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Infant and Maternal Mortality in the Tibetan Community

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  • 1. Smulian 1 Elizabeth Smulian July 6, 2010 Dharamsala Summer Program 2010 Women’s Health Group Maternal and Infant Mortality in the Tibetan Community Maternity is a universal experience. Women around the world endure the joys and hardships of conception, gestation, and eventually, birth. Unfortunately, not every pregnancy is perfect. Yearly, over a half a million women die worldwide from complications relating to pregnancy and childbirth, 99% of which are in developing countries, and nearly 8 million infants die before they can reach their one-month birthday (Dickerson et al. 2010). These harrowing statistics illustrate the dire need to examine more closely the causes and consequences of high maternal and infant mortality rates in developing communities. Tibet maintains some of the highest maternal and infant mortality rates in the world (Adams et al. 2005). These rates are hard to measure accurately, as the Tibetan community is scattered across a remote landscape and has much of the information censored by the Chinese Government, but it is estimated that anywhere from 9% to 30% of infants die before they can reach their first birthday (Craig 2009). In contrast, the infant mortality rate is only .67% in the United States (World Bank, World Development Indicators 2010). Though these statistics vary and are far from precise, they all point to a high rate of infant death. Maternal mortality rates are also extremely high in the Tibetan
  • 2. Smulian 2 population. Though not nearly as high as the infant mortality rates, the maternal mortality rate has been reported as .4%, in relation to the much lower .01% in the United States (Craig 2009). In their native Tibet, women must fight the physical complications of pregnancy, the stress of the harsh environment, the lack of adequate prenatal and postnatal care, limited access to emergency care, and poor nutrition (Dickerson et al. 2010). This paper will explore selected Tibetan medical practices that are followed during pregnancies, examine the contributors to the high maternal and infant mortality rates of the Tibetan community, and investigate whether scientific modernization in the modern exile community has affected these mortality rates at all. For all of Tibet’s troubles with high mortality rates, the ancient religious and medical cultures have many lengthy recorded traditions concerning pregnancy and childbirth. Tibetan beliefs and practices surrounding maternity are often viewed through the lens of the dominant Buddhist culture and native Tibetan medical system. The Tibetan Buddhist perspective is greatly entwined with Tibet’s medical system, and governs many of the ideas about pregnancy and motherhood (Craig 2009). There are several basic Buddhist concepts that are applied to the process of conception and birth. Fundamental to the Buddhist philosophy is the idea of a cyclical existence, or samsara. Any birth or death is considered to be part of this larger cycle. The cycle has no beginning, and consists of many beginningless namshes, or consciousnesses. When a being dies, its consciousness enters the bardo state, an in between state between the past and future life. This bardo state lasts for up to 49 days, when the consciousness finds its future parents, sees them in sexual union, and joins with the father’s sperm to eventually
  • 3. Smulian 3 fertilize the mother’s ovum or joins with the ovum itself. Buddhists consider the moment the bardo consciousness enters the womb to be the moment of conception, at the union of the sperm and the egg. According to Buddhist traditions, this bardo consciousness retains its karma between lives. Karma is another fundamental Buddhist concept—one’s past actions will define how one is to be reborn in the next life. It is therefore a central concept to the idea of pregnancy, especially with complicated pregnancies, because the Tibetan medical system believes that many of the complications that arise during a pregnancy come from either the bardo consciousness or the mother having bad karma (Arya 2010). Complications such as miscarriage or maternal death may arise from this poor karma resulting from poor actions in past lives. Bad karma cannot be altered by any medicinal practices (Geshe Tobgyal la 2010). Another karmic concept is the idea of karmic compatibility between the mother, father, and bardo consciousness. For conception to even occur, these karmic connections must be positive. Without a favorable karmic connection between the parents and the bardo consciousness, conception may not occur or the mother may not carry to term, resulting in a stillbirth or a miscarriage (Arya 2010). Tibetan medical texts like The Four Tantras are quite explicit in describing embryology. The bardo consciousness, according to these texts, can enter the father or the mother during intercourse and become one with the father’s sperm or mother’s ovum. The union of the sperm, the egg, and the consciousness is what constitutes the beginning of life. The physical body of the fetus goes on to develop in accordance with the five basic elements: earth, wind, water, fire, and space. These elements, which come from the
