Gender and Health Reaction Paper
By: Tina Sang
This past summer, I conducted my public health internship at Surmang rural health clinic, which
is located in the Yushu Tibetan Autonomous Prefecture. My main project was to assist my supervisor, a
registered nurse from the U.S., to train 33 local Tibetan women to become birth attendants. A great
majority of the women in this rural area deliver children at home because the nearest hospital is more
than 5 hours away by car, and they would not be able to afford the high out-of-pocket fees for health
care.
Since returning to school, I have struggled with understanding the impact of our clinic’s birth
attendant training program. The local women only receive one to two days of training each year from
Western volunteers, and they are largely unsupervised by clinic volunteers and staff. During the
trainings, we emphasized the importance of birth attendants identifying high-risk pregnancies and
pregnancy-related complications. But birth attendants recognizing that a pregnancy-related
complication exists and educating the pregnant woman about the issue is not enough. “75% of
maternal deaths result from direct obstetric causes, such as hemorrhage, obstructed labor, infection,
toxemia, and unsafe abortion… a majority of these deaths could have been prevented with timely
medical treatment” (Thaddeus & Maine, 1994). The delays pregnant women face when deciding to seek
care, reaching an adequate health care facility, and receiving adequate care at the facility are all
influenced by the low status of women (Thaddeus & Maine, 1994). Thus, the social construction of
gender has a direct impact on health and can mean the difference between life and death for mothers in
developing countries.
In Thaddeus and Maine’s article, the authors describe three phases of delay that often result in
maternal mortality. I will draw upon my internship experience to discuss how Phase I and Phase II
delays occur in the Tibetan countryside. Phase I delay is “delay in deciding to seek care on the part of
the individual, the family, or both” (Thaddeus & Maine, 1994). Though I did not directly witness this
type of delay during my internship, I can make an informed assumption on how Phase I delay occurs in
the rural Tibetan context. One of the birth attendants involved in our training arrived at the training
session two hours late because she had to milk the yaks. She is a woman in her fifties with 8 teenage
and adult sons, but none of them stepped in to help their mother with the chore. Milking the yaks is
socially constructed as women’s work. In addition, pregnant Tibetan women living in the countryside
continue with their household duties, many of which require hard physical labor, almost up until the day
they begin delivery. Time-consuming, daily household duties that are essential for the well-being of the
family are designated as women’s work. With the heavy responsibility of taking care of the household,
it is very likely that pregnant women will delay seeking care even when they feel their health is at risk.
Seeking care entails pregnant women committing their time and their family’s financial resources to
transportation and health care fees. These opportunity costs are high enough to prevent women and
their families from seeking care until the symptoms or pain worsens. However, by then it may be too
late to avoid maternal morbidity and mortality.
Phase II delay is “delay in reaching an adequate health care facility” (Thaddeus & Maine, 1994).
The Surmang rural health clinic is located in a valley that contains six villages. For the residents of Tsokie
who live on the border of Qinghai Province, China and the Tibet Autonomous Region, traveling to our
clinic is a one-hour drive over rough, dirt roads. The distance and road conditions lead women in Tsokie
to seek medical advice and purchase medicine from their village store owner even though professional
health care and medications are available for free at our clinic. Inadequate or inappropriate selftreatment of pregnancy-related complications increases the likelihood of maternal morbidity and
mortality.
In an obstetric emergency, our primary care clinic would be unable to perform the surgeries that
can save women’s lives. Pregnant women would need to travel by car or motorcycle for more than 5
hours and cross two high mountain passes in order to reach a surgical hospital in Yushu City, the
prefecture capital. Once again gender plays a role in delaying care because motorized transportation is
not readily available to Tibetan women. Many women living in the rural area do not know how to drive
a car or ride a motorcycle. They depend on the men in their family for transportation. However, their
men may be far away due to gendered occupations that place women near the home and men in society
(e.g. logging in the mountains, trading goods in Yushu, and driving trucks to ship goods). So when a
pregnant woman is in a life-threatening situation, the other village women want to help but it is likely
that none of them can bring her to an adequate health facility. Delays continue as women try to locate
a man with access to a car who is willing to provide assistance. During my internship, one of our birth
attendants told me about a pregnant woman who should receive an ultrasound because her child is
situated horizontally. The birth attendant said the pregnant woman wants an ultrasound, but no one is
willing to give her a 30-mintue ride to our clinic. One man said he was unwilling to help because he does
not have a car and only has access to a motorcycle. He did not want to be responsible if the pregnant
woman accidentally falls off the motorcycle during the journey.
Considering the gender factors and lack of adequate health facilities in the Tibetan countryside, I
can understand Thaddeus and Maine’s point when they say “training of traditional birth attendants in
safe, hygienic birthing practices may be of limited efficacy” (1994). Maine and Rosenfield argue that
“No matter how many resources are devoted to improving women’s education and nutrition, or to
prenatal care and training traditional birth attendants, no substantial reduction in maternal mortality
will result without access to emergency obstetric care” (1999). The issue of access becomes much more
complicated when public health professionals must address not only the distribution of adequate health
care services and health care costs, but also the effect of women’s gendered status. Maternal mortality
is a phenomenon caused by the intersection of females’ biological capability to bear children and
women’s lower status. Campbell and Graham discuss family planning for women who do not want more
children as a way to reduce maternal mortality since “prevention of pregnancy is an effective form of
primary prevention” (2006). I wonder how public health interventions can make headway in family
planning within the rural Tibetan context. My supervisor, our Tibetan interpreter, and I trained the birth
attendants about the different types of contraception. When we asked them to role play a wife and
husband discussing family planning and contraception options, the birth attendants did not know how
to respond. They all agreed that it would be almost impossible for the woman to ask her husband to use
a condom. They said if they did not want more children, they would take oral or injection
contraceptives without informing their husband.
Reference List:
Campbell, O.M.R., & Graham, W.J. (2006). Strategies for reducing maternal mortality: Getting
on with what works. The Lancet, 368, 1284-1299.
Maine, D., & Rosenfield, A. (1999). The Safe Motherhood Initiative: Why has it stalled?
American Journal of Public Health, 89, 480-482.
Thaddeus, S., & Maine, D. (1994). Too far to walk: Maternal mortality in context. Social
Science & Medicine, 38, 1091-1110.