linic, as hand-held, battery-powered ultrasound is now available.

Mobile pastoralists of Tibet do have mobile phones, so maternal health initiatives in China
could provide essential prenatal health checks that often identify problem deliveries in
advance. Mobile ultrasound devices connected to mobile phones are a promising idea.
However, current m-health (health delivered by mobile phone) in China is solely for those
literate in Chinese language, which is very seldom spoken or read by Tibetan nomad
women.

CONCLUSION

Maternal mortality in Tibet remains high, official statements notwithstanding. Until

recently, this seemed inevitable, since Tibet has neither a tradition of skilled birth
attendants, nor affordable and accessible clinics or hospitals. The women of Tibet remain
caught between two models the efficiency model and the SBA model both of which
condemn them to giving birth alone and without access to help. Both models perceive the
land, the people and the culture of Tibet negatively, defined by what is lacking. From the
standpoint of the efficiency model, Tibet lacks, scale, density, concentration, and critical
mass. The answer from efficiency model standpoint is urbanization. From the CHW/SBA
standpoint, Tibet lacks a tradition of birth attendants; its healing system is male dominated
and androcentric. The answer in the CHW/SBA school of thought is to train a new breed of
SBA community health workers empowered to challenge the male bias ofsowa rigpa.
Unfortunately, neither model has the will or capacity to significantly alter the realities of
maternal health care in the foreseeable future.
Having dwelt at length on obstacles to reducing the MMR, we may conclude with two
promising prospects. One is for a revitalised role of the amchis, if they can be recognised by
official health care bureaus as having a more constructive role to play.
The other hopeful development is the prospect of scaling up small-scale projects targeting
MMR, initiated by NGOs, and suffused with traditional Buddhist beliefs of having positive
regard for others. They show that active compassion, relevant skills training and new
technologies can greatly reduce MMR. This new approach means creating a new profession
of community health worker birth attendants.
Much can be achieved, yet China remains wedded to the standard efficiency model of
restricting resource allocation to urban hospitals and clinics, and has little inclination to
decentralise. However, those centralised services are beginning to trial the training and
deployment of outreach staff, as community health workers. In four townships of Yushu
Prefecture, CHWs will bring the mothers to the clinic for ante-natal and post-natal exams,
and well baby exams in addition to birthing. This project has built-in triple incentivization:
incentivization of the mother, the community health worker and the doctor. The method

relies initially on training by highly skilled foreign doctors in the four township hospitals.
The training is selective and somewhat competitive, unlike the mass lecture training given
by UN WHO or the use of the Advanced Life Support in Obstetrics instructional materials.
A health policy goal of this training is to reduce the salaries of the trained doctors and
introduce a system of incentivization, so that when their performance increases, so does
their income. The measured criteria for increasing the pay of staff is patient numbers,
amount of medications prescribed, live births, return visits, referral from village providers,
referrals to County or Prefecture Hospitals.
Right now, Tibetan women remain at risk and will continue to experience one of the highest
maternal mortality rates in the world. Hopefully, that will change.
*********************************************
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.

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[3] Qian Long, Reija Klemetti, Yang Wang, Fangbiao Tao, Hong Yan and Elina Hemminki;
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