Pillars of Maternal Health - Education for all girls / Public Boarding Schools in the Marshal Islands

My friend, Jill, with her two children at the lagoon. Jill is teaching at the North Islands High School where her expertise and love of the Maarshalese culture shine through. Girls who finish high school have a greater chance of not dying in childbirth worldwide.  Their children are also more likely to survive and thrive. Investing in girls education, worldwide,
is an investment in maternal health,

Traditional weaving at Field Day

In many places around the world, girls are forced to stop their schooling to help their families.
Often the cost is too great and the schools are too far from home.  In the North Islands High School Field Day, the girls
compete to make a traditional basket.

In the Marshal Islands, most high school students attend one of three different boarding schools.  These three girls are building a traditional house as part of their senior project.

Traditional sailing canoe used for fishing and travel between the islands 

My friend in Wotje, writes to say they may close school early there and that she cannot come home for summer break.  She and her family are safe on their little island, as long as no one comes in and no one leaves.   There is no sheltering in place or masks.  The waves beat agains the shrinking shore line of the "ocean side" and the soft, blue lagoon gives life ease and grace on the "lagoon side."  In between people have their morning coffee and conversation in the town and children go to school.  Men harvest coconut to be picked up for coconut oil production in far away places.  The teenagers take bucket showers after school, in the hot island sun.  children, dogs, chickens and pigs escape the watch of care givers and run free.  Love songs drift from high school dorms over basketball and volley ball games until the dinner bell rings.

In my country, the poorest of our nation, the immigrants and undocumented refugees work in meat plants.  The Marsallesse, with there compact with the United States, are free to travel to the United States and work in its many slaughter houses and meat packing plants. All over the country, we send our newest immigrants to meat packing houses.  In this time of the coronavirus, they are considered essential services and the virus takes it toll.

Disease has always been hardest on trade routes.  Trade killed tens of thousands of North America's indigenous people.  It is then, no wonder that this virus, that breaks our hearts and tears our society apart followed trade routes.  That disease followed the need for gold, beaver pelts, oil and a never ending supply of inexpensive clothing.

The Marshal Islands and its people, have been occupied for hundreds of years; occupied and exploited to the point that true sustainability in the face of climate change would be hard.

Here is a brief pictorial tour of the occupations.

The Germans created a Treaty of Friendship in 1895.  At that time, there were about 15,000 people and each island was its own entity.  The Germans set up trading posts for coconut oil production.   This lasted until World War I/  The Germands also brought the first missionaries.




I am having a hard time downloading the other photos so it went like this.

After Germany, lost the war, the islands were given to Japan from 1914 to 1945, by the League of Nations.  They were suppose to educate them and provide health care and support their economic development.  They became war bases and wee used to attack Pearl Harbor.  The accounts of the Japanese treatment of some islands and their people is unbearable. 

Needless to say, Japan lost the war toad then the United Nations gave it to the United States to take care of.  The United States promptly used it to test nuclear weapons and build army bases.  Whatever their state of child well-being is a result of centuries of occupation and exploitation.

In the middle of a pandemic, it is hard to think much beyond ones own house an yard.  We are forced into a bubble but if one day someone reads this,know that this pandemic was most likely brought about by greed and foreign trade and the exploitation of our earth and all living things.  Will we come out of this, kinder and wiser or will we mount another huge assault on the earth ignorer to boost our economy.  

Will we let the seas rise around these small islands, forcing the people to flee and provide our country with a never ending source of meat.  Will we bemoan immigrants, without ever learning the long chain of their journey and our country's chapters in their lives.

Perhaps you will look up the Marshal Islands on a map and find them, there in the middle of the Pacific Ocean, and know a tiny bit more of this beautiful, rich culture and know that their spirit of welcome is alive and well and strong.  Perhaps, instead of saying, "Ah, is that the place we tested nuclear bombs?" you can slo say, "Ah, aren't they the people with remarkable skill in navigating the sea?  Aren't they the place where people sing and dance in rhythm with the earth.  Ah, The Marshal Islands - a place worth fighting for  in our work for climate justice and peace and fair trade. "  

Ah, the Marshal islands, where the sun sets over the lagoon and the skeleton of ancient corals, crunch beneath your feet.  Ah, yes the Marshal islands a place both simple and complex.  I know a little about that place.  The children, like all children, ar the most beautiful in the world.   

