WHY DO SO MANY TIBETANS DIE GIVING BIRTH?
IS CHINA FULFILLING ITS MILLENNIUM DEVELOPMENT GOALS (MDG) PROMISES?
by Gabriel Lafitte
published by DOLMA magazine, November 2011, annual journal of Tibetan Women’s Association
http://tibetanwomen.org/dolma-magazine/
WOMEN BLEEDING TO DEATH ALONE
The women of Tibet are dying. Each year hundreds of Tibetan women die in childbirth. To die while bringing fresh life into the world, giving a new human rebirth a chance to live, is shocking. The maternal mortality rate in Tibet is around 400, maybe even 500 per 100,000 children born live, every year. Yet the rate in China is 45.
Why do so many Tibetan women bleed to death? Why is so little done to help them, when most of these deaths are unnecessary, and can be prevented inexpensively?
“The maternal mortality ratio (MMR) for rural Tibet was reported to be as high as 400–500/100,000 in some areas, and infant mortality within the first 12 months was reported to be as high as 20%–30% in some areas.” If that is the baseline, in the early years of this century, how can China possibly fulfil its Millennium Development Goal promise to cut maternal mortality by three quarters, by 2015?
Globally, China is already congratulated for fulfilling all its Millennium Development Goal (MDG) pledges. China says it has already achieved all MDGs, the shining example among developing countries, a model for others to copy.
Not only is China’s maternal death rate down to 45 per 100,000 births, senior Chinese health administrators say: “Progress in reducing maternal mortality in China has been impressive; the MMR decreased from 95 deaths per 100 000 livebirths in 1990 to 45 deaths in 2005, a remarkable success given the size and diversity of the country.” China takes pride in this achievement that began not just in year 2000, with China pledging to fulfil the MDGs, but going back to the 1980 Safe Motherhood global conference in Nairobi. But has three decades of effort made much difference in Tibet?
In Tibet, the women often die alone. Government hospitals are too far away, and too expensive. International aid agencies have been required to cease working in Tibet. No-one now looks in from outside. The reproductive health agencies, the multilateral development banks, the health NGOs from around the world are no longer on the ground in Tibet. Some were present until China excluded almost all external agencies in 2008.
If China actually has reduced the maternal mortality rate (MMR) to 45 women per year per 100,000 live births, it deserves congratulation; yet the rate in Tibet remains ten times higher, or 1000% of the all-China rate, with no sign that it is declining. China conceals its failure in Tibet by focusing on the generalised average figure for the whole country, of 45 per lakh. Although China provides the United Nations with many health statistics, there is no MMR maternal mortality rate for Tibetan areas.
It is possible to look more closely, county by county, at maternal deaths, because China has its National Maternal and Child Mortality Surveillance System (MCMS), and its results are published annually by the Ministry of Health in its health statistical yearbooks. According to this surveillance system, in urban China, in the decade to 2006, the maternal death rate dropped to only 30, while in the poorest rural counties, including nearly all of Tibet, the rate was 147, nearly five times higher. Urban life means ready availability of hospitals, and the routine medicalisation of pregnancy. So Chinese health planners routinely see urbanisation as the answer. If urbanisation is the solution, China is thus excused for failing to reach remote drokma.
The bureaucratic procedures of this mortality surveillance reflect China’s urban bias. The MCMS operates through a chain of command which, in Tibet, simply does not exist in many areas: “In each selected city or county, public maternal and child health (MCH) institutions are responsible for reporting all livebirths and maternal deaths, and their cause. One health worker in each village or urban neighbourhood committee records all such events in his or her catchment area. Reports are transmitted monthly to the township or community MCH worker, and quarterly to local MCH institutions in each county or district. Local MCH institutions regularly search the records in hospitals, funeral homes, police stations and family planning offices to ensure that no maternal deaths are missed.
Once a maternal death is reported to the MCH institution, a medical doctor visits the family of the deceased to investigate the circumstances and to assign the timing and cause of death.” Because there is so little health infrastructure in rural Tibet, many maternal deaths in Tibet are never reported, and do not exist in official statistics. So no-one really knows how many Tibetan women die in childbearing, but the best estimate is a rate of 400, or thirteen times the Chinese urban rate. If it takes the availability of institutions and doctors to record deaths, it is hardly surprising so many deaths occur out on the open rangelands, where doctors are unwilling to live.