  • 4. Smulian 4 mother’s nutrition, are responsible for the different aspects of the human body during its development. The fetus then goes through a very detailed growth process in utero. Any disruption to the five elements can disturb development of the fetus. This balance of the five elements is the mother’s responsibility to maintain through her diet and behavior. The texts go on to describe several obstacles that may arise in delivery, such as blood loss, breech birth, or the subtle wind element Thursel-rlung malfunctioning in inducing normal labor (Arya 2010). The centuries-old Tibetan medical tradition is highly intertwined with the Buddhist beliefs of the people (Khangkar 1986). When it comes to the care of a pregnant woman, Tibetan tradition dictates that she will first consult a lama, a Buddhist teacher, and may perform some of the religious rituals prescribed by the medical texts for a healthy pregnancy and a short labor. The lama can also help protect the mother from any malevolent spirits that may attack and harm her or the fetus (Adams et al. 2005). She then may go on to consult an amchi, a Tibetan doctor, who will assess her condition via the traditional Tibetan methods. One such method is pulse diagnosis, through which the doctor can tell the state of health of the fetus and of the mother. Natural medicines may be prescribed according to the Tibetan medical texts, or the mother may be instructed to avoid certain foods that would aggravate her existing conditions or to complete certain religious rituals. Each person has a different balance of the elements and a different body composition, so therefore, there is no standard treatment regimen given to every expecting mother. Each woman is given a different regimen according to her personal conditions and balance of the elements. In this way, Tibetan medicine does not have a
  • 5. Smulian 5 standardized system of prenatal care in the same way that the West does. Prenatal care exists solely of individualized diet plans and behavioral restrictions according to the mother’s personal health as assessed by a Tibetan doctor. There are several general things that the Tibetan medical texts list to avoid doing during pregnancy, and are what the medical texts describe as “the factors for the disintegration of the womb, fetal death, and the drying of the womb”. These include activities such as engaging in sexual activity, consuming spicy foods, overexerting the self, taking non-physician recommended medications, consuming food that acts as a constipating agent or laxative, losing too much blood via bloodletting treatments, and sleeping during the day. Other than these behavioral instructions, there is no standard prenatal diet or care (Gyamtso 2010). It is not in the Tibetan tradition to have a professional birth attendant present at the birth itself. Women typically give birth at home, either with the assistance of a female relative, the husband, or equally as often, alone (Craig 2009). Though this practice is changing in light of the sudden modernization that has been forced on Tibet in the past 50 years, solo birthing is still practiced by many Tibetan women. In Lhasa, the modernized capital of Tibet where many hospitals are available, it is estimated that 66% of women still deliver at home (Dickerson et al. 2010). Though there is no amchi present at the birth itself, the amchi will often prescribe herbal medications like Agar35 and Shije11 to be taken alternatively with warm black tea to help with labor. These medications are believed to shorten contractions, relax tensions, and control the descendent thursel-rlung (Arya 2010). The rlung energy is known as one of the three humors of the body that Tibetan medicine recognizes, and can be equated with wind. Specifically, the thursel-
  • 6. Smulian 6 rlung wind is located around the genitals, and is responsible for urination, defecation, menstruation, ejaculation, and uterine contractions. Tibetan medical beliefs state that this thursel-rlung can be disturbed by the fear and pain of labor, and this can lead to a malfunction of the rlung. If this occurs, Tibetan medicine considers this to be a cause of delayed labor, as the uterine contractions are controlled by this humor. The Agar35 and Shije11 are intended to aid in avoiding this malfunction and the complication of delayed labor. Amchis often prescribe Shije6 as well, an herbal medicine intended to clean the uterus and expel the placenta after the baby has been born (Arya 2010). The rationale for having women give birth alone is consistent with the traditional Tibetan beliefs. There are many cultural reasons surrounding the aversion to hospitals and presence of others at the