The mother's womb is replaced by the womb of culture, which, comfortably or uncomfortably, cradles us all (Robbie Davis-Floyd 1992: 149).

Pregnancy, birth, breastfeeding -these practices are simultaneously natural and universal, connecting women across the world and over history. They are profoundly local and culturally shaped, with the potential to divide women from men, but also from other women in different circumstances.

In the past couple of weeks, I've had the pleasure of viewing two documentary films that examine reproductive experiences across culture, and stimulate a reconsideration of culture and birth. The first, Babies, is a French

Photo credit: http://focusfeatures.com/babies

documentary released in 2010 which centers on four babies from birth to their first birthday: Mari in Tokyo, Japan; Hattie in San Francisco, CA, US; Opuwo in Namibia, and Bayar in Baynchandmani, Mongolia. Babies is a delight to watch, and interestingly, it features no dialogue, no subtitles and no narration. The babies really are the center of the film-we see the world as they encounter it, whether a pet cat swishing by on the hard wood floors or a goat checking out the bath water through the window of a yurt. Each baby's lifeworld is vividly and intimately shared. The film's balanced portrayal of each culture means that we see the US as only one of many places a baby can be born and grow up. Even things we think are universal and timeless, such as birth and breastfeeding, are profoundly shaped by the cultural context in which they occur. Robbie Davis-Floyd's quote is apt here: culture can be a comfortable cradle, as it is for these individual babies, who are loved, healthy and safe.

However, without a cultural context, we have no way of knowing how their mothers' journey through pregnancy and birth affected their outcomes and life chances. Not all babies and mothers have an equal chance at a healthy pregnancy, birth and first year of life. A new documentary film on maternal health, No Woman, No Cry, introduces us to at-risk pregnant women in four parts of the world: a remote Maasai tribe in Tanzania, a slum of Bangladesh, a post-abortion care ward in Guatemala, and a prenatal clinic in the United States. Directed by Christy Turlington Burns, former fashion model, now mother of two, a public health master's student at Columbia University, NYC and an ambassador for CARE - the film is a courageous and inspiring look at the reality of women's lives when pregnancy occurs in the context of ill health, lack of access to timely and quality care, so that birth is a precarious, life-threatening event.

No Woman No Cry had its world premiere at the Tribeca Film Festival in NY last year, and is on a select west coast tour during which I saw it in the company of many public health students and professionals at the University of California, San Francisco campus in Mission Bay, SF. Speaking on the panel after the film were Suellen Miller, PhD, CNM, Associate Professor at UCSF [Director, Safe Motherhood Programs, Dept. Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, Center of Expertise, Women's Health and Empowerment, Global Health Institute]; Nan Strauss, a researcher at Amnesty International USA and the co-author of 2010 report on US maternal mortality, "Deadly Delivery: The Maternal Health Care Crisis in the US" and Christy Turlington Burns herself.

No Woman, No Cry is a beautifully photographed film, with haunting images. The music is a perfect accompaniment, never obtrusive. I admire Ms. Burns' vision for this film: to tell a story "giving viewers an informative and powerful look at this compelling global issue without having to leave their ZIP code." One such story is that of Janet from Tanzania, whose labor in her third pregnancy was long and protracted, and for whom the $30 bus fare to the hospital was a nearly insurmountable obstacle. Another story portrays the immense cost of anti-abortion policies on women's health with a focus on a Guatemalan physician, Dr. Linda Valencia, whose mission is to educate women about contraception and

provide nonjudgmental medical care to them following self-induced abortions. In Dhaka, Bangladesh, the focus is on Monica, a young mother living in the slums whose labor requires a visit to the hospital, where she is helped , but experiences as very traumatic due to her poverty and how she is treated. Finally, the US context, while not in the same scale as the other countries, is an important part of this story, showing that developed countries cannot be complacent. The US has fallen in world ranking to 50th, with maternal mortality ratios (24) higher than almost all European countries, as well as several countries in Asia and the Middle East according to statistics released in September 2010 by the United Nations.* The burden of worsening maternal health outcomes is felt most strongly by African American women, who face a three-four fold higher risk of death than women of other race/ethnicities, the largest and most long lasting disparity in public health. But as the film points out, some maternal causes of death do not distinguish by race or class - as the example of the woman who died from an amniotic fluid embolism, a common yet less preventable cause of death than more prevalent issues such as cardiovascular disease, hypertensive disorders and hemorrhage.

The film invites questions and dialogue. For those not familiar with pregnancy and associated risks, the stark presentation of women whose lives are at risk due to their cultural and individual circumstances may overshadow the reality that for many women, pregnancy is a low risk event. Even in Dhaka, where the lifetime risk of maternal death is 1 in 110, many women have babies without incident. The comparative risks are less elaborated, as is a discussion of the dual problems in maternity care - under utilization of medical care for some women and over utilization of medical interventions, including cesareans for others. Evidence of our greater misunderstanding of the gravity of this problem, the audience gasped when panel member Nan Strauss informed them that the US cesarean rate is now 33%.

Pregnancy and childbirth can be a joyous, rather than feared and dangerous time, but this requires a global reprioritization of women's reproductive health care. This can be done, with enough political, and moral, will. The obvious cost of a maternal death is seen in the eyes and heard in the voice of the US widower, who is clearly bereft after the death of his wife. Yet the hidden costs of maternal death are found in the torn social fabric remaining when a woman dies needlessly in childbirth - as a worker and major contributor to the household income and food sources, and as a mother, sister, friend.

There are more stories to tell than this film had the time or space to do. These include stories of poor women in the US, the voices of politicians who vote for increases in certain types of spending over that of maternal health - and of course, the voices of women in the US and the world, speaking out for the mothers who die.

Posted by: Christine Morton, PhD, CD

Disclaimer: Christine Morton provided consultation to the film's producers, and has retweeted and been retweeted by Christy - we follow each other on Twitter.

[For both documentaries, much more information, background and context, is provided on the websites and here].

*WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf.

Tags