September 21, 2004
The first of the six health clinics that Sera Bonds and Adam Rosenbloom visited in Tibet last June was the worst.
It served Ennyi township's 10 villages, with a total population of about 2,000, and was the main health post for pregnant women.
The ceiling was leaky, the dirt floor wet, the room dark without
electricity and the stained delivery table seemingly abandoned.
The village doctor spit on the floor, where the majority of women preferred to give birth in a squatting position, since it is easier than lying down. A Tibetan medicine doctor provided patients with remedies such as herbs, diet changes and prayers. But there was no midwife.
After visiting this and five other clinics in the Nagchu prefecture, which encompasses 11 counties of the Tibet Autonomous Region, and is under Chinese authority, the public-health field workers completed an assessment in August.
"The standards of quality of care in Tibet are one step below the rest of China," said Rosenbloom in an instant-message interview from Lhasa, Tibet.
Bonds and Rosenbloom, with Circle of Health International, based in Austin, Texas, are the latest to join a small cluster of health workers in the region.
Their study is one of the few to look exclusively at Tibetan women's health
issues. But the researchers' findings, published in August, concur with those
of other health advocates in the region; that Tibetan women require attention.
Health Care Gap With China
Arlene Samen, an obstetric nurse at the University of Utah, Salt Lake City, is founder of One H.E.A.R.T., a group that's been conducting midwifery training in Tibet since 1998.
"In mainland China most women have one child," Samen told Women's eNews. "They aren't living in the middle of nowhere without help and education. Hospitals are available; there are more doctors and facilities and they probably go to the doctor early. They're more locked into a healthcare network than Tibet."
All of which means that, depending which set of statistics are trusted, Tibetan women are 6-to-10 times more likely to die in childbirth than Chinese women. Their infants are up to 3 times less likely to survive.
"Because the great majority of births in Tibet occur at home to women who receive little or no prenatal care, none of us really have any idea about how many maternal or newborn deaths occur that are never registered," said Dr. Michael Varner, a professor of maternal-fetal medicine at the University of Utah who is also medical director of One H.E.A.R.T.
The Health Bureau of the Tibet Autonomous Region says that on average 325 women in Tibet die for every 100,000 live births. The Tibet Poverty Alleviation Fund, Cambridge, Mass., puts the maternal mortality rate at 500 per 100,000 live births. That higher figure makes Tibet among the most hazardous places for expectant mothers in Asia.
Sierra Leone in African has the highest global maternal morality rate with 2,000 deaths for every 100,000 live births, according to the World Health Organization.
Now that their research has been published, Bonds and Rosenbloom hope to
return to Tibet in March. Like other workers there, they intend to train maternal
and child health specialists. Within three to five years they aim to see a
trained midwife available to women in all 143 of Nagchu's townships.
Beliefs and Superstitions
Tibetan beliefs and superstitions about birth and pregnancy--some traditional, some religious--can impede women from seeking birth attendants or midwives and can hinder sanitation.
In rural Nagchu, for example, the researchers found that, as in many parts of the developing world, complications and death due to pregnancy and childbirth are considered natural. Other researchers have also found that traditionally, secrecy and privacy are thought to protect the mother and her baby. For example, one belief is that if others know a woman is pregnant they will be jealous and wish the expectant mother harm.
Some Tibetan women also consider the blood from childbirth to be polluted so they deliver in a dirty place such as the barn or a storage room in the house to prevent contaminating the main house. Some avoid hospitals because they are also considered polluted. Delivering at home leaves the child's health in the hands of the mother.
"It's not uncommon for the babies to die from basic things like not
cleaning their mouth out to breathe," said Samen, whose group, One H.E.A.R.T.,
has looked extensively at cultural beliefs around birth. "In surveys
we've done, more than 50 percent of babies that died were born alive. This
is due to lack of education."
Problem of Isolation
Tibet's large size and small population is a major hindrance, said Arthur Holcombe, director of the Tibet Poverty Alleviation Fund, which has been conducting programs such as midwifery training and health promotion in Tibet since 1997. "Tibet has 2.6 million people living in an area the size of Europe or Alaska. It's big and the people are dispersed. Communication and getting around isn't easy."
He and Samen agree that the Chinese government has recently begun doing more to redress the problem. "China has occupied Tibet over the last 50 years, but it's only in the last 20 years they've had healthcare," said Samen.
Though the introduction of Western medicine to Tibet is relatively recent, books on Tibetan medicine explore women's health in depth, according to Yangdron Kalveng, a Tibetan medicine doctor now living in California. However, the idea of birth as a health issue has long been obscured, she said. One possible explanation for that: Monks have traditionally provided healthcare and women may not have felt free to openly discuss their reproductive health with men.
Changing these ideas and taboos will take time, added Kalveng, as will finding the balance between traditional and Western ideas of childbirth and risk.
"There are still lots of women who don't like to give birth in a hospital. Western medicine uses all those cleaning things and chemicals that smell bad and women feel it's isolated, cold and not cozy," said Kalveng. "There are lots of other women at a hospital and you're just one of them. You're not given special care."
Juhie Bhatia is a writer for Women's eNews based in New York City.