birth. Expecting Tibetan mothers have a fear of hospitals because of the presence of strangers and spirits associated with death during the spiritually vulnerable time for the baby. It is believed that infants are much more susceptible to spirit attacks than adults are, and so the mother would seek to avoid any such place where the infant may be exposed to these evil spirits, like a hospital, where deaths occur daily. However, naturally, these hospitals would be where the trained professionals are (Adams et al. 2005). In addition to the fear of hospitals, delivering mothers often avoid having others present at the birth to prevent them from becoming contaminated with a polluting substance call the grib. The grib is associated with the blood of childbirth and other unclean things like feces, and is a potent spiritual toxin. Therefore, many families seek to isolate the mother during the birth to avoid spreading the grib to other people assisting with the birth. Sometimes there will be a woman with
  • 7. Smulian 7 birthing experience or the husband present to cut the cord, but these people must be ritually cleansed after the birth to remove the pang grib of childbirth (Daniel and Keyes 1983). The knife used to cut the cord is traditionally not washed beforehand, and is only cleansed afterwards ritually to remove the grib. In addition to not wanting to pollute others, it is believed that the grib can pollute and offend the protector spirits of a household. To avoid this, many mothers will deliver in an enclosed tent in the house, away from the hearth where the protector deities reside, or even outside in an animal pen or enclosure (Craig 2009). This lack of sanitation may lead to later infections and complications. These beliefs are all grounded in centuries of tradition, but because of the inherently isolated birthing conditions, if a traumatic complication occurs during a pregnancy, little can be done. There are several common pregnancy complications that often arise in the Tibetan population and that could lead to maternal or infant death. Both Tibetan medical texts (Craig 2009) and modern epidemiological research in Tibet suggest that some of the most common maternal and fetal complications include preeclampsia, hemorrhage, post- partum hemorrhage, fetal growth restriction, infection, and obstructed labor (Miller et al. 2007). These studies only are able to survey those women who do go to hospitals, and cannot account for those women who deliver at home. These pregnancy complications are not unique to Tibetan women, but the environmental conditions of Tibet are likely to exacerbate many of these complications, leading to the higher rates of maternal and infant death that Tibet experiences (Smulian 2010). Preeclampsia is recognized as a common disease across human populations. It is
  • 8. Smulian 8 considered to be a disease of the placenta that is associated with dangerously elevated blood pressure, swelling, headaches, and abdominal pain. There are many theories as to its cause, including poor nutrition, decreased oxygen supply to the placenta, cardiovascular changes, and genetic predisposition. Preeclampsia affects on average between 3 and 7% of all pregnancies worldwide, and is a leading cause of maternal and infant death. In Tibet, a large Lhasa-based study in 2007 of 1121 hospital deliveries showed that 19% of women were preeclamptic, which is much higher than the worldwide rate. The higher prevalence of preeclampsia in the Tibetan population is unusual and has several possible explanations. First, the high altitude of the Tibetan plateau results in less oxygen in the air, which means that the mother takes in less oxygen to be transferred across the placenta to the developing fetus. This chronic oxidative stress can lead to inflammation and may contribute to the development of preeclampsia (Smulian 2010). Second, the Tibetan population is often malnourished. Two key nutritional items that have been linked by Western research to the prevention of preeclampsia are calcium and vitamin D. Calcium is an essential ingredient in the maintenance of blood flow, in this case to the uterus. If a mother were calcium deficient, as many Tibetans are due to poor diet, this would lead to decreased blood flow to the uterus and therefore less oxygen being transmitted to the placenta and fetus (Preeclampsia Foundation 2010). Vitamin D deficiency has been shown to lead to a greatly increased rate of preeclampsia as well (Bodnar et al. 2007). Much of the Tibetan population is vitamin D deficient, either because of poor diet or minimal sun exposure due to the heavy traditional clothing. The nomadic population of Tibet was shown to have severe vitamin D deficiencies, and the
