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.