Meeting with midwives and mothers on Wotje Atol in the Marshal islands.

Meeting with midwives and mothers in the Marshal Islands

I love meeting midwives, when I visit somewhere.  My sister invites a midwife to visit with me on a recent visit to Boston.  I have lunch with a midwife in Oakland.  I love to hear what their experiences have been; their training and what the challenges are.

When I visit Wotje, I learn  that the women next door had recently given birth at home with the local midwife.  I was excited to meet her and hear her story.  I had met the community nurse at his clinic and asked him about care.  He said, "Prenatal care is on Thursday mornings but when I arrived, no one was there, including him."  I wandered off through the paths of coconut trees and women working in their yards.  I ask them,"Where does the midwife live?" They point towards the lagoon and eventually someone goes and gets her and we sit in the warm sun, visiting.

She had been trained some twenty years ago with a short course in the capitol of Majuro and reports she has had no training since.  She delivers most of the island's babies, unless a mother chooses to go stay in Majuro at the end of her pregnancy.  She has no way to listen to a heartbeat, no blood pressure cuff and no medications.  She uses her heart and hands as she always has.

When asked if she ever had a complication, she seemed to be focused on presentations, other than a head including a cord, foot and breech.  They can call a plane for transport, at no cost to the mother, but that would take several hours, at best.  Although the islands report high levels of high blood pressure and diabetes, she did not say she ever experienced eclampsia.

The nurse had prenatal vitamins and could come and check a blood pressure at the start of labor.  He did not have any means of listening to a heartbeat or a bag and mask to resuscitate a baby.  The nurse said he had medications to stop bleeding but running to get him, even on a small island, could be problem.

The women of Wotje sing to me after our birth gathering.  They also covered my hair with homemade flowers!
I felt so happy to bother with them.  Understanding that the birthing wisdom of their grandmothers still served them well.

Gathering of women and midwives at Wotje Atol, Marshal islands

Like the mountains of the Philippines, when I invited the midwife to a Helping Babies Breathe Training, all the women came.  We had a fun time sharing birth stories and doing some birth scenarios.  Some the younger women were interested in becoming midwives themselves and expressed concern about the birth services on the island.   They again shared that there was no prenatal care and that they were not prepared for an emergency.  They shared that many women do not give the baby colostrum after the birth and that few exclusively breastfeed.  The women had many babies and were only recently gaining access to family planning.  I left a fetoscope, a newborn bag and mask and a birth picture book with them.  I promised to send some materials including Hespiran's Book for Midwives and Where There is No Doctor for Women.  I also downloaded the wonderful training films from Global Media.  I suggested a study group until they can send someone from their island for a midwifery training.  

My hope is that one day, each atom can have a skilled birth attendant with the necessary emergency supplies and training.  In the best models, it seems that the newly trained midwives can work with the older traditional midwives and within the health center.  

While teaching the Community Health Module, to midwives in Haiti, I came to appreciate the value of observation,  conversations and a walk about the area.  As part of the WHO curriculum, the students were asked to go on such a walk and find people to interview.  This method of learning about maternal health was compelling and life changing.

Road in the Marshal Islands 

I had started my midwifery career because I observed young children with fetal alcohol syndrome.  I noticed a problem in the community where I was working and could see that it took route in early pregnancy as well as in how women perceived themselves.  Within the context of Head Start, I saw maternal health as an integral part of the community.  But once I was a midwife I focused on clinical measurements with far less of a focus on the community.  Healthcare in the United States was rarely embedded in a specific community, reflective of its unique strengths and challenges.  Mothers were islands within a large healthcare system, disconnected from culture and community.

When I arrived in the Marshal Islands, I knew I would be meeting with the midwives and mothers. I quietly began this informal and enjoyable way of doing a maternal health assessment.  I do this now, without even thinking, everywhere I go.  Doing this, in Portland, led me to begin to see the Portland Harbor and it fossil fuel hub and their relationship to maternal health.  I began to see the world in relationship to how it cared for and protected mothers and babies.

The premise of these walks is that the well-being of mothers and babies, is directly connected to the resources available to them from the time of their own birth.

Children in the Marshal Islands at a morning assembly.  All children in the Marshal Islands receive a free k-12 education.