  • 9. Smulian 9 city population was shown to still have an insufficient intake of vitamin D, though better than the nomadic population (Norsang et al. 2009). The symptoms of preeclampsia can manifest quickly and without much warning, and can lead to the rapid deterioration of the health of both the mother and the fetus. The treatment for preeclamptic mothers is to induce immediate labor when the symptoms are recognized and proceed with delivery before the condition worsens (Smulian 2010). In Tibet, inducing labor is often not an option, and preeclampsia may go untreated. For those many women who remain at home and do not consult a pregnancy professional at all, there is no way to diagnose the disease and intervene early in the condition. Tibetan medicine addresses a disease of “swelling” during pregnancy, but the only treatment recommended is to massage the body and tie a cord around the woman’s waist to prevent more rlung, or wind, from entering the body and causing the swelling (Dorjee 2010). This Tibetan treatment does not identify the root cause of the actual illness as the placenta, and would not be able to affect the course of the disease. There is a high rate of maternal and infant death for those cases left undiagnosed and untreated. Hemorrhage is another universal pregnancy complication that is often present in Tibet and is a leading cause of maternal and infant death according to the Lhasa-based 2007 study. Hemorrhage is a severe loss of blood from the circulatory system, leading to debilitating medical difficulties (Smulian 2010). The two most significant types of pregnancy related hemorrhage are abruption and post partum hemorrhage. Abruption occurs when the placenta separates too early from the uterine wall during the pregnancy or during labor. It is considered an emergency, because it results in sudden bleeding and
  • 10. Smulian 10 endangers the life of the mother due to blood loss, and the life of the baby due to diminished nutrient supply and/or premature birth. There are varying degrees of severity of abruption, ranging from partial separation to total separation of the placenta (Mayo Clinic 2010). There are many risk factors for an abruption, including preeclampsia, physical trauma, smoking, and previous complications during pregnancy. If left untreated, the mother and the baby are at serious risk. In general, immediate delivery improves outcomes, which often is best performed by emergency Cesarean section (Smulian 2010). Post partum hemorrhage, on the other hand, occurs anywhere from immediately to 6 weeks after delivery, and results from the uterus’ inability to contract down again after delivery. Contraction of the uterus after delivery allows for the separation of the placenta and the constriction of blood vessels that previously supplied the womb. Without this contraction, the blood vessels will not be compressed and excessive bleeding occurs. Risk factors for post partum hemorrhage include prolonged labor, infection, incomplete delivery of the placenta, and trauma (Yiadom 2010). Many of the risk factors for these two types of hemorrhage are present in the Tibetan population. As mentioned before, preeclampsia is extremely prevalent in Tibet, and will predispose a woman to experiencing either type of hemorrhage. Trauma is also common, as women lead difficult lifestyles and often must walk for miles to work to earn money for their families throughout the pregnancy (Nurse-la 2010). This overexertion is cautioned against by Tibetan medicine, but women often have no choice and must work, leading to potentially traumatic accidents that put the pregnancy at risk from both types of hemorrhage (Gyamtso 2010).
  • 11. Smulian 11 Infection is a serious issue in the population, because the environment is not always sanitary, especially due to birthing conditions. Living conditions may be extremely poor, resulting in exposure to many infectious diseases and bacteria (Nurse-la 2010). All of these factors can lead to hemorrhage, infection, and subsequent maternal and infant death. Tibetan medicine does offer some treatments if bleeding does occur, such as applying melted butter to the bleeding area or applying and ingesting certain herbal remedies (Dorjee 2010). However, these are not intended to staunch severe bleeding, as Tibetan medicine is most often used to treat chronic illnesses and is less helpful in emergencies (Gyamtso 2010). If women do not deliver in a hospital, there is little that can be done alone in the case that a hemorrhage occurs. Tibetan babies frequently have a low birth weight and develop poorly. This often stems from a complication called fetal growth restriction (FGR). The Lhasa hospital study states that 24% of infants were born with a low birth weight and were small for their gestational age (Miller et al. 2007). This compares to the lower statistic of 9% in the United States (Centers for Disease Control and Prevention 2006). FGR most commonly occurs when the uteruo-placental unit is not able to supply the fetus with enough nutrients to thrive and develop properly. This inability of the nutrients to be passed through the placenta can occur because of preeclampsia, partial abruption of the placenta, or diminished oxygen delivery (Ross 2010). If the mothers are underweight and malnourished, nutrients may also not be transmitted properly. All of these factors greatly affect the Tibetan population as discussed previously. Infants that are affected by FGR are often able to survive, but the likelihood of survival is diminished in the Tibetan
