Pregnant women are risking their lives to bring people tea

Assam, India — Rama is scared. She's six months pregnant and increasingly worried about the health of her unborn child.

The 22-year-old casual laborer earns her living by picking tea leaves in India's north-eastern Assam state.

She does not take a break from the hard labor even if she is in pain.

"Sometimes I feel good, sometimes not so good," she said. "I am new to this, so, I don't know what to expect."

Meanwhile, local health and social workers continue to raise significant concerns about the welfare of workers in Assam's tea gardens and a recent report by the World Bank's independent watchdog, Compliance Advisor Ombudsman (CAO), agreed.

To investigate the issues raised, CNN visited two un-certified gardens in Assam where workers, like Rama, shared experiences of poor access to health care and inadequate working conditions, particularly during pregnancy. Smaller plantations like these two form almost 50% of the Assam market.

A spokesperson from Hindustan Unilever said the company purchased "a small amount of tea" for its domestic market in India last year from these two plantations, while Tata Global Beverages said it did not source tea from these particular plantations.

One owner of a plantation visited by CNN, speaking via the telephone, refused to comment on the specific health issues facing his laborers, but said his estate provides ambulances, medical vans and transport to hospitals for women when needed.

"The medical issues (like excessive bleeding) that happen are problems which are not in our hands but whatever we can do, we do," he said.

The Indian Tea Association, meanwhile, told CNN that "workers are eligible for primary health care as per the Plantation Labour Act," with free medication provided to a worker and their family and maternity care provided to cover anemia treatment, immunization, institutional deliveries and mother and child care projects.

Human rights lawyer, Jayshree Satpute, who works with local plantation workers, disputes the claims that the medical facilities are available to most female workers. "If you look at the infrastructure on the ground, it is not enough," she said. "There are not enough doctors, the hospitals do not have enough facilities, not enough beds, the primary health centers do not have enough infrastructure, there are not enough doctors, there is not enough staff."

Rama says she has personal experience of the weak infrastructure, saying that while her plantation has one ambulance, it takes a long time to arrive and is not provided easily.

"It is always busy shifting patients to the hospital," she said. "Sometimes it even goes out of the town."

Lawyer Satpute said she has seen many of women in the later stages of pregnancy working on the plantation, with several having delivered their babies there. "Mostly these tea plantation workers are highly anemic and have not been able to access the health facilities or have (not) been able to register themselves."

Knowing her condition, this is what Rama fears -- that she won't have medical care for her child and herself.

With baskets strapped to their heads, throngs of women set out each day moving from one patch to another -- circling the same plantation -- typically taking a break just once a day, even when heavily pregnant like Rama.

Rama earns about Rs 1000, or $14, a week and is expected to gather around 24 kilograms of leaves each day. If she and others like her don't meet these targets, their daily wage is cut, she and other workers told CNN. At the end of each day, they drag their bags of leaves to be weighed, recorded and collected by plantation managers.

Workers are split into two groups: temporary and permanent, with the majority of the 1.5 million tea plantation workers in the region being temporary, according to Satpute. More than 70% of the workforce are women, she added.

Eligibility for maternity benefits do not discriminate against temporary workers, the Indian Tea Association told CNN. And according to the country's maternity benefits act, a woman is eligible for paid leave if she has worked for more than 80 days in the last one year, before going into labor.

But not all workers appear to be aware of these laws.

Rama, for example, says she was under the impression that only permanent workers are entitled to health benefits such as maternity leave. It's a common misconception, says Satpute.

Casual laborers often work throughout their pregnancy and rarely attend hospital appointments because they cannot afford to give up even a day's wages.

"It is difficult, but work is work, I have to do it," said Rama, adding that taking breaks is frowned upon and often results in a scolding from her supervisor.

She explained how she walks slowly to work these days, but with caution. "When they see us resting, they ask, 'who will pay for your wages?'"

Rama admits she is largely unaware of the health care needed to keep her baby healthy.

And officials believe that local habits add to this unawareness to make situations worse.

"Some of these populations have salt in tea, where the normal population uses sugar, they have a high salt consumption," said J.V.N Subramanyam, Director of the National Health Mission in Assam. "There is high amount of alcoholism and low availability of nutritious food at the labor lines," he said, pointing to the prevalence of anemia.

Women are often in need of supplements and blood transfusions, but are just too far away to get it, or to be informed.