If “institutional birth” is the answer, what hope is there for Tibetan women on the ploughed fields and open plateau pasturelands, far from any official institution? According to China’s statistics, in the poorest counties, the proportion of women giving birth in an institution rose sharply between 1996 and 2006, from 20 percent to 45 percent. This hardly applies to most Tibetan women.
A 2003 assessment of the fairness of China’s health system said: “15% of urban and 22% of rural residents had affordability difficulties when accessing health care. Although health-system coverage improved for both urban and rural areas from 1993 to 2003, affordability difficulties had worsened in rural areas. People with low income not only receive lower health-system coverage than those with high income, but also have an increased probability of either not seeking health care when ill or undergoing catastrophic medical spending.” For remote Tibetans, things have not improved since; health remains the ultimate urban service.
Over recent decades China’s health system shunned taking responsibility, having downshifted health care to local levels, making users pay, leaving poor counties with poor health services. China continues to be largely a user-pays system that privileges the rich and urban, leaving the rural and poor to fend for themselves, with upfront fees payable in advance before anyone can even come through the door of a hospital. China’s maternal mortality surveillance system reports that “Income-related inequalities in institutional births increased in rural areas between 1993 and 2003,” which means that when rural women do get to a hospital, the gap between the poor and the rich who can afford upfront fees for treatment is widening. Slowly, rural health insurance schemes are extending into remote areas, but Tibet remains too remote, after decades of neglect, and health post staff having to earn most of their incomes by selling expensive medicines.
If the international health agencies can no longer work in Tibet, and China’s health system has only hospitalisation as its maternal mortality reduction strategy in Tibet, do Tibetans notice this epidemic of unnecessary deaths?
In Tibet, everyone knows giving birth brings many dangers, both to the mother and the child. Because the dangers are many, so too are the elaborate rituals to be performed, to satisfy local spirits and remediate pollution caused during childbirth. After a birth, and in seclusion, there is much a mother can do, over a period of weeks, to restore purity.
But it is these beliefs which China sees as proof of the primitive mentality of Tibetan women; evidence of green brained backwardness, clinging to superstition when institutional birth in a hospital is the modern alternative. If Tibetan women do not get to a hospital in time, and dies at home in childbirth, it is her fault: so goes the logic of almost all Chinese medical journal research reports. The state cannot be blamed, neither for such individual deaths, nor for the obstinately high maternal mortality rate overall. Thus, if there is, in Tibet, a failure to achieve the MDG goal of a three-quarters drop in maternal mortality, between 2000 and 2015, it is hardly the fault of the central authorities.
China, it seems, has got science and statistics on its side. Giving birth in Tibet is inherently risky, Chinese scientists say, because of the high altitude, and made riskier by primitive beliefs in spirits that are offended by the messiness of birth. The state can do only so much in the face of such superstitious attitudes. Some westerners go a step further, expressing alarm that it is not part of Tibetan tradition that a woman about to give birth is attended by an experienced midwife, such as the dai of India. It shocks some westerners that Tibetans often give birth alone.
Such attitudes polarise, reducing the debate to just two choices, two mutually exclusive places: home or hospital. Such dualism is great for argument, but not much good at capturing the complexities of lived reality. In the actual lives of Tibetan women, home versus hospital is not a simple either/or choice.
Anthropologist Kim Gutschow in 2011 published a detailed case study of a pregnant Zanskari woman’s strategies as birth nears. She has much to consider. In Ladakh, as in Tibet, hospitals are being built, but they can be expensive, especially if one goes to town, to be close to the hospital, well before the birth, just in case. But if the baby is due in winter, the passes may be snowed in and impassable. Possibly, in an emergency, an Indian army helicopter might take her to hospital, but it might take days to get the message to the Army, and then the weather might make flying impossible. There are so many risks to juggle. Staying in town with relatives can be burdensome, best avoided if possible. Many Tibetan women prefer to be alone, completely alone, while giving birth, as undistracted by social obligations as when passing from this world. Kim Gutschow quotes a friend of hers, who says: “ I would prefer to have all my children at home, alone, even now when going to the hospital is an option. I am most comfortable pushing the baby out alone, with nobody present, not even my husband.” She said her labour was easier and quicker that way.
