The chal­lenges to safe moth­er­hood vary depend­ing where in the world you live. In some areas the chal­lenge may be to get ade­quate nutri­tion or clean water; in other areas, it may be to pre­vent infec­tion; and in still other loca­tions it may be try­ing to avoid preg­nancy before your body is ready or get­ting access to pre­na­tal care. In the U.S., it may mean avoid­ing being seden­tary and mak­ing poor food choices, or hav­ing to deal with the high tech­nol­ogy envi­ron­ment of med­ical birth that can sab­o­tage the innate phys­i­o­log­i­cal process of labor and birth.

The biol­ogy of birth is a com­plex series of cause-effect processes…baby’s brain releases chem­i­cal sig­nals to the mother and the pla­centa begins to man­i­fest the mater­nal immune system’s rejec­tion of the fetus.

To help the ball get rolling, relax­ation (the trophotropic response) helps pro­mote the release of oxy­tocin. With the help of grav­ity, the head presses on the cervix, ampli­fy­ing the uter­ine con­trac­tions. After an ultra-distance aer­o­bic endurance test, the cervix opens enough to let the baby move into the vagina and the mother’s dis­com­fort moves from sharp cramp­ing into the bony struc­ture as she tran­si­tions to the strength test of push­ing. She tran­si­tions. Relax­ation mod­u­lates into an ergotropic — adrenal — response to gather her power.

Push­ing is an inter­est­ing term…more mas­cu­line, I think, than the one I pre­fer:  Releas­ing. Releas­ing or let­ting go of the baby. It’s a cathar­sis. In this por­tion of the labor another set of impor­tant processes help the baby clear its lungs of amni­otic fluid, stim­u­late its adrenal sys­tem and chal­lenge its immune sys­tem, as the con­trac­tions drive the baby down­ward. The mother’s deep trans­verse abdom­i­nal mus­cles — if strong enough — squeeze the uterus like a tube of tooth paste, to aid this expul­sion. In the mean­time, the labor is help­ing set up the mother to fall in love and pro­duce milk. When the baby emerges and moves onto the mother’s chest, s/he smells and tastes the mother, rec­og­niz­ing her mother’s fla­vor and set­ting up the poten­tial for bonding.

Any way you slice it, there are two parts to safe moth­er­hood. One is a safe preg­nancy…healthy nutri­tion, phys­i­cal fit­ness, safe water, infec­tion pre­ven­tion, sup­port and a safe envi­ron­ment. The other is a safe labor. In a safe labor, there is both an envi­ron­ment that pro­motes the nat­ural process of labor and the means nec­es­sary for med­ical assis­tance when needed. Women die at an alarm­ing rate from preg­nancy or birth-related prob­lems. Despite some progress made in recent years, women con­tinue to die every minute as a result of being preg­nant or giv­ing birth.

What keeps us from hav­ing a bet­ter record on moth­er­hood is often lack of care in the devel­op­ing world and too much inter­ven­tion in the U.S.. They are two sides of a coin. Moth­ers’ expe­ri­ence and health needs are not on equal foot­ing with other cul­tural val­ues. In places where basic pre­na­tal care or fam­ily plan­ning are low pri­or­i­ties, at-risk women are vul­ner­a­ble to the phys­i­cal stresses of preg­nancy and birth. In the U.S., machine-measured data is para­mount, even if it pro­duces high rates of false pos­i­tives, unnec­es­sary inter­ven­tions or coun­ter­pro­duc­tive pro­ce­dures. We are learn­ing that obe­sity and seden­tary lifestyles have detri­men­tal effects, but fewer preg­nant women than their non-pregnant coun­ter­parts exercise.

Despite the money spent to sup­port the tech­no­log­i­cal model of preg­nancy and birth in the U.S., there are parts of the world with lower rates of mater­nal deaths — espe­cially Scan­di­navia, North­ern Europe and parts of the Mediter­ranean and Mid­dle East (Greece, the United Arab Emi­rates, Israel, Italy and Croa­tia). In fact, in the U.S., mater­nal deaths are on the rise.

It’s a tricky busi­ness. Clearly West­ern med­i­cine has a lot to offer the devel­op­ing world when there are med­ical con­cerns. On the other hand, import­ing the U.S. model could cre­ate more prob­lems than it solves. Instead, the micro-solutions now being devel­oped in many loca­tions will be observed and evi­dence col­lected by orga­ni­za­tions such as the White Rib­bon Alliance and UNICEF.

There is an effec­tive inter­na­tional mid­wives model adopted by JHPIEGO, the Johns Hop­kins NGO work­ing toward improved birthing out­comes. It assesses the local power struc­ture, social con­nec­tions, poten­tial for trained birth assis­tants, and loca­tion of avail­able trans­porta­tion to cre­ate a net­work so that locals will know when a labor is in trou­ble and who can get the woman to the near­est hospital.

In the U.S., there are in-hospital birth cen­ters that allow low-risk moth­ers the oppor­tu­nity to labor and birth in a set­ting designed to encour­age the innate processes. Women are begin­ning to vote with their feet…staying home for birth. Women are going abroad to give birth. At the same time, women are com­ing to this coun­try to give birth, believ­ing it is safer than where they are. There are sev­eral ways these scenes could play out.

But, I’ll wager, improv­ing out­comes will involve com­pro­mise:  Watch­ful­ness and sup­port in most births, plus bet­ter ways to assess dan­ger and pro­vide tech­nol­ogy. No mat­ter where you live in the world, the solu­tion may be essen­tially the same.