Assam, India - Malnourished, Angela Dungdin sits uncomfortably on a hospital bed she shares with two other pregnant women. 

Mould covers the walls of the overcrowded maternity ward at Assam Medical College (AMC) in northeast India.

The bed sheets are filthy and the floors are covered with dirt and blood. Relatives sit on the floor in the hallway.

Member of the Adivasi tea tribes, 28-year-old Dungdin is seven months pregnant with her first child. She was brought to the hospital one week ago after experiencing a placental abruption, which resulted in the placental lining separating from her uterus.

The complication is a major cause of maternal mortality worldwide, and given the circumstances, Dungdin is one of the lucky ones.

She was able to make it to hospital early enough for successful intervention to stop the internal bleeding.

"I'll be discharged soon and then I'll have to go back to the tea gardens to work. I was working until the minute I came here, and I'll have to work until the minute I give birth," she says.

Assam is the largest tea growing region in the world, yet it accounts for the largest number of maternal deaths in India [Reuters]

Dungdin works at one of Assam's 800 large tea estates and earns roughly $19 for 10 days of work.

"Missing my wages for the last week is the biggest problem for me. I have no option but to work through this."

On the bed opposite hers lies another underweight tea garden worker, 20-year-old Anjali Karranter, who was 31 weeks pregnant when she arrived at hospital a few days ago.

"I wasn't feeling my baby move, and I just found out the baby died in my uterus, so it will have to be removed," she says with a blank expression.

An ideal picture 

Though India has been reporting a steady decline in its maternal mortality rate (MMR), the country still accounts for the largest number of maternal deaths in the world.

According to the Millennium Development Goals (MDGs), India's target is to reduce its MMR by three-quarters, from 437 maternal deaths for every 100,000 live births in 1990, to 109 by the end of 2015. 

However, experts don't believe it will reach its target with the current number standing at 190, according to the latest figures from the World Health Organization (WHO). 

Assam produces 51 percent of India's tea and is the largest tea-growing region in the world, yet it accounts for the largest number of maternal deaths in India. Of the approximately 400 deaths for every 100,000 live births, 77 percent are in the tea gardens. 

The health of tea garden workers has long been a controversial issue; local tea garden managers and international corporations, such as Tata Global Beverages, which controls more than 50 tea gardens, have faced criticism for exploitation and poor working and living conditions for their workers. 

The main motivator for the manager is earning, not the welfare of [the] employees. The industry is not doing the thing it should be doing, rather it's exploiting the people.

Dr Tukila Mahanta, associate professor at AMC

"Any tea manager pretends conditions in the gardens are like Switzerland," says Dr Tulika Mahanta, referring to the more idealised picture displayed on advertisements. 

Mahanta, an associate professor of community medicine at AMC, has been working on maternal health for the past two decades and is one of a few who speak openly about the situation in the tea gardens.

While the sweeping lush green tea gardens of Assam are renowned for their beauty, the living conditions are a far cry from the pretty visuals gracing tea boxes. The workers often live far away from the tea gardens in isolated but crowded and unsanitary conditions. The houses, made of bamboo and plastered with mud, are vulnerable to monsoon rains.

As a result of cramped living conditions with large families living on top of one another in small spaces and poor sanitation, tea gardens have long been subjected to outbreaks of infectious diseases, such as tuberculosis, as well as other illnesses, such as diarrhoea.

Many tea gardens lack access to basic services such as schools, healthcare, safe drinking water, food ration shops, latrines and proper drainage. The cycle of poverty has created illiteracy, underage employment and poor health conditions.

"The main motivator for the manager is earning, not the welfare of [his] employees. The industry is not doing the thing it should be doing, rather, it's exploiting the people," Mahanta says. 

"The living conditions are not good - these people have been isolated and held captive for so many years."

A community uprooted

The British brought the Adivasi communities, also referred to as the tea tribes, from neighbouring states of Bihar and Odisha more than a century ago. Many of the workers were forcibly uprooted from their land and brought to the tea plantations in Assam and West Bengal. 

While there are no exact figures on the number of tea workers on the plantations, the tea tribe community is estimated to number about 6 million - 20 percent of Assam's population, according to the latest census. 

The Adivasi community stands as one of the most oppressed communities in Assam because of the unremitting exploitation they have faced by tea management and the subsequent neglect by the government. 