Hospitals are temples of scientific modernity and reductive simplification, which choose to ignore the complexities of drib (ritual pollution) caused by birth, and the behavioural taboos that go with the woman taking care to minimise any offence that might be taken by local spirits of earth and water. Hospitals insist on radical dualism; confident that they alone have the technologies to reduce maternal and infant deaths. Because hospitals choose institutionally to be wilfully ignorant of traditional rituals to protect mother, baby and the community from the dangers of childbirth, the hospital has no idea of what is going through the mind of the mother of a newborn. How can I get back home with my baby without crossing streams where the water spirits will be offended if I cross before I can ritually purify? How can I tread the mountain paths home without going too close to a shrine, polluting it and angering the protector deities?
“When a new mother returns home from the hospital, she puts herself and her child in danger, as her unpurified presence angers household, village, regional, and monastic protectors whose shrines she passes on the way home, “ Gutschow says.
Because the hospital chooses to ignore such complexities, many Zanskari women feel uncomfortable giving birth in the presence of strangers, Gutschow reports. Because the hospital staff are seen as arrogant and aloof, women delay going to hospital unless and until medical intervention is a necessity, for which they are scolded by staff. To the staff, this is further proof of the superstitious, primitive mentality of pregnant women; to the women it is further evidence that the hospital refuses to be part of the community. What is true of Zanskar and Ladakh is more so in Tibet, where there is a stronger assumption that Tibetan women are cai (stupid bumpkins), mian gua (idiots), ruo zhi (dull witted).
Is there no middle way? In reality, each woman assesses the risks, costs and rewards of remaining at home wherever possible, yet accessing a hospital if necessary. In real life, both are good, both have their place. Both have their dangers. The medicalisation of pregnancy and birth, as if a natural process must be institutionalised, has been much criticised for the institutional insistence that immediate access to biomedical technologies overrides all other considerations. In Ladakh, emchis (healers in the Tibetan tradition) are barely tolerated in the hospitals; in Tibet sowa rigpa and biomedicine both exist, but separately.
In practice, each woman finds her own middle way, as Kim Gutschow’s case study illustrates. Each woman near to birthing finds a path that includes rather than excludes, that involves home and local support wherever possible, and timely access to hospital, also wherever possible. But that individual middle way may fail, if complications occur, and if the hospital is days away.
A middle way that does not leave it all up to each woman to calculate risks and rewards, costs and benefits alone, taking chances on the unknowable, would be more skilful. Can’t there be a middle way that does not force a choice, in advance, between home and hospital? A middle way in which society is mobilised to be ready to assist, as needed, or to stay at a distance and let nature take its course?
Neither Tibetan tradition, with its lack of dai birth attendants, nor the centralised hospital system in towns, offer any such middle way that give the mother-to-be support when she most needs it. Fortunately, just such a middle way was pioneered by one woman from Utah, USA, called Arlene Samen, in response to a request from the Dalai Lama, in 1997, that she go to Tibet and help women in childbirth. http://tedxtalks.ted.com/video/TEDxSF-Arlene-Samen-Dying-to-Gi
When Arlene Samen began work, she had no way of knowing she would have at most a decade to invent a new process, before China, suspicious and angry, responded to Tibetan unhappiness by closing Tibet to foreigners, including health NGOs. She did not arrive in Tibet with a ready answer, but a willingness to work with Tibetan women to collectively find out how to surround the woman about to give birth with meaningful, trained, experienced, appropriate support. Through trial and error, Arlene Samen gradually came up with a simple and inexpensive process, that avoids the extreme of medicalising pregnancy in distant urban institutions, and the opposite extreme of leaving each woman to deal with crises alone, if they occur.
“Arlene founded a nonprofit organization in 1998, called One HEART (Health, Education, and Research in Tibet), which provides supplies and education for mothers and healthcare providers. The first initiative was a Skilled Birth Attendant Training Program, followed by the Pregnancy and Village Outreach Tibet program. In this program, basic life-saving skills training and birthing kits were given directly to expectant mothers and their families. The simple medical kit included a sterile razor blade, three baby blankets, a fingernail brush, and a tiny newborn stockinette hat. In addition, One HEART provided mask and bag resuscitation equipment to be used when neonatal resuscitation was taught.”
