Achieving safe motherhood: applying a life course and multiple determinants perinatal health framework in public health.

Safe motherhood has begun to be identified as a priority for the health of American women. We argue that safe motherhood can be achieved through application of a life course and multiple determinants framework. This framework, with its focus on the preconception period, poses a dilemma in that it links together periods of life and domains of activities that have traditionally not been linked with maternal health. The interests of women and children have often been juxtaposed in the making of policy. Further, the domains of women's health, maternal and child health, and family planning have often clashed over policy priorities and funds. This framework shows that the research literature now links them inextricably to better health outcomes, albeit indirectly; there are no intervention studies that have demonstrated the empirical efficacy of this approach. Thus, although this framework creates a strong rationale for the linkages described, it also demands attention to a set of implementation strategies that will overcome existing barriers. Through a focus on one maternal factor, obesity, we discuss how a range of strategies grounded in the framework can be undertaken to address maternal morbidity and mortality. We then examine selected strategies at each level of the multiple determinants life course framework and emphasize how public policies and public and private sector professional practice can be reexamined to improve outcomes for women in all time periods and aspects of reproductive potential, which in turn might enhance outcomes for their offspring, both at birth and beyond. Our intent is to influence how policy makers, public health professionals, clinicians, and researchers approach safe motherhood.