Why is it “inefficient” to save the lives of mothers?
This is the first in a series of four blogposts on why so many women in Tibet die in childbirth, usually alone, bleeding to death.
As with almost anything to do with Tibet, even the basic facts are contested. As we rapidly approach the fulfilment date for the Millennium Development Goals, including the universally agreed responsibility to reduce maternal mortality by three-quarters, by 2015, China claims credit for being the exemplary developing country, with a far better record than any in the developing world.
So this first blog seeks to establish some basic ground truths: is it true that the maternal mortality rate (MMR) in Tibet is one of the worst in the world? Is that inevitable, due to the scatter of nomads across a vast landscape, or is this due to state failure? Is it asking too much of China to extend effective health services to remote nomadic pasturelands; or is that by definition inefficient, even impossible? Or is the MMR in Tibet a failure of Tibetan civilisation, of entrenched sexism and complicated pollution taboos that condemn women to give birth alone, in unsanitary conditions?
In the second blog, we look more deeply into Tibetan culture to see what it can offer. In the last two blogs, we look at fresh approaches, and fresh solutions.
This Rukor blog first looked at maternal mortality back in 2011, and a lot has changed since. That’s why the fourth and last blog in this series, despite the appalling statistics, ends on an optimistic note, that things are starting to change, on the ground, in quite remote areas of Tibet. New lessons are being learned, new, decentralised ways of helping pregnant women are being trialled, and taken up by the official public health bureaus.
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 approximately 400, perhaps even 500, per 100,000 children born live, every year. Yet the rate in China is 45 per 100,000. Why is so little done to help Tibetan women, when most of these deaths are unnecessary, and can be prevented inexpensively?
Why do so many Tibetan women bleed to death? Mobile populations need accessible, mobile health care, which traditional Tibetan healers, or amchis, continue to provide. But sometimes, in an emergency, preventive and restorative medicine is not enough. Maternal mortality in Tibet is among the highest worldwide, and has not been reduced by China’s urban-centric, user-pays health care delivery system; which fails to meet the needs of a widely dispersed Tibetan pastoral population making skilful use of one quarter of China’s land area. Extensive dryland users’ worldwide need highly decentralised health services, especially for timely access to emergency care when pregnancy complications occur.
In an emergency, not only are existing clinics too far to reach, accessible on roads impassably muddy in summer, but the clinics are also ill-equipped, understaffed, and rely on presales of the most expensive intravenous medicines to make a profit. Upfront payment is necessary before a patient is allowed in the door remains the norm, despite recent reforms. China’s Rural Cooperative Medical Scheme (RCMS) has reduced outpatient costs for the poor, but remains less effective than planned. Because of the expense, and the need for the right “connections”, women expecting a normal pregnancy are nowhere near a clinic until it is too late. Recorded journey times to reach a maternity clinic in Tibet may be several days.
Over recent decades China’s health system has shunned taking responsibility, having downshifted health care to local levels, making users pay, and leaving poor counties with poor health services. Although recent reforms have ameliorated the situation in some parts of the region, they have not been effective in the poorest and remote areas, including rural Tibet. The RCMS covers the costs of basic medicines, but doctors still have incentives to over-prescribe expensive medicines from which they can profit.
Small-scale pilot projects have shown it is possible to educate community health workers (CHWs) as skilled birth attendants, even in very remote areas of the Tibetan Plateau, who are capable of identifying complications within sufficient time to evacuate to a biomedical clinic when necessary. However China has been reluctant do this sort of community work, instead relying on women to come to hospitals, and blaming them when they do not.
This chapter argues for alternatives to the maternal mortality situation in Tibet, one based on strengthening deeply embedded capacities within Tibetan culture and its sciences of healing; another on upscaling the successful pilot projects training CHW interventions.
Contemporary Tibet is a classic test of the capacity of the modern state to extend its reach into remote areas and deliver the services inherent to modernity, including timely interventions to prevent maternal mortality.
The maternal mortality Millennium Development Goal (MDG) of the United Nations, set in the year 2000 and culminating in 2015 as the target date for completion, is a specific, deliverable goal well within the capacity of a middle income country such as China, with its strong tradition of social engineering, resource allocation, state intervention and many aspects of dirigiste planning still intact.
What do we know about the maternal mortality ratio (MMR) in Tibet? Few official statistics are available that span the five provinces that constitute the Tibetan Plateau. China claims overall success in meeting the MDG target 5A of a three-quarters reduction in the Tibetan MMR between 1990 and 2015. And yet: “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.”