“Once she understood the local views of the Tibetans she then set-up a Skilled Birth Attendant Training Program, which focused on village and township doctors in providing clean birthing conditions and medical attention to pregnant women. Arlene found that much of the knowledge and life saving skills and medical supplies were not filtering down to the local village level. So she began training the local village women on learning basic life saving skills and supplying clean birthing kits so that they could take their skills back to their local villages as birth attendants. Samen and her organization, One HEART, have designed and implemented a successful repeatable and sustainable maternal newborn model for rural cultures all over the world.”
“Role-playing is the most common learning method used during training. Outreach providers take turns in mock outreach sessions during which they practice imparting interventions to simulated outreach recipients. Using the continuum model, role-plays involve practicing delivery of educational messages and hands-on skills, such as uterine massage. Skills such as basic newborn resuscitation are practiced on models. Finally, they practice the distribution of material resources, such as maternal micronutrient supplements and safe and clean birth kits, and how to counsel outreach recipients regarding appropriate use. They are taught to reinforce key messages and skills by encouraging questions during outreach and by reviewing each intervention at each home visit.”
“Outreach recipients are encouraged to develop an emergency birth plan that includes choosing a location and, wherever possible, a skilled attendant to attend the birth and securing transportation and financial resources necessary for obtaining obstetrical and neonatal care well in advance of the expected date of birth. Women are counseled to enact the birth plan when they suspect the onset of labor or if they recognize certain “danger signs”’.
Arlene stresses her approach works with local custom, rather than imposing an alien model of health, illness and danger. Her success comes from mobilising local Tibetan women, all members of Chian’s Women’s Federation (funu) as her helpers and “foot soldiers”, equipped with basic education and kit to deal with most births, except the few that do require a hospital. The foot soldiers were the key to what she calls the “network of safety” surrounding each woman due to give birth; a network that engages local government and community working together, something seldom seen in Tibet.
“Based on our experience, One Heart World-Wide developed an effective, replicable and sustainable model to reduce preventable deaths related to pregnancy and delivery among vulnerable rural populations. Simply put, we work with local communities and local health providers to develop a culturally appropriate Network of Safety around mothers and infants, by raising awareness, teaching good practices, and distributing essential supplies to ensure that mothers and infants survive delivery and the first months of life. The Network of Safety is innovative in that it is tailored to the local cultural context, that it puts the mother first and that our interventions are aimed simultaneously at several different levels to insure appropriate continuity of care for the mothers and infants.” http://www.oneheartworld-wide.org/index.php/about/
Why did it take a woman from Utah to organise Tibetan women to help each other? Now that she can no longer enter Tibet, is anyone replicating and building on her work? Organising work in Tibet has to be low key, almost invisible, since Chinese fears and suspicions of organised Tibetans are so strong, even if the sole purpose is to reduce death in childbirth. But this is at most only a partial explanation. Women in Tibet have long been told they are lesser births and must wait passively for the state, in its benevolence, to provide modern hospitals. Almost no-one has been encouraging women to believe in their own strengths. Emily Yeh, a Colorado anthropologist, has shown how much Tibetan men and women have come to believe China’s message that Tibetans are lazy. Yet it did not take much to turn this belief around, just basic community development skills, time and dedication.
Such initiatives will not come from above, from a state that is suspicious of Tibetans and sure its own institutions are the only answer to maternal mortality. Only Tibetan women can help themselves. Otherwise the maternal mortality rate, estimated in 2005 to be 400 to 500 women dying, for every 100,000 live births, will persist. China will have failed to fulfil its promise, in 2000 to reduce maternal mortality by three quarters, as per target 5 of the Milllennium Development Goals. Meeting that target would require a drop in maternal deaths from 400-500 to around 120. To put that in international context, it would mean shifting the situation in Tibet from a death rate comparable to Cambodia or most of Africa, to that of central American countries, a big jump.
China disputes most of this story. It gives quite different figures for maternal and infant death rates, past and present, and disagrees that the solution is a mobilised community of local midwives and birth attendants with health professionals, always scarce and often remote, available as a backup. According to China’s official publications, old Tibet was far worse than now, and the situation now is greatly improved, since professional health workers do contact and educate pregnant Tibetan women, and a fast rising proportion of Tibetan women, even in rural areas, have their babies in a hospital.
