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

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.

Integrating gender and rights into sexuality education: field reports on using It's All One.

International policy agreements, along with emerging evidence about factors influencing programme effectiveness, have led to calls for a shift in sexuality education toward an approach that places gender norms and human rights at its heart. Little documentation exists, however, about the degree to which this shift is actually taking place on the ground or what it entails. Field experiences in using new curriculum tools, such as It's All One, offer one lens onto these questions. To gain a sense of practitioners' experience with this tool, a two-part exercise was conducted. First, responses from an on-line survey of It's All One users were synthesized. Additionally, five programmes were selected for documentation, including two school-based programmes (Nigeria, China), two reaching extremely vulnerable youth (Haiti, Guatemala), and one reaching adolescents from a polygamous Mormon community (United States). Findings suggest the shift to an empowerment approach is indeed taking place in diverse geographic and programmatic contexts, and that It's All One has strengthened the ways their programmes address gender, foster young people's critical thinking skills and use interactive teaching methods. A common challenge across many programmes is strengthening teacher capacity. Recommendations for further implementation and research are presented.