Champion of Choice

Midwives on Motorbikes

midwife Ofelia Soares MadeiraTibar, East Timor

On a July evening Ofelia was awakened by a strange man knocking at her door. She threw on some clothes, grabbed her bag, pulled on her white helmet, then hopped on a motorbike to shoot off into the night. She was headed to his house, although the stranger did not go with her. The woman wound up the treacherous hairpin turns of Fahi-Ten Mountain, avoiding the hazards she knew were waiting for her in the dark: the free-roaming goats, dogs and cattle, and of course the other drivers who would hurdle around a blind curve dead in the center of the narrow thoroughfare. On top of this, Mother Nature had voided the plan to introduce civilization here in the wilderness, creating an obstacle course by washing boulders and uprooted trees down the slope. The resulting condition of the roadway proved to be more rutted earthen track than smooth concrete, and in spots the surface suddenly dropped several feet in jagged tiers; in other places the pavement had washed away altogether, leaving potholes several yards wide, yawning like jaws as they waited silently to swallow the unsuspecting rider. And the rainy season had not yet begun.

As I retrace Ofelia’s route in daytime, in an off-road vehicle, I cannot imagine navigating this course in the black of night. On a dirt bike. My driver Carlos sits stoically behind aviator sunglasses as he steers along the edge of a cliff. The valley lies hundreds of feet below, the view slightly hazy as the fresh morning air suspends dust particles from the arid hillside, and the scent of dried grass and minty eucalyptus rushes in the open window. We round the bend and come upon what I initially take to be a pond covering the road, reflecting blue sky. Carlos cuts the wheels sharply, and as we careen around the edge, to my horror I realize that it’s not water we’re avoiding; rather the cliff has eroded and I am staring through a gaping hole larger than our truck, into the void. He has just saved us from dropping through nature’s manhole to freefall through the heavens and flatten one of the unsuspecting thatched huts dotting the basin below.

It’s not an unusual occurrence for Ofelia to have men awaken her in the middle of the night. She’s a midwife in this remote district in East Timor, the world’s newest nation, and she delivers twenty to thirty babies a month. Everyone in the district knows where she lives, and so when this gentleman’s wife went into labor he rushed straight to the midwife’s home to summon her. The dutiful husband had waited hours for a bus to pass by the winding, isolated route down Fahi-Ten Mountain, and there is no phone service in this region where even the health professionals communicate by shortwave radio. When he finally reached Ofelia she dressed quickly and leapt aboard her Honda Supra X Astrea, a bike built for rough terrain, and headed up the treacherous road in the dark to deliver Ermelinda’s baby. Unfortunately, she did not succeed.

Ofelia Soares Madeira is part of a program called Midwives on Motorbikes, an operation begun by UNFPA in 2003, where the maternity professionals of Timor use motorcycles to traverse the mountain passes of this country bordering Indonesia. The agency ordered sixty-five cycles from Honda, and the manufacturer threw in another fifteen for free. Local healthcare workers also ride the dirt bikes to reach their remote clientele for other projects, particularly to deliver immunizations.

Ofelia herself coordinates the midwife program, having practiced since 1989. She’s lost track of the number of babies she’s delivered after sixteen years. Her professional training was thorough—attending nursing school for three years followed by a year of midwifery courses. Her husband taught her how to ride the Honda and he sometimes accompanies her on missions. She thinks the motorbikes are a great asset to healthcare workers’ ability to reach patients, but laments the poor communication options in the district. If she runs into problems with a delivery, she must ride back to the clinic to radio for an ambulance, wasting valuable time that has cost lives.

Today I am traveling to visit the home of the man who summoned the midwife in the middle of the night. As we climb, I take in the breathtaking tropical scenery of mountain vistas, the leafy green of banana and coconut trees , the brilliant magenta bougainvillea, the delicate feathery limbs of acacia trees sheltering the coffee plantations, the gatherings of thatched huts built of bamboo and palm fronds, the baby goats and full grown cows meandering aimlessly, the vans barreling around blind curves as Catholic schoolchildren amble across this same road in their spotless white shirts and dark trousers, heading to morning mass.

On this sunny September morning, we find the new mother, Ermelinda, sitting on a bench outside her hut, a one-room box built of twigs topped by a corrugated tin roof. She is a petite woman, with mahogany-colored skin and large eyes luminous with worry; her ebony hair sweeps back from her face into a bun. She is dressed in a simple black cotton skirt and blouse with tailored lines and fitted, puffed sleeves, an outfit that looks oddly formal for life in the wilderness. Ermelinda holds two-month old Maia, whose face is contorted beneath a shock of wild hair. The infant howls until mama removes one breast to nurse and it’s clear this newest member of the family has a healthy appetite.