In China, the maternal death rate has decreased to 45 per 100,000 births. Senior Chinese health administrators have stated: “Progress in reducing maternal mortality in China has been impressive; the MMR decreased from 95 deaths per 100,000 live births 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, when China pledged to fulfil the MDGs, but goes back to the 1980 Safe Motherhood global conference in Nairobi. But has 35 years of effort made much difference in Tibet?
Using auto-regressive statistical methods, Chinese scientists predict that by the year 2020, China’s MMR will drop to 22 per 100,000 live births, a figure that is comparable to the rate in the USA. While China is confident it will soon be the equal of the US, the maternal death rate in Tibet remains statistically similar to such resource-poor nations as Cambodia, Benin, Gambia, Ivory Coast, Kenya, Madagascar, Senegal, Uganda or Zambia.
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. Few now look into Tibet from the outside. Very few reproductive health agencies, multilateral development banks, or health NGOs from around the world are any longer on the ground in Tibet.
In 2015 China has been hailed as a great MDG success story, and as an example to the rest of the developing world, in achieving almost all goals. Yet if the Tibetan Plateau – representing one quarter of China’s area – is disaggregated from national statistics, the available evidence suggests the maternal mortality rate (MMR) remains alarmingly high, at levels found only in the poorest of countries. China now ranks in the middle of countries worldwide assessed by the annual State of the World’s Mothers. Officially, “In Tibet, the death rate of women in childbirth dropped to 174.78 per 100,000, or nearly six times of the national level in 2010.”
Yet an in depth survey of women in a remote area of eastern Tibet reports the deaths of three women over a 19 month period, in which there were 103 live births, suggesting a far higher MMR. The investigators, a large team from Johns Hopkins University in the United States, and many Tibetans, conclude that: “The majority of women in Surmang were very worried about dying in childbirth, and the report of 3 recent maternal deaths in this small population suggests exceedingly high maternal mortality in this region. Facility delivery rates <1% in Surmang in the 5 years between 1999 and 2004 can be compared with facility delivery rates of 92% for China overall.” 
Although this report is from a small study population, and is too anecdotal, to make generalizations (as the authors point out), there are almost no other comparable studies. International health NGOs active in Tibetan areas, mindful that embarrassing statistics represent “loss of face” for local officials who have power to deny ongoing access to Tibet, are understandingly reluctant to publish their data.
The few other village level studies in Tibet report similarly: “Maternal and child health findings were alarming with high rates of miscarriage and infant loss, with no traditional midwives to assist in pregnancy and delivery. A quarter of all infants born after 7 months of pregnancy in the previous 5 years died. On the other hand, during the same period, none of the pregnant women died, in either township, at any time in pregnancy or within 6 weeks after delivery. In 18 percent of the pregnancies women were reported to have suffered severe swelling of ankles and legs, 12 percent had postpartum haemorrhage (PPH) immediately after birth and 12 percent within a few days of birth, and 37 percent had a fever within a few days of birth. In the focus groups, however, some women described knowledge of maternal death from childbirth—some in first degree relatives.” 
In summary, Tibet has one of the highest maternal mortality rates in the world. The alarming statistics of maternal death in Tibet are concealed by the routine aggregation of Tibetan data into large corpus of Chinese national statistics. Comparable rates are found in post-conflict countries recovering from war, but in those nations the data are available for all who care to see. If an extraordinary proportion of Tibetan women haemorrhage and die during or shortly after giving birth, we need to ask why. Several plausible explanations come readily.
Tibet has been isolated more than ever in recent years from global scrutiny. We can not only ask, but partially answer, the key question of how this shocking death rate of mothers and their infants has occurred. Although fieldwork surveys and experimental interventions to reduce MMR in Tibet are rare, there is enough known to define the aetiology of this ongoing crisis.
The purpose of seeking the origins of the crisis is not to apportion blame or responsibility. What needs clarifying is whether the problem is a state failure, a failure of traditional Tibetan culture, or both. Those are the options canvassed in the existing debate, and the answers which investigators reach deeply influence the design of projects intended to improve the situation. Thus, it matters greatly which of the dominant discourses: of state failure or Tibetan culture failure, is to be believed.
This chapter explores both master narratives, finding them both plausible, internally consistent and logical; yet both are seriously flawed. The conclusion is that we need a fresh approach. Two new approaches are discussed.