  • 12. Smulian 12 population without proper care and post-natal nutrition (Smulian 2010). Finally, the Tibetan medical texts highlight the issue of obstructed labor. Tibetan women often experience this condition, in which the baby physically cannot fit through the mother’s pelvis. Tibetan women typically have small stature and subsequent small bone structure of the pelvis, and if the baby cannot fit through its mother’s pelvis, it cannot be delivered. There are many procedures that can be done surgically, like a Cesarean section or the dislocation of the infant’s clavicle, but without a hospital, these procedures cannot be performed safely. If this is the case, then the baby often dies in utero. This can lead to severe maternal complications such as infection, hemorrhage, pelvic organ damage, or even death (Smulian 2010). This is another emergency case in which Tibetan medicine cannot help, and further elevates the high maternal and infant mortality rates (Gyamtso 2010). Postnatal care is lacking as well. There are many rituals that Tibetan medicine describes that must be completed after birth, such as feeding the child a mixture of butter, honey, saffron water, and musk water to protect it from evil spirits. However, when it comes to the physical care of the infant, there is no standardized postnatal care routine to follow (Craig 2009). When it comes to breastfeeding, mothers are often malnourished, and cannot produce enough milk for the child. In this case, when the breast milk is no longer produced, the infant is introduced to an inappropriate diet too early in its development. In speaking with a Tibetan nurse, it was mentioned that she often sees 2- month-old babies being fed black tea, which is completely unsuitable for a newborn (Nurse-la 2010). Early weaning decreases the amount of protective maternal antibody
  • 13. Smulian 13 from breast milk that reaches the baby, as well as causing malnutrition. An inappropriate diet like this before the infant has reached 6 months of age can increase susceptibility to diarrheal disease, one of the leading causes of infant death (Donoghue 2010). It must also be taken into consideration that Tibet is a country that is being absorbed rapidly into the People’s Republic of China. After the invasion in 1959, Tibet rapidly modernized and many of the cities were updated to match the medical standards of China and the rest of the world. It has caused an interesting juxtaposition between Tibetan medicine and modern medicine. In Lhasa, though 66% of women do deliver at home, the rest go to a hospital where Western technologies are available. The Chinese post many numbers about mortality rates that may not be completely trusted. It is not clear whether the maternal and infant mortality rates have changed drastically since Tibet’s westernization, but it can be inferred that the presence of Western technologies and knowledge about emergency care have only helped the rates, and not hurt them. There is a large Tibetan community in exile in Dharamsala, in northern India. Medical practices have also changed there, by the nature of being refugees. Tibetans are still allowed to practice their native traditions when it comes to medicinal care during a pregnancy, but it is necessary for women to go to a hospital for the birth itself. Tibetans are still wary of hospitals, but by giving birth in a state-recognized facility, they can receive a birth certificate for the infant (Nurse-la 2010). This is key, as the Tibetans in exile are stateless, and being born in India is an opportunity to gain a birth certificate that could be useful to the newborn in the future in obtaining residence permits and Identity Certificates (UN Refugee Agency 2006). Therefore, the majority of Tibetan women in
  • 14. Smulian 14 the Dharamsala community do deliver now in a hospital setting due to the refugee circumstances. The Tibetan community does not resent the integration of the two systems in India in exile as long as their culture is respected and can remain as intact as possible (Nurse-la 2010). This has enabled Tibetan women to have access to newer methods of labor and delivery care, and this has lead to lower rates of maternal and infant death. In a very small sample of the greater population, the Delek Hospital in Dharamsala reported an infant mortality rate of only 7%, reduced from the 9-30% in Tibet (Delek Hospital 2010). This rate is still high in comparison to the United State’s .67%, but it is headed in the right direction. The merging of the Tibetan medical system and the western technologies has proven to work well for reducing mortality. In summary, there are many factors contributing to Tibet’s high maternal and infant mortality rates. The fact that mothers deliver at