As mother and child stare transfixed into one another’s eyes, they form the hub for the melee of life swirling around them: the newborn’s six siblings—some teenagers dressed in t-shirts and baseball caps, some naked toddlers wearing nothing but dust. Other villagers in this outcropping called Aldeia, a name which means “small community,” come out to meet the visitors.   A neighbor walks up balancing a plastic jug of water on her head, while roosters crow, baby chicks peep and peck around our feet, goats endlessly search for something to eat, and puppies look for playmates. A grey monkey studies us solemnly with his tail curved around his feet, and the morning calls of songbirds float down from the palms.

I am accompanied by Cecilia da Silva from UNFPA and the midwife, who tells me the story of what happened on the night Maia was born. While Ermelinda’s husband made his way into the village, his wife lay at home alone in labor. Before Ofelia arrived the mother had pushed her tiny daughter out on her own, but she was frightened because even though at thirty-two she had already given birth to eight babies, only six had survived. Of additional concern was the fact that on this night the mother’s placenta had not come out, a situation that could cause hemorrhaging because the uterus won’t contract, and she could bleed to death.

When Ofelia arrived at the hut on that dark night, she set to work cutting the umbilical cord, then massaging the top of Ermelinda’s uterus while pulling steadily on the cord to deliver the placenta. This procedure allowed the patient’s womb to begin contracting, thus returning to its normal size—a necessary step that ceases the flow of blood.

With her patient stabilized, the midwife packed up her equipment and boarded her Honda Supra X for home. Now the sun was rising, casting a golden light over the coffee plantations as she rode slowly back down the mountain, dodging the obstacle course. Ofelia yawned, hoping she could get some sleep before another baby decided to enter this world.


Champion of Choice

Cairo: September 5, 1994

Over the course of the coming week, dignitaries from around the globe will be arriving for the International Conference on Population and Development, their limos gliding down a grand circular drive lined by palm trees and a colorful cornucopia of national flags. They will stop at the VIP entrance to the conference center, a sleek white circular building featuring arched windows—a design reminiscent of a space-aged Roman Coliseum. When the passengers exit their cars, they’ll look out upon a wide expanse of green lawn and manicured trees. Peeking up above those treetops, they’ll be able to see the point of a contemporary pyramid marking Anwar Sadat’s grave—a poignant reminder of the risks those dignitaries will face when they enter this facility.

Egyptian president Sadat may have won the Nobel Peace Prize for his diplomatic efforts, but that didn’t save him from dying in a pool of his own blood when terrorists machine-gunned him as he sat a short distance from this conference center, watching a military parade. In the reviewing stand alongside Sadat that day were the future secretary-general of the UN, Boutros Boutros-Ghali, and the man who would become the new president of Egypt before that day was done: Hosni Mubarak. Thirteen years later, as this Arab nation’s head of state, he would be responsible for protecting twenty thousand dignitaries from violence by the same type of fundamentalists who had murdered Anwar Sadat.

So for Mubarak—who had served as a military man for three decades, who had been seated just to the right of Sadat and watched him die, who had himself escaped multiple assassination attempts in his lucky thirteen years as president—the importance of security during ICPD was a very real concern, not just another perfunctory item on his administrative checklist. With four thousand journalists in town and the eyes of the international community focused on Cairo, he did not want any deaths—least of all his.

Part of the president’s strategy to prevent this was to station ten thousand armed troops around the city—circling the conference center, along the streets, at the airports—and to position soldiers and metal detectors at every hotel. A member of the U.S. delegation said the omnipresent security could border on the comical at times: “Our entire delegation and other invited guests spent one night on the Nile for dinner, a sort of relaxed evening. And ringing us on the river were police boats. They were just cruising around us, good and slow, making sure that nobody else came close.” In the meantime the leader of the U.S. team, Tim Wirth, wore a bullet-proof vest under his suit jacket.

Stirling Scruggs, as one of the UNFPA spokespersons handling the conference, remembered being coached on what to do in case someone was killed or taken hostage. “The White House Advance Team and the Secret Service from the U.S. government came in and laid out this map to show me where the U.S. was involved and where the vice president’s escape routes would be if there was an attack, or anything like that. There were fundamentalist threats against the U.S.—some of the dignitaries and Al Gore—but there were also threats concerning the issues.” Gore, hobbling around on crutches after surgery to repair his Achilles tendon, had better hope he didn’t’ have to beat a hasty retreat on foot.