China says it is on track to fulfil its MDG promise: “China has reduced t h e M M R f r o m a baseline o f 9 4 . 7 maternal d e a t h s p e r 100,000 live births in 1990 to 36.6 per 1 0 0 , 0 0 0 in 2 0 0 7, a reduction of 61.4%, and placing China on track to achieve this MDG target. However, a g a i n r e g i o n a l differences indicate that the MMR in rural areas is far higher than that of urban areas, and also higher in poor than in developed regions. Disparities in access to and the quality of health services for rural, poor, migrant a n d ethnic minority women continue, leaving many o f t h e s e g r o u p s w i t h a disproportionate burden of mortality” Using auto-regressive statistical methods, Chinese scientists predict that by 2020, China’s MMR will drop to 22. That is comparable to the USA. While China is confident it will soon be the equal of the US, the maternal death rate in Tibet remains statistically akin to that in Cambodia, Benin, Gambia, Ivory Coast, Kenya, Madagascar, Senegal, Uganda or Zambia.
Who will act to help the women of Tibet who die to give birth? Women in exile speak up for imprisoned women, and sterilised women in Tibet, but not for the inexorable daily toll of unnecessary deaths in childbirth.
What Arlene Samen pioneered was not revolutionary or even new. The methods that effectively reduce maternal death rates are, as she says, quite simple. They involve being with the pregnant woman, where she is, as she is, supporting her to be who she is as she goes through the birthing process, with basic medical help close by if needed. That’s all it takes.
The Millennium Development Goal of reducing maternal deaths in Tibet by three quarters is achievable. Arlene Samen’s OneHEART showed that it could be done, in Meldro Gongkar and Tolung Dechen, not far from Lhasa. But China will n ot do this sort of community work, instead relying on women to come to hospitals, and blaming them when they do not.
In 2008 Wang Shaoguang, of the Department of Government, at Chinese University of Hong Kong reported: “In the year 2000, the World Health Organization (WHO) assessed the health system performance of its 191 member nations. In terms of overall health system performance, China was ranked 144, worse than Egypt (63), Indonesia (92), Iraq (103), India (112), Pakistan (122), Sudan (134), and Haiti (138). With respect to the fairness in financial contribution, China was placed even lower at 188, the fourth country from the bottom, only slightly better than Brazil, Burma, and Sierra Leone. All other countries with large populations, such as Pakistan, Indonesia, Egypt, and Mexico, performed better than China. This was in striking contrast with the praise China had received for its health system two decades before. For a self-styled “socialist” country, this was truly a great humiliation.
“How could China build up one of the most affordable and equitable health care systems in the world and make remarkable strides in improving the health status of its population during the era of Mao Zedong when the country was dirt-poor? Why is it that despite a stronger economic base, higher scientifi c and technical level, and greater expenditures, the performance of the nation’s health care system has been so disappointing under the market-oriented economic reform?”
The paradox of China’s emergence as a country able to afford anything is that Tibetan women and their babies are left further behind, with no likelihood China will, in Tibet, achieve its Millennium Development Goal obligations.
IS THERE A BETTER WAY?
China’s model of centralised, hospital-based maternal health is simply not appropriate to the vast distances, poor transport, and scattered population of mobile pastoral nomads of Tibet. China says it supplements these expensive, centralised services by also providing decentralised community health workers who go to where pregnant women live, providing early warning of pregnancy complications that may require hospitalisation. But Tibetan women say they seldom get to see such outreach staff, who in practice seldom go far from their urban base, no matter what Chinese statistics say.
If we want to find decentralised delivery of maternal health in Tibetan areas, that actually accommodates the extensive land use of mobile Tibetan nomads, we must shift our gaze from Tibetan areas of China to the Tibetan portion of India, in Ladakh. In the uplands and empty plains of Ladakh, the women of the Association of Traditional Tibetan Medicine are out in the remote villages, training local midwives in how to diagnose and treat early signs of a difficult pregnancy, using the herbs and minerals of sowa rigpa: the traditional medicine of Tibet. This new generation of Tibetan midwives also trains in diagnosing those uncommon circumstances that do require hospitalisation, in time for a medical evacuation, by helicopter if necessary, to a hospital. Ladakh demonstrates that China’s one-size-fits-all urban-centred model is culturally inappropriate, and a direct cause of the high death rate.