"No one has told me what to do," says Rama. "What can we do?"

In theory, a lot.

An array of initiatives by the Indian government are meant to be making pregnancy safer for India's poor.

Since 2005, the government has been providing free pre-natal care, blood tests and cash payments for each baby that is delivered in a government hospital, registered with the state and given their first cycle of shots.

It has also launched nutrition-based programs where pregnant mothers are entitled to free meals at local community centers. Each state government then typically adds more benefits.

But due to a lack of awareness, rampant illiteracy and inaccessibility, women in the tea plantations aren't aware of these options, say social workers, leaving many with fatal outcomes.

A number of factors contribute to the problem: excessive bleeding during labor, the expense of medical fees at city hospitals or because they're unaware that their pregnancy might be high risk. They reach hospitals too late, or not at all, and any facilities they make it to have minimal equipment and expertise, said local social workers.

The tea plantations in Assam are a legacy bequeathed to India by the colonial-era government where local tribes were employed, or in some cases got into indentured servitude, in the gathering of tea leaves. Entire generations have resided in the plantations, passing on the legacy of servitude and human rights violations on over time.

The men and women working today, see the same future for their children.

The plantations work under the 1951 Plantations Labour Act -- written to encompass practically all plantation workers in the country and to ensure their rights -- which set a standard wage that experts like Satpute say haven't kept pace with broader labor market rates.

The average wage for an unskilled laborer in agriculture in India is Rs 320 or about $4.50 per day. An individual working in Assam's tea plantations earns about half that, at Rs 167 or $2.27 per day, local plantation workers told CNN.

Satpute says that some plantation owners even restrict the movement of their workers -- a claim that's denied by local authorities.

"They are free to go everywhere," said Manoj Kumar Deka, Deputy Commissioner of the Sonitpur District in Assam. "They go to the markets, they go to the haats (local festivals). They enjoy. There is no issue."

"The government is aware that this is a major human rights (issue)," said Subramanyam from the National Health Mission, referring to problems that workers have in accessing healthcare.

There are 35 tea plantations in the district of Sonitpur alone and more than 800 in Assam, all in need of sustained effort to their health facilities, he says.

There has been some progress. Over the last five to six years there has been a sustained effort by the state government to improve healthcare access, explained Deputy Commissioner Deka.

The state government has deployed new ambulances, more dispensaries and even mobile medical units -- small vans equipped with emergency medical care -- as well as doctors and nurses, he said.

But resources remain inadequate, one medical dispensary supervisor, who declined to be identified, told CNN.

Local social workers described how some of the existing dispensaries are dilapidated sheds served by a visiting doctor who comes a couple of times a week to work for just two hours. The result: a woman arriving at the dispensary will be seen by the nurse and a non-medical supervisor, while the doctor is called in, according to the supervisor.

"If something (medical facilities) is provided within the tea garden things might become more convenient and the conditions might improve a lot," one social worker told CNN.

Plantation hospitals should have a doctor, a nurse, a midwife and a pharmacist there every day but they only come once a week, according to Satpute, who in addition to her legal work co-founded Nazdeek, an NGO working in Assam and across India to promote the welfare of tea garden workers.

Labor rooms often have rusty gurneys on which women are expected to deliver. With a few shelves filled with medicines and no equipment like an oxygen tank or an ultrasound machine present, the women depend on the skills that the doctors possess, which often isn't enough, one social worker said.

It's common for the women to need blood transfusions, and, according to a national entitlement initiative, pregnant women are entitled to free blood during delivery. But the practice is hard to implement due to the shortage of blood banks in the gardens of Assam, according to Subramanyam, who is in-charge of all government-funded medical schemes in the state.

A healthy level of hemoglobin is 12 grams per deciliter of blood, but many of the pregnant women who come to the hospitals in Assam have just one third of that, with just 3-4 grams per deciliter, said Dr Reena Dutta Ahmed, former associate professor at the Assam Medical College (AMC). "Somehow, they are still walking around"

Of the women who die of childbirth in Assam, most die due to anemia and hypertension, added Ahmed.

Rama fears a similar fate for herself, having heard of a few women who died during their delivery.

She's sought help. To increase her strength, she says she's tried asking local medical workers for more food -- something that she says can't afford on her own. The response? Go buy your own food.

And she also worries about getting the medical supplies she will need. "When we need blood etc. it should be provided," she said.

"We receive no help."