Too much, too soon” means care before, during and after childbirth that is too much, unnecessary, inappropriate, and possibly even harmful. It is one extreme of maternity care, with “too little, too late” at the other extreme end. “Too little, too late” means a lack of access to good quality care, or care that cannot be accessed quickly enough, and covers inadequate access to services, resources, or evidence-based care. Efforts to improve maternal health have traditionally focused on “too little, too late”, but “too much, too soon” can also harm. “Too much, too soon” care is increasing everywhere as more women around the world give birth in health facilities.

While these problems have many causes, they can both be addressed by adhering to evidence-based guidelines for maternity care.

What are the issues?

Unnecessary medical interventions

The world has seen a rapid increase in births taking place in health facilities. In many facilities, too many unnecessary medical interventions, and sometimes even the wrong ones are performed. For some of these interventions, there is no evidence that they provide any benefit at all. For others, like episiotomies or enemas on admission for labour, there is even evidence that they cause harm. Overuse, without clear medical indication, of labour induction and augmentation has been associated with significant maternal morbidity, including uterine rupture. The overuse of unnecessary interventions can be seen alongside an absence of beneficial interventions, like having a birth companion.

“Too much, too soon” can also refer to interventions that provide a benefit in some contexts, but which cause harm in others. For example, although induction and augmentation can be effective and sometimes even life-saving when they are needed, using them when they are not needed can cause serious problems like rupture or prolapse of the uterus.

Many high-income countries—and a growing number of low and middle-income ones where maternal survival rates are improving—show worrying trends of health facilities using inappropriate obstetric interventions. Women are rarely informed of the risks of these interventions.

The use of potentially harmful practices such as caesarean section, especially in the private sector, is often a sign that a country’s legal and regulatory systems are not strong enough, and that health providers in that country are not following evidence-based guidelines.

The cost for health systems

Unnecessary interventions can be expensive for health systems—which in low and middle-income countries might already be weak and struggling, and competing for scarce resources. These costs get worse if interventions cause unnecessary harm that then needs to be treated.

Poor quality care – lack of evidence

Evidence-based care should be available for all women, regardless of background—but it is not. Care should be available everywhere that includes respect for women’s circumstances, rights, and choices, and screening for diseases or conditions that might be more prevalent among refugee, migrant, marginalised, or indigenous groups—but it is not. There are often conflicting recommendations among different guidelines on the benefits and harms of interventions, and the Series found no high quality guidelines developed by low-income countries anywhere in the world.

The picture is made even muddier by uncertainty about why differences exist, different systems for grading evidence, and inconsistent terminology.

What can be done?

High quality guidelines are needed for clinical practice that are consistent all over the world—developed in a spirit of worldwide agreement about what is needed, using similar language, and making similar recommendations everywhere.

Policy makers and professionals from different sectors must work together to develop these guidelines, and scientists and academics must make sure that they are used properly, and that countries stick to them.