What the Lancet has to say about TLTL and TMTS

Acronyms have become a part of our culture, especially with texting. LOL, ICYMI, and others are part of our new vernacular.  However, two new acronyms were introduced on September 15, 2016 by the Lancet: TLTL and TMTS.  Here's what authors Miller et al had to say:

In a recent article titled "Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide", authors Miller et al have identified that we are at an intersection in maternity care: too little, too late (TLTL) and too much, too soon (TMTS).  They describe TLTL 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 in many countries, not just the United States. Also described is the concept of TMTS:  the routine over-medicalization 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. It has been found that TMTS causes human harm and increases health costs, and many times, concentrates disrespect and abuse. 

Moving from "just" a maternity issue to a global public health issue, TLTL and TMTS has at the core a lack of evidence-based maternity care (EBMC).  EBMC includes care that is humane and dignified, and delivered with respect for a woman's fundamental rights.  In the Lancet's Midwifery Series, it has been shown that women not only value appropriate clinical interventions but also timely information and support so they can make the best possible informed decisions.  Patient satisfaction with care rises when this information and support leads to a feeling of dignity and control. Yet, evidence continues to demonstrate that women are too frequently not informed of risks nor have they been given informed consent for medical interventions. Leading international childbirth education and maternal/child health organizations have been say this for decades.

A prime example is the 2010 estimation that there were 3.5-5.7 million unnecessary cesareans done.  Cesarean section is an aspect of maternity care that is globally monitored and an example of an intervention that can be either TLTL or TMTS with disparity rates in nearly every country on earth.  While cesarean rates appear to be somewhat decreasing in the US, they are rising globally.

Significant to this conversation is the failure of the medical community to embrace and put into the practice evidence-based care.  Known as the "Know-do" gap, research shows that there is a sluggish effort for implementation of evidence-based care.  A dynamic effort must be made to target providers of maternity care for dissemination of this information, while also doing an audit of action, feedback and additional targeted educational interventions.  In short, the buy-in for reducing the "Know-do"gap and improving maternity care (plus improving maternal/infant morbidity/mortality rates) must be felt at all levels of management.  

The words "move toward more respectful maternity care" should basically scare the hell out of care providers today.  The implication that today's care is not respectful to a woman's physical, mental and emotional health goes against what many of us joined the profession to provide.  It can be shocking to know that traditional practices that are the "way we've always done it" are actually harmful for women.  Denial and anger are common responses to this epiphany.

As more and more research and statistics are revealed, the pressure on care providers will increase.  For hospital policies, procedures and practice guidelines to change there must be also social and economic pressure for change.  There needs to be intense pressure from the customer of maternity care for respectful care without fear of retribution.  There should also be pressure from insurance companies to refuse reimbursement for non-evidence based care.  Unfortunately, if we cannot appeal to the care providers' hearts, we will need to hit them in the wallet.

Providing evidence- based respectful care is not impossible.  There are providers, facilities and whole health care systems that have embraced implementation and currently practice this type of health care.  Sadly, the majority do not.

The authors state that excessive, unnecessary or inappropriate use of obstetric interventions in health facilities are a cause for concern.  I believe we've been concerned and complacent for too long.  Too many women have been the victim (yes, I said victim) of this type of inadequate care.  I say it is now time to sound the alarm.


Miller, S. et al. (2016)  Beyond too little too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.  The Lancet. Published online September 15, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31472-6