Every morning, as the mist lifts over the emerald hills of Assam, thousands of women bend over tea bushes, their fingers moving in a blur to pluck the "two leaves and a bud." They produce more than half of India’s tea, a beverage savored in drawing rooms across the globe. Yet, in the cramped, damp labor lines where these women return at dusk, a quiet tragedy continues to unfold.
For decades, Assam has recorded some of the highest maternal mortality ratios (MMR) in the country, as documented in the special bulletins of the Sample Registration System (SRS). While the state’s overall numbers have improved over the last twenty years, this progress has not trickled down to the tea estates. Here, among the Adivasi communities—descendants of workers brought from central and eastern India in the 19th century to clear land and pluck leaf—mothers are still dying from entirely preventable causes.
When a woman from the labor lines dies in pregnancy or childbirth, the death certificate will list a medical cause. But the true culprits are rarely just medical. They are social, economic, and systemic.
The Silent Killer Beneath the Surface
The immediate medical causes of these deaths are familiar to obstetricians worldwide: postpartum hemorrhage, high blood pressure disorders like pre-eclampsia, infections, and obstructed labor. The World Health Organization notes that most of these are highly preventable.
But in the tea gardens, these acute crises are built upon a chronic foundation: severe anemia.
The National Family Health Survey (NFHS-5) found that around two-thirds of women aged 15 to 49 in Assam are anemic, with the numbers even higher among pregnant women. Studies from tea-growing districts reveal the problem is acutely worse among garden workers. Their diets are notoriously low in iron and protein. Worm infestations and malaria compound the blood loss, and the grueling physical work of plucking continues late into pregnancy.
Simply put, an anemic woman has no physiological reserve. The blood loss that a healthy mother’s body would easily survive can be fatal to hers.
This physical vulnerability is compounded by early and closely spaced pregnancies. NFHS-5 shows that child marriage before 18 and teenage childbearing are more common in Assam than the national average. A girl who conceives at 16 or 17, already thin and anemic, and then has a second child within two years, enters each labor weaker than the last.
The Gauntlet of the "Three Delays"
In public health, maternal deaths are analyzed through the "Three Delays" model. In the tea gardens, these delays are not just bureaucratic hurdles; they are a physical gauntlet that can claim a life in a single night.
The first delay begins at home. Danger signs—swelling, severe headaches, fits, or bleeding—may not be recognized as emergencies by the family. Furthermore, a day away from the bushes is a day without wages for the woman, or for the family member who must accompany her. The decision to seek care often rests with a husband or mother-in-law, and the hesitation costs precious time.
The second delay is one of distance. Many estates are located far from a hospital equipped to perform a caesarean section or administer a blood transfusion. The roads inside and around the gardens are poor, turning into impassable slush during the monsoon. An ambulance called in the middle of the night may take hours to navigate the terrain.
The third delay is the hardest to accept, as it happens inside the healthcare system itself. A woman may finally reach a facility, only to find no obstetrician, no anesthetist, or no blood on the shelves. She is referred onward, sometimes more than once, losing time she simply does not have.
Patches on a Torn Fabric
It would be unfair to say Assam is standing still. The proportion of women delivering in hospitals and health centers has risen sharply since the inception of the National Health Mission (NHM). ASHAs (Accredited Social Health Activists), including those specifically appointed for tea-garden areas, are the unsung heroes of this shift. They register pregnancies early, accompany women to check-ups, and are often the first to notice when something is wrong. Free ambulance services and free delivery care under central schemes have removed some of the financial barriers that kept families at home.
The state has also targeted the gardens directly. Mobile medical units visit the estates, and some garden hospitals have been upgraded through partnerships with the health mission. A wage compensation scheme for pregnant women in tea gardens pays them to rest and eat better before and after delivery, conditional on attending check-ups and delivering in a facility. Anemia testing and iron-folic acid supplements are now part of routine antenatal care.
These interventions are lifelines. But they are not reaching everyone equally.
Beyond the Clinic: What Must Change
To truly protect these women, we must look beyond the delivery room.
First, the Plantations Labour Act of 1951 mandates that estates provide medical facilities for workers and their families. On the ground, compliance varies wildly. Some garden hospitals boast doctors, nurses, and functioning labor rooms; others are little more than empty buildings. The government and the tea industry must agree, estate by estate, on clear responsibilities. Inspections must be regular, and their findings made public.
Second, blood must be closer to the bushes. Establishing and maintaining fully staffed, well-stocked blood storage units at first-referral hospitals in the tea districts would save more lives than almost any other single intervention.
Third, we must treat the girl before she becomes a mother. Anemia must be found and treated long before labor begins, starting in adolescence. Handing out iron tablets is useless if no one checks whether they are being taken, or if the patient isn't tested again. Furthermore, girls need to stay in school and marry later. Couples need reliable access to contraception so that pregnancies can be safely spaced.
Fourth, every maternal death must be reviewed honestly. These audits should be conducted to find out where the system failed, not to assign blame to the family or the ASHA.
Finally, we must mandate respectful care. A woman who is shouted at, ignored, or made to wait on the floor will not return, and she will tell her neighbors not to go either. Care delivered in a language the woman understands, by staff who treat her with basic human dignity, is not a luxury. It is a medical necessity.
A Legacy Worth Saving
For over 150 years, the women of Assam’s tea gardens have carried a massive industry on their backs. That they still face a significantly higher risk of dying in childbirth than most Indian women is a profound failure of policy and attention. But it is a failure that can be corrected. It is time the system that relies on their labor ensures their survival.
---
Dr. Bhimi Daimari, MBBS, MS (Obstetrics and Gynaecology), is an obstetrician-gynaecologist from Assam. Click here about the author
Comments