39,000 girls under 18 will marry today.

Child marriage is defined by the United Nations as any child who marries before the age of18.  It is estimated that 39,000 girls under 18 will marry today.

Between 2011 and 2020, it is estimated that 140 million children will be married and of those 50 million will be under the age of 15.

One half of all the girls in South Asia will be married before they reach their 18th birthday.

These women walked several hours to wait for a government midwife to immunize their children and get prenatal care.  They wait at a small store and if she does not come, walk home again and try the following month.   There is no care in their villages.  Mostly they come for immunizations.

When I am there, in a small community, I offer prenatal care and work with the community health workers and Gigi, the newly graduated midwife.   I ask a young woman who is only 14 if this is her first pregnancy.  "No" she answers.  "I had one other who died."    "When?"  I ask. She looks at me and says, "The day he was born.  That day."   I wonder why.  "Did he cry at birth?"  "Yes, she says."

I ask who the midwife was and she answers that her husband delivered the baby.   

"Oh."  

She is fourteen, pregnant for the second time and has already lost one baby.  They tell me that the girls are frequently given in marriage for a dowry such as two horses or some other thing the family might need.  The  men are older and perhaps have other wives or children.   

The next day, I have a women's circle and we talk about birth and some things that might help in an emergency.   I suggest having a first baby after 18 but they laugh.  This is not possible.   They are married between 11 and 14.  

Mountains and Motherhood and Midwives

Childbirth in the mountains

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Twenty-seven percent of the earth' s surface is mountains and these mountains are home to over 720 million people.   They are also some of the poorest people on earth and the place where far more women and babies die in childbirth.

In many countries that I have visited, the mountains were the places that people fled to when escaping slavery, state making and colonization.   The people down below in the valley land see them as living ancestors; carrying with them the traditions and knowledge of the past.  Most people originally lived closer to the coast where  trading, better soil and more opportunities for growing and hunting for food existed.

In Haiti and as in the Philippines, when the Spanish came some died of disease and were enslaved and some escaped to the mountains.  They were sometimes known as maroons; people who escaped from slavery and went to live in the mountains.   Brave and resourceful they came to make the unwanted land of the mountains their home.  They learned to farm, hunt and build communities high in the crevices of these places.

There were and are still are few roads.  Paths connect communities and are often a long way from the road.

In the Philippines, they ask what is to be done about our poor maternal health rating?

"It is" I say,  "A matter of mountains."

"Mountains?"

"Yes, mountains.   The women can not get down when they need help and no one wants to bring care to them so far up in the mountains.  It is matter of roads and people."

The governments hope that the women will come down.  They plan for waiting homes and birth homes but they are far from the mountain communities and difficult to get to.  They must leave farm and family.

But it is not just roads, it is that the mountains are fragile ecosystems and things like mining and deforestation destroy their source of food and cause severe starvation and malnutrition.  Streams are filled in by landslides destroying a source of water.

There is also war.   I think of the sandy roads of Cambodia that offered many,well staffed rural health centers.   The roads were flat and easy to use.   People road bikes and walked and healthcare was greatly improved in this landscape.  But even there, high in the mountains, on the border of Thailand and Cambodia, soldiers camped with their families and in that place- that place of on-going conflict, the women had no access to care and were far from help, should it be needed.

In the Philippines, a people fearful of the army and foreign mining companies, have difficulty worrying about birth.  The government says, "Come down out of the mountains and give birth down here."

They threaten them with fines; fines for the mothers and fines for the traditional midwives.  A woman at a small store says, "They just more further into the mountains where no on will bother them."

When I teach a workshop, usually for the traditional midwives, all the women, children and some men of the village come.  I can see from their stories that there, everyone is the midwife.  Anyone could find them self beside a woman giving birth; on the road, in a field or by the water.  They tell me that there in the mountain they all need to know.

On my way down the mountain, the motorcycle weaves around many new landslides and through mud from hard rains.  It is a long, hard ride and even when we get to the main road, it is a long way still to the nearest birth center and even there the midwife is gone and would not be there, even if the woman had made that long journey or could have afforded the motorcycle ride on a day when the road was not washed out.

I too, live on a mountainside.   I am 67 and people sometimes say, "I am afraid to come up there on that road to see you" and sometimes friends say "maybe it is time to move off that mountain."

Other times, I sit on a rooftop in LaGonave or sit by the school in Mindanao or sit on my little mountain and look out.  Buried in the mountains, we can see lights in the distance and know there is a life  out there.

A doctor says , "And how is America?  " I consider and say., "It is big place so its hard to say but I live on a dirt road on a little mountain and look out at the dusk creeping over the valley.  I have chickens and sheep and the children run and do not want to stop playing. "   She can see it is much the same.  But it is not.   The army has never once come up my mountain and if they are mining this mountain range it is not on my land and mostly never could be.  I can get in my car easily, and drive to town.  When my grandchildren are born on the side of this mountain, I can easily get down in an emergency.

I look at the group gathered to ask what I think about maternal health in the Philippines and I consider the question.  "Mountains.  You have to have a plan that considers the mountains and the people who live there; not one just for getting them down but one that respects their culture and their need to be near family and farm.  I think the midwives have to go to the mountains."

The Ladder System of Midwifery in the Philippines

The Ladder System in the Philippines - from Midwife to Doctor

This is my friend, Gigi, who lives and works and volunteers in the Philippines.  I spent my first week in Mindanao with her.  She has just finished her third year of midwifery school and was suppose to volunteer in the summer before she started a  year of nursing school in the fall.  

She and her other class mates are part of an amazing program, in which they complete three years of midwifery school and then can go on to complete a year of nursing school and then go on to medical school.  They can stop at any point in the program or just keep on going.   To qualify they must be chosen by their community or Baranga.   She was chosen for her obvious enthusiasm, intelligence and dedication.  

Her school is a large modern building. It is great, but what is amazing is the village of traditional houses across the field where all the students live, cook and study.   It is a remarkable model of improving healthcare in remote communities.   

Gigi and I had so much fun together.  We did prenatal care and taught classes and gave presentations as well as so much singing and riding motorcycles up to the communities and cooking and telling stories.  What was so impressive about her and the community health workers, was their true wish to help their communities and a sense of volunteerism.  She is becoming a doctor, via becoming a midwife and a nurse but her mission seemed so much larger.  It was to make her country a better place for everyone and most all of all those who have the least. She is eager to understand her country's history and the culture of the people she serves.  

There is much that can be said about maternal health in the Philippines but I want to start with this amazing woman and her path to becoming a doctor.   Her courage was as big as her heart and her smile.   

You may be surprised that it starts with 3 years of midwifery.  I think its inspiring  because its basically saying," let's start at the beginning of life and get that right."  A midwife also does many things including prenatal care, births, immunizations and family planning.  Each midwife there covers a large area that includes many remote villages.  There job is very hard, even with the help of community health workers from the World Health Organization.  There is no doubt that when Gigi graduates her community will be so happy to have her.  As part of the program, she made a commitment to stay in her country and return to her rural community.  

**** Just a note of caution, the Philippines did not meet the millennium goals in maternal and newborn health and the communities we visited had no prenatal care and no access for transport or even trained traditional birth attendants.  It is currently agains the law to have you baby at home with no ability to serve women in birth centers that they can have access to.   Gigi is part of the solution but in the mean time there ei much that can be done.