THE DISCOURSE OF EFFICIENT MODERNITY
China promotes what could be called the efficiency argument. The six million Tibetans occupy a plateau the size of Western Europe, scattered extensively across a vast area; and not even the wealthiest state can possibly extend health services to small and remote communities. The logic of efficient resource allocation for service delivery requires centralising clinical services in county seats, of which there are 150 in the Tibetan Plateau, in five Chinese provinces. It is thus unreasonable to expect China to extend the reach of the state beyond the county capital, and pastoral nomads should realise that effective clinical treatment for complications of pregnancy is just one of a package of benefits available by abandoning mobile pastoralism for peri-urban settlement. Only when nomads cease wandering will the MMR decline, along with access to general health care, schooling and electricity. The efficiency argument is a familiar one, and worldwide.
Over recent decades China’s health system has shunned taking responsibility, having downshifted health care to local levels, making users pay, and leaving poor Tibetan counties with poor health services. China continues to be largely a user-pays system that favours the rich, privileged 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. The Rural Cooperative Medical Scheme (RCMS) has gradually increased its scope, yet RCMS: “had little impact on reducing its participants’ out-of-pocket payments for outpatient services.”
China, it seems, has 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.
THE DISCOURSE OF CULTURAL FAILURE
A different argument shifts the focus to Tibetan tradition. This argument, sometimes advanced by NGOs active in Tibet, notes the absence in Tibetan culture of skilled traditional birth attendants (TBAs or SBAs), women in the community known for their capacity to support pregnant women and identify complications early enough to ensure emergency medical help is accessible when needed. This TBA argument is, like the efficiency argument, plausible and based on worldwide experience in more densely settled areas of the developing world, where community health workers (CHWs) with TBA experience are common. This argument sometimes goes a step further, suggesting the Tibetan traditional healing system of sowa rigpa, being a branch of Buddhism, is largely delivered by male practitioners who have neither the knowledge nor understanding of the urgent circumstances in which a pregnant woman can bleed to death. Traditional pollution taboos force women to give birth alone, in unsanitary places.
Taken together, the efficiency and TBA arguments are complementary, and seem to encompass a full, if depressing, explanation of why MMR in Tibet remains alarmingly high. The conclusion is grim – the modern state has failed, and so has Tibetan tradition. Only eventual urbanisation offers a long term prospect of reducing MMR. At best, China may outgrow its urban-centred clinic model and employ community health workers.
Plausible as these two arguments are, they require critical evaluation to discover their many assumptions, which may not be applicable to the actuality of being a Tibetan woman about to give birth. Starting over, we might seek a different approach, utilising the strengths of sowa rigpa traditional healing, and the global TBA movement, and the capacity of modern states to extend their reach (using new technologies) into even the remotest communities. Instead of seeking whom to blame, this alternative approach seeks solutions that build on existing capacities.
Unless and until all Tibetans acquiesce to China’s plans for urbanization as the solution to all problems of development, MMR included, viable alternatives are needed. The CHW/TBA midwifery approach has worked all over the world, and in Tibet, where low population densities mean little scope for vocational specialisations of any sort, small scale NGO projects have experimented with training skilled birth attendants. This seems a very promising strategy, in that it provides early warning of pregnancy complications, allowing women in danger time to get to a centralised clinic or hospital in a county capital. In Tibet, widespread rural poverty and bad, potentially unpassable, roads, especially in the wet summer months, can mean a trip of days, or even a week, to get to a hospital. Thus, early detection of pregnancy complications is essential to bridge the gap between decentralised populations and centralised biomedicine.
However, small scale experimental training and support programs for birth attendants seem hard to replicate, and to subsequently expand to cover the entire Tibetan Plateau, unless integrated into the existing, decentralised, trusted rural health service provided by the Buddhist sowa rigpa healers, or amchis. Some programs import a western feminist model that lacks a basis in Tibetan tradition, as well as lacking support from official health delivery ministries, though that is beginning to change. Implementation of such a programme depends on international NGOs whose presence in Tibetan areas within China is precarious in a state preoccupied with threats to stability, and wary of foreign agencies. They may yet succeed in persuading local governments to embrace the CHW approach.