home alone may account for a large portion of the maternal and infant deaths that occur. Combined with the realities of poor nutrition and a stressful environment where overexertion is common, complications are likely to occur during a Tibetan woman’s pregnancy. Without a properly trained professional present at the birth, there is no way to assist the mother or the infant properly if such a complication occurs. Prenatal care and postnatal care are deficient, and this frequently leads to malnourishment. Tibetan medicine can be used throughout the pregnancy, but if an emergency occurs, there is little that Tibetan medicine can do. However, as Tibet modernizes, there is hope for the future reduction of the high rates of death. With the integration of the ancient Tibetan traditions and modern practices, the lives of many Tibetan mothers and babies will be saved, and many of the Tibetan medical
  • 15. Smulian 15 traditions concerning pregnancy will live on. Works Cited Adams, V et al. "Having a "Safe Delivery": Conflicting Views from Tibet. Health
  • 16. Smulian 16 Care Women International 26. 9 (2005), [825-851], http://www.ncbi.nlm.nih.gov/ pubmed/16214796. (accessed July 5, 2010). Arya, Dr. Pasang Y. "Teachings on Tibetan Medicine: Tibetan Embryology." 2010. http://www.tibetanmedicine-edu.org/index.php/n-articles/tibetan-embryology-1. (accessed 5 July 2010). Bodnar, Lisa M. et al. "Maternal Vitamin D Deficiency Increases the Risk of Preeclampsia”. Journal of Clinical Endocrinology and Metabolism. 92. 9 (2007), 3517-3522. http://jcem.endojournals.org/cgi/content/full/92/9/3517. (accessed July 5, 2010). Centers for Disease Control and Prevention. "Birthweight and Gestation (US)." 2006. http://www.cdc.gov/nchs/fastats/birthwt.htm (accessed 5 July 2010). Craig, Sienna R. “Pregnancy and Childbirth in Tibet: Knowledge, Perspectives, and Practices”. In Childbirth Across Cultures: Ideas and Practices of Pregnancy, Childbirth and the Postpartum, ed. Helaine Selin. 145-160. Springer Science+Business Media, 2009. Daniel, E. Valentine and Charles F. Keyes. Karma: An Anthropological Inquiry. London: University of California Press, Ltd., 1983. Delek Hospital staff. Interview by Jazmin Raadsen. Written notes. Dharamsala, India. 17 June 2010. Dickerson, Ty et al. "Pregnancy and Village Outreach Tibet: A Descriptive Report of a Community and Home-Based Maternal-Newborn Outreach Program in Rural Tibet. Journal of Perinatal and Neonatal Nursing. 24. 2 (2010), [113- 127], http://www.nursingcenter.com/prodev/ce_article.asp?tid=1018781#P20%2
  • 17. Smulian 17 0P20. (accessed July 5, 2010). Donoghue, Dr. Elaine. Interview by author. Written notes. Allentown, PA. 2 July 2010. Dorjee, Dr. Pema. Interview by author. Written notes. Sarah College, Dharamsala, India. 17 June 2010. Gyamtso, Dr. Khenrab. Interview by author. Written notes and copy of Powerpoint slides. Sarah College, Dharamsala, India. 10 June 2010. Khangkar, Lobsang Dolma. Lectures on Tibetan Medicine. 4th ed. K. Dhondup. Dharamsala: Library of Tibetan Works and Archives, 1986. Mayo Clinic. "Placental Abruption." 5 Dec 2009. http://www.mayoclinic.com/health/placental-abruption/DS00623 (accessed 5 July 2010). Miller, S et al. "Maternal and neonatal outcomes of hospital vaginal deliveries in Tibet”. International Journal of Gynecology and Obstetrics. 98. 3 (2007). http://www.ncbi.nlm.nih.gov/pubmed/17481630. (accessed July 5, 2010). Norsang, G et al. "The Vitamin D Status among Tibetans”. Photochemical Photobiology. 85. 4 (2009), 1028-1031. http://www.ncbi.nlm.nih.gov/pubmed/19508646. (accessed July 5, 2010). Nurse-la. Interview by author. Written notes and tape recording. Sarah College, Dharamsala, India. 13 June 2010. Preeclampsia Foundation. "Preeclampsia FAQ." 2010. www.preeclampsia.org/faq.asp (accessed 5 July 2010). Ross, Dr. Michael. "Fetal Growth Restriction." Feb 25, 2010. http://emedicine.medscape.com/article/261226-overview (accessed 5 July 2010).
  • 18. Smulian 18 Smulian, Dr. John. Interview by author. Written notes and copy of Powerpoint slides. Allentown, PA. 2 July 2010. Geshe Tobgyal la. Interview by author. Written notes. Sarah College, Dharamsala, India. 4 June 2010. UN Refugee Agency and The Immigration and Refugee Board of Canada. India/China: Whether a Tibetan whose birth in India between 1950 and 1987 was not registered with the authorities would be recognized as a citizen; whether the Indian government accepts birth certificates issued by the Tibetan government-in- exile; whether the Indian government issues birth certificates to Tibetans born in India. 6 February 2006. http://www.unhcr.org/refworld/docid/45f147d1a.html [accessed 2 July 2010]. World Bank, World Development Indicators, "Mortality rate, infant (per 1,000 live births)." 15 June, 2010. http://data.worldbank.org/indicator/SP.DYN.IMRT.IN?cid=GPD_55. (accessed 5 July 2010). Yiadom, Dr. Maame. "Pregnancy; Postpartum Hemorrhage." Apr 20, 2010. http://emedicine.medscape.com/article/796785-overview (accessed 5 July 2010).