People often like to think their moms are the best, but is their country the best place to be for moms?
On a list of best and worst places to be a mom, the United States ranked 28th -- between Croatia and Luxembourg, according to the "State of the World's Mothers" report by the Save the Children foundation.
A range of measures -- from mother's education, to infant mortality to representation in national legislatures -- was included in the study, which Save the Children has produced for the past 11 years.
This year, Norway and Australia topped the list, while Afghanistan came in last out of 160 countries included in the study.
"The United States just isn't doing as well by its own mothers as our European colleagues are," said Mary Beth Powers, newborn and child survival campaign chief for Save the Children.
Yet some U.S. doctors say international measures of health or death records vary too much for the rankings to be meaningful.
"The ranking... is interesting but I'm not sure what practical value it has and how it can be properly assessed," said Dr. Michael Katz, the senior vice president for Research and Global Programs at the March of Dimes Birth Defects Foundation.
"Comparing Norway with Bangladesh is not a reasonable approach," he said.
Powers said Save the Children did tailor the rankings and measurements to developing and developed nations.
The survey found the U.S. did worse than European countries in infant mortality, maternity leave and representation in Congress. Women make up 17 percent of Congress in the U.S. but in Norway, 39 percent of the national legislature is made up of women, according to the Inter-Parliamentary Union.
But it was maternal mortality -- or the risk that a woman will die in childbirth or from pregnancy-related causes -- that really sank the U.S. rankings.
Maternal Mortality Drags Down U.S. Rankings
In the U.S., one out of every 4,800 women died of causes related to pregnancy. In Ireland the risk is less than 1 in 47,600.
"In places like Niger and Afghanistan you have a one in eight chance of dying after birth," said Powers.
Save the Children and The Advertising Council teamed up in a "Where the Good Goes" campaign to raise awareness, and funds for programs in the countries that ranked at the bottom of the index.
"We need more health workers, we also need health workers beyond the clinic walls -- you really need women there to counsel moms and newborns," Powers said of the lowest-ranking countries.
But how to improve a rich, yet complicated country like the U.S. has drawn debate and criticism -- particularly on the measurement of infant mortality.
Who Counts What, When
"Infant mortality is defined as the number of children born alive who die after birth -- but this differs state to state and country to country," said Dr. Benjamin Sachs, a fellow of the American Congress of Obstetricians and Gynecologists.
For example, in the U.S., if a woman delivers a baby at 17 weeks the child might have a heartbeat and move before it dies, but it could not survive outside of the womb.
"A child born at 17 weeks would be considered a miscarriage," said Sachs, who is also dean of the Medical School of Tulane University in New Orleans.
But a child born prematurely at 23 weeks, weighing one pound, has a 20 percent chance of survival. In some countries that would be considered a miscarriage, but in others it would be considered an infant death.
"In large part we [the U.S.] include every child born alive," said Sachs.
Sachs thought abortion rates also play in to the numbers.
"About 20 percent of the children who die in the U.S. do so from birth defects," said Sachs. "In a country that has a liberal abortion policy, those children will die in abortion -- some countries even allow third-trimester abortions so their rates [of infant mortality] are going to be lower," he said.
But maternal mortality, which is the measure that cut the U.S. rankings the most, is more complicated to report.
The Obvious Problems for the U.S.
"I think there is a real difference in terms of maternal mortality, but no one knows what it is," said Sachs.
For instance, Sachs said a woman who dies of an ectopic pregnancy may or may not be counted as a maternal death.
"But I do think the maternal mortality is a little bit higher in the United States," said Sachs.
Sachs estimated that the high numbers of uninsured women, including illegal immigrants with "scant prenatal care" are driving up the U.S. maternal mortality rate.
"Those women are at risk," said Sachs.
Sachs and Katz agreed that insuring that every pregnant woman has access to health care and prenatal care would help the U.S. improve mortality rates and other birth complications. Katz pointed out that currently 40 million people in this country do not have health insurance -- or more than 13 percent of the population .
But Katz said that going without health insurance alone is not an explanation for bad pregnancy outcomes in the U.S.
While the high obesity rates in the U.S., rates of older mothers and other health factors play a minor role in the bad health outcomes for mothers in the United States, Katz said, "The major question I would ask is, 'Why do African American populations have worse results than the white population?'"
Powers said Save the Children's research has also found that pregnant "minority" women who seek medical care do not end up getting the same quality of care as pregnant women "in the majority."
Katz said currently it's hard to measure which social, economic, and health care realities are influencing which poor outcomes.
"The United States is a very complicated country -- we have a tremendous number of diverse populations, of diverse economic groups," said Katz. "It's impossible to answer the question 'why?'"
"Once you create good access to health care whatever else that is adverse can be dealt with," said Katz.