Dr. Sadik flew in three weeks prior to the conference opening, and as soon as she hit the tarmac, she was under the watchful eye of Mubarak. As she traveled throughout the capital, UN bodyguards sat in the car with her. Two others, holding automatic weapons, hung out the windows of her limo on either side; this dynamic was repeated by the Egyptian security in the lead car in the motorcade and the car to the rear. As she walked around the conference center she became a very popular woman indeed, followed by four men: one in the front, one on either side, and one to the rear. They searched the ladies’ bathroom before they permitted her to enter; they accompanied her at lunch and sat at another table, with some staring at her throughout her meal while others scanned the perimeter; they monitored her conference command headquarters, which became a real nuisance as she was running this enormous event. “My office had two doors, one to enter and one to exit, and once I went out of the entrance door to look for some staff members. My security opened the door for something and when they found out that I wasn’t there, they went crazy and shut everything down. They said, ‘You can’t do that, you have to leave from this door and we have to see that you’re leaving.’ I said, ‘Well, obviously, you should have had somebody guarding the other door!”


An excerpt from Champion of Choice: The Life and Legacy of Women’s Advocate Nafis Sadik (University of Nebraska Press 2013)

© Cathleen Miller

Champion of Choice

Welcoming the Girls


We have all questioned the luck of the draw that shapes our destiny, examining how fate favors one girl born into a wealthy family that gives her every opportunity versus another girl who comes into this world as chattel to be traded for cattle. Although there are as many theories for shaping personality as there are philosophies and religions—from karma to reincarnation to environment to genes—for those who believe in the influence of the stars, we must consider what it means to be born a Leo, the lioness of the zodiac.

On the eighteenth of August, 1929, Iffat Shoaib gave birth to the couple’s first child. The baby was a girl, a situation that normally would have prompted grief and condolences in most traditional Indian households, but not in this one. After the Shoaibs christened the newborn “Iffat,” like her mother, they always called their daughter “Nafis,” meaning “precious or extraordinary.”

Following the child’s birth, acquaintances all asked the proud parents: “Does the baby have light skin?” referring to a desirable trait in Indian culture. No, she did not. The infant’s gender and complexion had both failed to pass the mark, because Nafis had dark skin and a temperament to match. However, her family—particularly her grandfather—adored the child all the same.

The patriarch of Nafis’s family, Mohammed Abdulla, had left his village in the United Provinces in eastern India and moved to Jaunpur, located about two hundred miles west of Calcutta, to practice law. There he built an impressive estate surrounded by gardens and fields, which would serve as the home of three generations and dozens of extended family members. He ran an open household where a constantly changing diorama of characters came and went: servants, sons, their wives, grandchildren, cousins, second cousins, and relatives with such a tenuous thread to the family fabric that no one could quite remember how they were woven in. The visitors arrived with their baggage and bunked in spare rooms, the children’s rooms, wherever there was room. They stayed for weeks, months—sometimes long enough to get a college education. It was the patriarch’s concept of noblesse oblige that prompted his generosity, a concept his son would later emulate.

A private inner courtyard served as the heart of Mohammed Abdulla’s whitewashed brick house. It was surrounded by the numerous rooms of the family’s private residence, which included separate quarters for his sons and their wives and children. A broad, shady verandah rimmed the second story.

As his legal practice thrived, Mohammed became such a respected member of the community that he designed a special room to receive guests who came seeking advice and favors. He made his headquarters a study that had an outside courtyard, and on the door to these chambers the gentleman placed an enormous photographic portrait. The subject was an unlikely representation for such a grand work: a one-year-old baby Nafis, with a couple of teeth and a shaved head—the shearing a practice that was thought to encourage a lush, full head of hair upon regrowth.

Nafis’s grandfather died when she was just seven years old, struck down by kidney failure. As was the custom of his generation, Mohammed Abdulla had not kept track of his age, but his family believed him to be in his sixties. Nafis remembered that “he always had his arms outstretched for me to run to him.” He doted on his granddaughter, bragging about how clever she was and prompting her to recite for guests. Perhaps this was because his two female babies had died in infancy and a third daughter had succumbed to tuberculosis in her twenties. Nafis’s grandmother had wailed, “There are no girls in our family!” Thus when her son Mohammed produced a daughter, the baby was joyously welcomed into the family. This fact was unusual in a society where the news of a girl’s birth was frequently greeted with pity: “Maybe you’ll have better luck next time.” Instead of being treated as a second-class citizen, Nafis was celebrated for her gender; as she grew up and went about the world, she found the absence of this fact in other households as unnatural as she did intolerable. On the global stage she would spend the rest of her life promoting her family’s vision of the fundamental worth of girls.



An excerpt from Champion of Choice: The Life and Legacy of Women’s Advocate Nafis Sadik (University of Nebraska Press 2013)

©Cathleen Miller 


Champion of Choice

A true story of fistula in Ethiopia

Fistula Hospital in Addis Ababa

Excerpt from Champion of Choice: The Life and Legacy of Women’s Advocate Nafis Sadik
by Cathleen Miller

Zadia Birru*
Addis Ababa, Ethiopia

[*A pseudonym has been used to protect this girl’s privacy.]

