Across the barren, rugged reaches of the high Tibetan plains, women from the nomadic yak-herding tribes ride for days in search of a doctor to treat their "stomach ache". Too often, they don't realise they are pregnant. Many die en route.
Mortality rates for babies and mothers in childbirth among these often-forgotten people in "the roof of the world" have long been at epidemic proportions. In a world where statistics are almost non-existent, the last known survey put the toll at 400 babies per 1,000.
Extraordinarily bereft of traditional community birthing attendants, their knowledge of basic care and hygiene is limited. Infants born with airwaves blocked by mucus - a problem that can easily be solved - are deemed to be stillborn. Even the need to keep the baby warm in freezing temperatures is frequently ignored, leading to cases of hypothermia. Having spent the day working with yaks, family members appear oblivious to basic cleanliness as they begin to deliver a child. Many women die from septicaemia.
"They tend to marry relatively young and the girls start having babies at 16 or 17 and go on for some years," explains Mark McKeown of Children in Crisis, one of the charities being supported by this year's Independent Christmas Appeal. "They may have eight or nine pregnancies with three or four surviving. Most of the doctors are male and women don't like consulting men on gynaecological problems. They are very shy." The British charity, working in partnership with Jinpa, a Tibetan development organisation, has launched a major programme to combat the problem by training young women as midwives. Children in Crisis has already trained two sets of 50 midwives - selected by their communities - with a third course now under way.
Often separated from their families for the first time, the initial hurdle is to teach them how to fend for themselves and even clean up. Each is handed a welcome gift including a toothbrush, flannel and hair brush. " They are very protected. They come to the big city and a lot of them don't have the skill to manage their own lives, to live on their own, so they need to learn," explains Mark McKeown. The charity has discovered that these new recruits, who are usually illiterate when they arrive, have shown an incredible aptitude and enthusiasm for learning.
"From a standing start, very little education, the speed at which these girls pick it up and want more and more is amazing," he says. "The girls go back to their dormitories and spend the night talking about what they have learned. This is seen as a huge privilege and these girls work their socks off. Their families are so proud because they are the first people in the family who can read. It gives them status in their communities when women usually have a very low status."
Using a hollow basketball to simulate a womb and a doll, the youngsters are taught about childbirth. After completing six months live-in tuition, and a month's practical learning at the local hospital, they spend three months working in their community before returning for a month-long refresher course and an opportunity to exchange experiences.
As well as raising the profile for women, particularly pregnant ones, they also deliver a general message of basic care and preventative medicine. In a world where communities drift constantly and hospitals can be eight days' ride away, emergency treatment is rarely an option. So the young women are trained to look out for early signs of ante-natal problems.
Armed with basic medical equipment, including stethoscopes and blood pressure monitors, the 100 new trainees have returned with posters - often pictorial - highlighting such issues as disease transition. They give regular talks to groups of 50 to 100 nomads and hold educational puppet shows at the horse festivals, which attract nomads from all around.
With current plans to train 300 young women - 50 for each of the six counties - Children in Crisis knows that it will not solve the problem in this vast and deprived land. But reports are already filtering back of lives saved. Even some men are now consulting the women. "Hopefully it will see the creation over a period of time of a healthier society," adds Mr McKeown.
The charity has worked in the Tibetan Autonomous Prefecture of Yushu building schools since 1997. They and their Tibetan partners take care, given the political sensitivities in the area, to be apolitical.
But providing education and health care for the nomadic tribes is contributing to the preservation of an ancient culture.
Mr McKeown recalls receiving a Tibetan vote of appreciation from one of his local partners: "I said to him, 'If this midwife training comes off the result will be a lot more Tibetans.' He grabbed me by the head and rubbed his forehead against mine in delight."Reuse content