One of the first things I am interested in is the state of education in a community.  If all children and particularly girls are able to receive a free k-12 education with access to higher education, they are far more likely to avoid a child marriage, plan when they give birth and access health care.  They are more likely able to prevent abuse of themselves and their children and to be able to contribute to the community.  In the Marshal islands, all children receive a free k-8 education.  In high school, they go to regional boarding schools and have an opportunity for college.  Requiring uniforms, certain shoes and ribbons, may serve as a barrier to education.  Here uniforms are not a barrier to education.

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Here we see a coconut charcoal burner, a common source of fuel in the Marshal Islands.

Another thing I look at is the fuel that people use to cook their food.  How far they had to walk to get fuel and the impact that fuel has on their well- being, including air pollution.  In my community, we are often dependent on fossil fuels such as gas and oil and coal to cook our food.  This method of cooking our food, heating our homes and transportation has a desperate impact on our own health as well as the people in other places in the world.  Climate change and pollution impacts a small island like this, while they create a sustainable method of producing charcoal from cocoanut husks. In many countries, the few trees available in a community are cut for charcoal so that families can send their children to school or pay for healthcare.

Water capture system installed but the government. In the marshal islands, most drinking water must be captured
from rainfall.  Draught is one of the most serious problems facing a country with almost no fresh water sources.

Collecting water is one of the greatest challenges many women face around the world.  Young girls and women may walk hours a day to collect water from a pump.  Rain catchment, in the Marshal Islands, saves women hours of work each day and assures them a clean source of water.  This system prevents contamination of a water source by human or animal waste.  Because it is covered, it can not provide a breeding place for mosquitoes.  It is easy to see that water catchment, makes a significant impact on women's health.  

A community health station in the Marshal Islands.  Each atol has a community health clinic with a trained nurse who provides preventative and day to day care.  The nurse can communicate with the health department in the capitol and order medical transport, as needed.  This model provides the community basic healthcare, immunizations and first-aide.  This basic level of free community care assures the people on this island the security of health care.

How and where women and children receive healthcare, is critical to any community assessment.  Is the care easy to assess? Is it close by and are the clinics well supplied with necessary medications and supplies?  Can women access prenatal care, family planning and a safe birth?   Although the island had no skilled birth attendants, it had a certain level of health security.  All women could choose to fly to the capitol for their birth.

Access to food is a critical need of any community.  The people of the Marshal Islands, lived
for thousands of years in a culture of sustainability.  They gathered shell fish and fished and ate local coconuts and breadfruit.  World War II and the subsequent years, have destroyed much of their food security.  It is now estimated that 90 percent of their food is imported.  Locally grown and gathered food has been replaced by white rice, processed meat and sugar.  With this comes, higher levels of diabetes and high blood pressure.  There is evidence of stunting in children and a decreased life expectancy.  A culture's ability to produce their own food is critical to their well-being.

Catholic Church in the Marshal Islands

The role of religion in any community is an important part of a community's health.  Does true freedom religion exist?  Do religious leaders abuse their power and exploit the resources of the community?   Religion appears to be important in the Marshal Islands but I did not observe the abuses that we see both in my country and Haiti.  There was no evidence of a class based religious system.  I was never in a community in Haiti, where I did not observe some sort of abuse by priests which impacted women and children and almost universally remained unchallenged by NGO's.  In my country, fundamental branches of  many religions, negatively impact health outcomes of women in our country and around the world.   Women appeared to be able to use church spaces for community education and gatherings in this community.

Harms and Risks 

The Marshal Islands face many risks including climate change, over fishing by other countries and drought.  Because of the compact it has with the United States, they estimate that 1/3 of the country has left for the United States.  Residents of the Marshal islands do not need a Visa to enter the United States.  The outer islands are losing their populations and thus their culture.  Many people move to the crowded urban center on Majuro or to the US military base for work.  Rising seas, the loss of traditional foods and the on-going military relationship with world powers, puts the people of the Marshal Islands at risk. Despite a good education and healthcare system, the risks are still high.  Once in Hawaii and the mainland United States they face discrimination, cultural barriers and exploitation.   

The impact of dropping atom bombs on these small islands, can not be underestimated.  The United States works to avoid responsibility for the harm done to this island nation.  

Birth and Women's Health

I'll share my visit with the midwives in the next post.

Mejemkwaad, Managua and the Monsters all over the world who steal newborns

Around the world, people must grasp the concept of a corona- virus.  They are asked to prevent the spread of an invisible germ that can be passed from person to person, as they pursue everyday activities.