Probably no other rite of passage is capable of changing a woman’s life like giving birth–an event that can alternately propel her into the joys of motherhood, provide caretakers for her old age, earn her the respect of a community, ensure her place on a nation’s throne, offer undeniable proof of an illicit affair, trap her in a miserable marriage, maim her for life, or kill her.

No group knows this better than the patients lying here in the hospital ward in Addis Ababa, a room that is so clean that upon entry, the viewer has the momentary feeling of being snow-blinded. The whitewashed walls and ceiling gleam, reflecting the sparkling sunshine that flows through polished windows. Two facing rows of hospital beds covered in sky blue blankets line either side of a central divider. This hygienic atmosphere presents a refreshing contrast to the patients lying in those beds, all of whom have dwelled–some for as many as fifty years–in the constant filth of their own bodily waste as a result of giving birth.

I see them recovering in the ward and walking around the lovely parklike grounds, all draped in handknit shawls, the contribution of a ladies’ church group from Australia. Most of the patients are mere girls, like Zadia Birru. She doesn’t know her age, but she looks about thirteen or fourteen. If she had been born in different circumstances, this classic beauty could have easily been a model. With her dark wavy hair pulled into a French braid, her face possesses an elfin charm, a gracefully curving jaw line, large expressive dark eyes, a full-lipped heart-shaped mouth and a beauty mark that highlights her café-au-lait colored skin. Her smile sparkles, transforming her face like sun bursting through clouds.

Zadia’s tiny frame measures around four foot eight; draped in a pale blue cotton nightgown and a handknit shawl of primary-colored squares, her body hunches with pain. Through the opening of her gown I can see that her breasts have stretch marks, a detail that seems strangely out of place on such a waif-like girl. But when I hear her story, I learn the reason for the telltale puckered lines.

Zadia had never been to school when her parents arranged her marriage to a farmer from their community. She doesn’t know how old she was when she wed her husband, but they had been married for three years before she started her period. In the beginning their relationship was good, but during the fourth year–with no access to birth control–she learned she was going to have a baby. This was when her husband began seeing someone else. The couple quarreled constantly, and when Zadia was four months pregnant, he left her.

The child bride returned to live with her parents in the village of Aju. When it came time for her delivery, she was in labor for two days at home with unbearable back pain because the baby was unable to pass through her tiny pelvis. When she started getting weak, her father decided to take her to the hospital. The family loaded her onto a bench and walked two hours, carrying the child to a district health center. Precariously balanced aboard the plank, she thrashed about in labor.

At the health center Zadia finally gave birth to a stillborn son. Later she learned that ironically his death had allowed him to be born. The fetus, which cannot withstand the rigors of days of obstructed labor, detaches from the placenta and dies. At this point the bones soften, and the baby shrinks enough so that it can pass through the birth canal.

Zadia herself nearly died and was unconscious in the hospital for fifteen days. When she came to, she learned that the stressful delivery had ripped a hole between her vagina and bladder, a condition called obstetric fistula, which permits waste to leak uncontrollably into the vagina. Like an infant herself, she was constantly soiled and reeked with the stench of urine. At this point her doctor referred her to the Fistula Hospital.

Unfortunately Zadia’s experience is not a rare occurrence in Africa, where one in twelve births results in the mother’s death. Although the choice to marry has been enshrined as a human right since 1948, in much of Africa half-starved girls as young as six are married off by their families. The poverty-stricken parents look at them as a commodity to be traded for livestock or other goods. In most cases they feel they’re doing their daughters a favor to try and place them in stable homes where they’ll be provided for. And when these girls become pregnant–as they immediately do without birth control–their young bodies are too small and frail to withstand the rigors of childbirth.

This combination of events results in an untold number of cases of obstetric fistula per year, but thousands and thousands of victims have come forward for treatment. The force of delivery on these slight, malnourished bodies can rip the fragile birth canal and tear holes between the girls’ rectum or bladder, allowing feces and urine to flow uncontrollably into their vagina. In the vast majority of cases the husband divorces the girl because she is unclean and unfit for sex. Zadia was one of the lucky ones whose family was willing to take her back. In many instances the family refuses, and the girl–whose only crime was obeying her parents and then her husband–is turned out into the street with no home, left to live in daily humiliation as a social outcast who scavenges for food like an animal.

I hear similar stories to Zadia’s from the other patients: a childhood marriage, an early pregnancy that results in a fistula and stillborn delivery, followed by divorce….

© Cathleen Miller, 2013