‘The Lancet’s Maternal Health Series paints a sobering picture of the state of maternal health today…’ says a Comment in The Lancet by Lynn Freedman (Averting Maternal Death and Disability Program, Columbia University, USA).

‘Seemingly, what counts is that facility-based delivery has increased, sometimes dramatically. [But what] do women experience when they arrive at facilities ready to give birth?’

‘Suellen Miller and colleagues identify 51 high-quality global and national clinical practice guidelines issued since 2010 for routine maternity care in facilities. Focusing on middle-income countries to determine what actually transpires, they document pervasive, health-threatening deviations from those guidelines, characterised by too little, too late (insufficient appropriate care) and too much, too soon (excessive medicalisation).’

Miller et al point out that ‘On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS) [eg excessive use of episiotomy and caesarean section]’. While the former and latter are often perceived as problems of LMICs and high-income countries, respectively, these two extremes often co-exist within the same country [and even, I would suggest, within the same health facility and at different times in the care of the same patient].

The paper highlights (inter alia) that ‘women value not only appropriate clinical interventions, but relevant, timely information and support so they can maintain dignity and control’ and that care should include:

‘- Provide information about normal course of pregnancy, including breastfeeding if possible, by written material…
– Provide information about consumption of well cooked meat, drinking water and food preparation hygiene, washing hands after gardening and handling of animals (cats), to prevent toxoplasma infection and other infectious diseases…
– Treat every woman with respect, provide her with all information about what she might expect, ask her about her expectations, and involve her in the decisions about her care…
– At time of discharge from health facility, provide information about danger signs for the mother and baby, and counsel women on adequate nutrition, hygiene, handwashing, and safe sex…’

Both papers are freely available (after free registration):

Citation 1: Lynn P. Implementation and aspiration gaps: whose view counts? Thye Lancet Volume 388, No. 10056, p2068–2069, 29 October 2016  DOI: http://dx.doi.org/10.1016/S0140-6736(16)31530-6

Citation 2: Miller, S, Abalos, E, Chamillard, M et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016; (published online Sept 15.) http://dx.doi.org/10.1016/S0140-6736(16)31472-6.

Best wishes, Neil

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