Generation after generation, the Adivasi people have been forced to work in the tea gardens with little opportunity for outside employment. The tea in every box of Assam tea sold internationally by tea giants, such as Lipton and Tetley, is picked by tea garden workers who work long hours in the heat for about $2 a day. 

The community, despite being Indian, also have no documents to prove their nationality, further keeping them under the strict control of tea garden owners.

The tea in every box of Assam tea sold internationally by tea giants is picked by tea garden workers who work long hours in the heat [AFP/Getty]

Unaddressed problems

Diets high in salt and low in iron as a result of poverty and poor nutritional education contribute to two of the leading causes of maternal death among the tea tribes: anaemia and hypertension-related complications.

Meanwhile, complications arising from traditional homebirths, which amount to about 40 percent of deliveries in Assam, combined with a lack of trained birthing attendants, increase the danger for both mother and child.

While some medical interventions have been implemented, such as setting up affordable health food stores in the gardens that sell leafy vegetables, eggs, and even iron and folic acid tablets, these stores haven't reached all the gardens and haven't addressed the root cause of the maternal health problems.

"Even if you give iron tablets, you need protein so it's not being absorbed. Another problem is that everyone is consuming tobacco, locally made alcohol, and salt. This leads to pre-eclampsia," Mahanta says.

Pre-eclampsia, which is one of the three leading causes of maternal morbidity and mortality worldwide, occurs when a pregnant woman develops high blood pressure, among other issues, during her pregnancy. If left untreated, it can result in seizures, and in areas of the world like rural Assam, with little access to quality healthcare, these complications are deadly.

While every tea garden must have a hospital on-site, they are often ill-equipped, face drug and staff shortages, and lack quality antenatal care.

Meanwhile, for women to get to AMC, the largest hospital in Dibrugarh, the state's administrative district is a costly trek and can involve hours of travel on poor roads.

Shortage of physicians

"Assam has a shortage of 31,000 doctor," Mahanta says. She is advocating for government policies to address the doctor shortages in the state and for newly trained doctors to spend time in the tea gardens.

"We need government policy decisions. We need to train doctors to go into the tea gardens," she said.

Every day I work in the tea gardens and I'll work until my baby is delivered.

Sumanti Kisko, tea garden worker

"We are promoting hospital deliveries to reduce maternal deaths, but this hospital is not efficient enough. I can't say we're giving good services. It's just not true. We're completely overburdened."

"The sad reality is that these deaths are preventable."

At Tingkong tea estate, a few hours out of Dibrugarh, 30-year-old Sumanti Kisko is about to make the 5km walk home after spending seven hours plucking tea leaves.

She's five months pregnant and hopes to be able to give birth in hospital after losing her second child in a botched homebirth six years ago.

"Every day I work in the tea gardens, and I'll work until my baby is delivered," she says. The manger is nearby, 
so she's hesitant to say much more about her dismal living conditions and pay.

There are some that insist that the claims of poor nutrition and high rates of maternal death are exaggerated. 

Chandan Bora, manager of Tingkong tea estate, says the majority of women in the garden aren't anaemic and that their hospital is well-equipped and staffed.

"I don't just sit here," Bora says. "I supervise health, hygiene and the tea plantation. Workers receive housing, food and medical benefits."

However, a recent study by UNICEF and AMC found that out of the 14 meals consumed in a week by a tea tribe family, only two are nutritional.

Dr C R Hira, who now works at the Centre for North East Studies and Policy Research (C-NES) in Guwahati, Assam's largest city, worked in the tea gardens for a decade trying to improve maternal healthcare.

"I couldn't change the scenario," he says. "I'm really worried. Tea community health is a big problem for Assam. Maternal mortality rates are really bad. We need a new approach to address this problem."

Dr B C Bora worked as a doctor in the tea gardens for nine years and echoes Hira's thoughts.

"The tea gardens have hospitals, but there [are] no doctors. If you increase education, then people will demand more, but it's in the management's best interests to not improve education levels."

For Dungdin, at least, despite the poor living conditions and pay she will return to, she is grateful her baby is safe and she can be discharged soon.

Follow Sophie Cousins on Twitter: @SophCousins

Source: Al Jazeera