Proponents of the CHW/SBA movement are quick to relegate Tibetan culture to irrelevance, on the basis that there is no such customary profession in which independent, self-actualising, empowered women earn their living as specialist professionals exclusively providing birthing services. Tibetan culture and Tibetan Buddhism are said to be silent, or even inimical, to this global movement which is now blossoming in Tibet into a wider feminist challenge to traditional patriarchy. The CHW/SBA movement and clinic-based biomedicine are alike in their impatience with Tibetan tradition. The complex choices faced by Tibetan women – where and how to seek help – are seldom noticed. One exception is anthropologist Kim Gutschow, whose fieldwork in the Indian part of upper Tibet, Zanskar, offers a fine-grained depiction from the perspective of the new mother.
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 occurring in 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 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 pregnant 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, as is often said, cai (stupid bumpkins), mian gua (idiots), and ruo zhi (dull witted).
Hospitals are temples of scientific modernity and reductive simplification, Gutschow argues, which choose to ignore the traditional Tibetan complexities of drib (ritual pollution) caused by birth, and the behavioural taboos that go with the woman taking care to minimize 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.
Tibetan women, in such circumstances, face difficult choices. A woman who mixes customary and modern healthy behaviours soon finds that: “Her body became the ground upon which modern subject-citizen making took place.”
A version of this blog series will be published in 2015 by Nova Science Publishers, in a global textbook called ‘‘Maternal Mortality: Risk Factors, Anthropological Perspectives, Prevalence in Developing Countries and Preventive Strategies for Pregnancy-Related Death”, edited by David Schwartz.
 Vincanne Adams, Suellen Miller, Jennifer Chertow, Sienna Craig, Arlene Samen and Michael Varner, Having a “safe delivery”: Conflicting views from Tibet; Health Care for Women International, 2005, 29 , 821-851
 Feng X, Zhu J, Zhang L, Song L, Hipgrave D, Guo S, Ronsmans C, Guo Y, Yang Q.; Socio-economic disparities in maternal mortality in China between 1996 and 2006; British Journal of Obstetrics and Gynaecology, 2010, 117, 1527-1536
Juan Liang., Xiaohong Li., Li Dai, Weiyue Zeng, Qi Li1, Mingrong Li, Rong Zhou, Chunhua He, Yanping Wang, Jun Zhu; The Changes in maternal mortality in 1000 counties in mid-western China by a government-initiated intervention, PloSOne, May 2012 | Volume 7 | Issue 5
Beibei Yuan, Xu Qian and Sarah Thomsen; Disadvantaged populations in maternal health in China: who and why? Global Health Action 2013, 6: 19542
Qing Du, Oyvind Nass, Per Bergsjo, Bernadette Nirmal; Kumar determinants for high maternal mortality in multiethnic populations in western China; Health Care for Women International, 2009, 30:957–970,
 Ren Zhenghong, Forecast of the indicators on maternal and child health of China in 2020; Health Sciences Journal of Peking University, 2010, 42 , 221-224
 State of the World’s Mothers 2014: Saving Mothers and Children in Humanitarian Crises; Save the Children 2014
 Life expectancy in Tibet nearly doubled over last six decades: white paper; Xinhua, 11 July 2011, http://news.xinhuanet.com/english2010/china/2011-07/11/c_13978305.htm accessed 7 December 2014
 Mary Wellhoner, Anne CC Lee, Karen Deutsch, Mariette Wiebenga, Maria Freytsis, Sonam Drogha,
et al., Maternal and child health in Yushu, Qinghai Province, China; International Journal for Equity in Health 2011, 10:42 http://www.equityhealthj.com/content/10/1/42
 Peter M. Foggin, Marion E. Torrance, Drashi Dorje, Wenzha Xuri, J. Marc Foggin, Jane Torrance; Assessment of the health status and risk factors of Kham Tibetan pastoralists in the alpine grasslands of the Tibetan plateau, Social Science & Medicine; 2006, 63, 2512–2532
 Feng at al., Socio-economic Disparities op cit.
 Wei Yang and Xun Wu; Paying for Outpatient care I Rural China; Cost escalation under China’s New Co-operative Medical Scheme, Health Policy and Planning, 28 Jan 2014
 Kim Gutschow, From Home to hospital: the extension of obstetrics in Ladakh; ch 8 in Vincanne Adams, Mona Schrempf and Sienna Craig eds., Medicine between science and religion, London, Berghahn, 2010
 Jennifer Chertow, Gender, Power, Space: transnational bodies and the cultures of health in contemporary Tibet, PhD dissertation, Stanford University, 2007, 94