 At first we are told that it will spread if we cough or sneeze on someone and now are told it can spread just from talking.  We are asked to stay six feet from each other and to wear masks.  Six foot x's are placed on the grocery store floors.  We are asked to stay home and wash our hands with soap over and over again.

Those of us who can, listen to scientific explanations of the structure of the virus and how it spreads.  We come to see that only soap and water can destroy the virus on our hands.  The concept of a bar of soap a mystery to the younger generation who search frantically for fragrant, foaming soap in bottles.


These invisible foes, have existed for thousands of years in many forms.  Long before we knew about germs, epidemics were called plagues and were blamed on mysterious enemies and human flaws.  A mold led to the Salem Witch Trials.  Stories of vampires emerged from misunderstood European diseases.  Diseases were blamed on a lack of religious fervor, on nationality and gender.  Yesterday a very old friend, posts three maps on Facebook that illustrate that the carom-virus is related to immigration and being a democratic.  We look someone to blame, beyond the actual virus and its ability to spread and survive.  When I was a child I was told ice cream and public swimming pools caused polio.  There are Old Testament verses that beg God to deliver pestilence and disease on a person's enemy.

My drawing of a mythical monster that seeks to harm the newborn.  In my interpretation the "baby" is the earth and all it offered us.  The monster is all the forces that make the world unhealthy for newborns everywhere.  The wings are air, water and soil pollution.  The claws represent the greed that robs children of good health.  

People used human attributes of cunning and greed, to explain newborn and maternal death.  While most likely true that the deaths were caused by broad forms of cunning and greed, they were of a human sort that most often denied them an education, health education and the right to choose their own future.  Epidemics often were brought by colonial powers to far away parts of the world, without the immune system to defend them.

In Haiti, a well educated translator told me that there is a bad spirit that kills babies and mothers, after birth.  We have just done a home visit.  He seems skeptical that all our advice will be of use because if the spirit comes and takes the breath from the baby, there is nothing that can stop this.  I reason. There are a few things that could cause an otherwise healthy newborn to die.  I review the things that we test for; the silent germs and genetic disorders that could cause a newborn to die.  I review the need for exclusive breastfeeding, proper cord care and hygiene.  The need for some filtered sunlight and skin to skin contact.  Ah, he says.  This is all true but the spirit may still come in the window at night and draw the baby's breath out and cause death.  This spirit may be sent by your enemy's or someone who is quite jealous of you.

The almost universal baby stealing monster who exists the world around.  The monster who explains the unimaginable  grief of losing a perfectly healthy newborn.




In light of this, cultures developed rituals and customs to protect the newborn; a piece of red string, a knife by their head when they sleep, amulets and prayers.   Beautiful traditions accompanied by deep fears that are hard to shake.  Fears that sometimes keep parents from having healthy babies.

I try to think.  How many babies, I delivered, would have died quietly in their sleep without newborn screening or testing cord blood for incompatibilities.  Not a lot, but babies in low resource communities, do not have access to these screenings and so some babies, will surely mysteriously die.  Some will die because someone told the midwives to cover the cord or to not give the baby the first milk.  Some will die from post colonial birth practices.  Some will die from the many issues of environmental exploitation.

Monsters.

In the Marshal Islands, the unbearable loss of a newborn was blamed on the monster, Mejnwaad.  This female monster steals newborn babies and eats them!  These unexplainable deaths must have a villain and someone to blame.  In the Philippines, its Mannanggal, a winged monster who comes and devours newborns.

Today, in many communities around the world the monster that threatens the newborn, lives in the form of those who would pollute the world; its air, its water and its soil. It lives in the greedy claws of those who de-forest; destroying indigenous cultures, contributing to climate change and destroying food sources.  The monster dwells in the industries, built along our rivers and streams that are jammed with pollution and chemicals.  It wraps its tendrils around affordable housing and healthy food sources.  The world is polluted with radiation from nuclear bomb testing and chemical waste.  The terrible monster delivers its blow in premature births, a lack of equitable, not for profit healthcare.  The monster who sucks the life out of our newborns flies amongst us, only now we don't know how to name it.  There is no story to scare young children.  There are no rituals or amulets.  The monster has no name.  It flies without boundaries throughout the world - as a virus, as a war, as a baby in a refugee camp.

Watch out.  This baby eating monster is at all of our windows.  The ancients understood this and were beware.