A Self Sustaining Perinatal Care System for Tibet 
The People's Republiuc of China (PRC) has made dramatic improvements in its maternal and newborn mortality rates (MNMRs) over the past few decades. However, certain geographic and cultural areas continue to have higher MNMRs. The Tibet Autonomous Region (TAR) continues to have significantly higher MNMRs than the overall PRC due to the rural and impoverished nature of the region, logistic and financial constraints on the availability of biomedicine and cultural mores that have historically isolated pregnant and laboring women. Investigators on this project have previously documented, beginning in 1993, that prenatal care is virtually non-existent in rural TAR and that very few births are attended by skilled birth attendants. In addition, the TAR has no organized medical transport system. A multidisciplinary approach to these problems is outlined that will include representatives from medical anthropology, United States biomedicine, TAR biomedicine and TAR traditional Tibetan medicine. The unique capabilities and accomplishments of the individuals represented by this collaboration will allow testing of the hypotheses: 1) ethnographic research in Tibetan women can identify the current status of, and barriers to, maternal and newborn care and transport, 2) that rates of antepartum care and peripartum attendance by skilled birth attendants can be increased by development of a culturally sensitive Traditional- Biomedical Perinatal Training and Care Program, and, 3) a functional maternal transport system can be developed and utilized. The proposed project will be implemented in two counties of the Lhasa prefecture of the TAR, with two matched counties serving as concurrent controls. 4) A concurrent maternal and newborn mortality review mechanism (Continuous Quality Improvement) will allow further improvement in outcomes for pregnant women and their newborn babies, both during the life of this proposal and beyond.