Notes from the Field | Gayatri Misra and Vaishali Saikia, Unveiling the Crisis: The State of Maternal Health among Assam’s Tea Tribal Women
In 2018, an expert committee on Tribal Health, constituted jointly by the Ministry of Health and Family Welfare and the Ministry of Tribal Affairs, released the first comprehensive report on the health status of tribal populations in India. A landmark report and a first of its kind, it elucidated the health challenges faced by Indian tribal communities and offered strategic recommendations to address these issues. While the implementation of these recommendations remains in question, the tea plantation workers in Assam are far removed from this reality. Their precarious tribal status means that the improvements suggested in the report are still a distant dream for them.
Constituting around 18% of the total population of Assam and forming the cornerstone of one of the largest organized industries in the country, the tea plantation workers of Assam continue to be marginalized and overlooked. The most conspicuous manifestations of this marginalization have been reflected in the perilous health status of the tea plantation workers, especially the dire state of maternal health. According to a report by the Registrar General of India ‘Special Bulletin on Maternal Mortality’ 2018-20, Assam has reported 195 deaths per lakh live births making it the state with the highest MMR in the country. The causes of maternal mortality in Assam are manifold ranging from biomedical factors to socio-cultural. While Biomedical causes and health determinants accompany this social evil, there also exists an alarming discrepancy concerning the extent to which various stakeholders deal with these contributing factors.
Assam belongs to the Empowered Action Group (EAG), which primarily includes the states where key indices of maternal and child health are extremely poor and lag behind the national and internal demographic needs. The absence of a comprehensive database for these individuals, coupled with generational servitude, complicates the identification and resolution of gaps and the implementation of policies to enhance their well-being. This challenge is amplified by limited disaggregated data, compounded by low literacy rates and a lack of awareness regarding their rights violations. Tea tribe communities are scattered throughout Assam, with a predominant presence in districts such as Darrang, Sonitpur, Nagaon, Jorhat, Golaghat, Dibrugarh, Cachar, Hailakandi, Karimganj, and Tinsukia. Upon closer examination, it becomes apparent that the districts, which bear a significant burden of maternal deaths, coincide with areas where tea tribe communities are concentrated. While various socioeconomic and cultural factors contribute to this sad state of affairs, the one often not accounted for is the complex intersection of maternal deaths and crimes against children which underscores the critical need for integrated approaches to gender-based violence and improved health outcomes.
An important indicator of the rising maternal deaths among women aged 15-19 in Assam is the declining sex ratio in this age group. The current overall sex ratio in the state is 1012 females per 1000 males (NFHS 5). However, a concerning trend emerges when comparing sex ratios across different age groups, particularly from 0-18 years. The sex ratio shows a significant decline, reaching its lowest point at 860 females per 1000 males at 17 years of age. The analysis of the National Family Health Survey 4(2015-16) and 5 (2019-20) highlights a concerning trend of high incidences of early marriage and teenage pregnancy among the women in the region, that may account for this declining sex ratio. According to the data, the median age at first marriage among women aged 20-49 years is 18 years. Furthermore, almost one-third (32%) of women aged 20-24 years got married before reaching the legal minimum age of 18 years, a rate that has remained largely unchanged since NFHS 4 (31%). Early marriage and teenage pregnancy heighten the risk of maternal health complications due to limited access to prenatal care, skilled birth attendants, and emergency obstetric services. However, these circumstances among the tea tribes are compounded by restricted educational and economic prospects for women, exacerbating their vulnerability to maternal health risks.
As evidence concurs, out-of-school children are a major concern in Assam, more pronounced among the tea tribes, with the last Census data revealing that 27% of the state's 12.7 million child population, approximately 3.4 million children, were not attending school. While issues such as accessibility, infrastructure bottlenecks, and poor transportation are commonly cited as reasons for this, data indicates a deeper connection with the incidence of child marriage. Child marriage, which often leads to adolescent pregnancy, is a significant contributor to maternal deaths in these regions. The correlation between out-of-school children, child marriage, and maternal deaths is particularly evident in Assam's high-burden districts: Nagaon, Dhubri, Barpeta, Sonitpur, Cachar, Kamrup, and Karimganj. These districts face overlapping challenges, where a lack of education correlates with higher incidences of child marriage and subsequent maternal health issues. According to NFHS 5 (2019-20), the proportion of women aged 15-19 years who have begun childbearing is significantly higher among those with no schooling compared to those with 10 or more years of education. In districts like Karbi Anglong, Dima Hasao, Sivasagar, Tinsukia, and Barpeta, an increase in women with 10 or more years of schooling has been observed. Notably, only Barpeta has recorded an increase in maternal deaths, suggesting that while education is a crucial factor, there are other underlying causes needing further investigation.
As we discovered from our pilot study conducted in the tea estates in Kamrup district and Darrang district of Assam, it is a long-standing tradition for women to have as many children as possible, as this practice is believed to secure a future source of income. Once they reach a certain age, the children of tea workers are typically guaranteed positions in the plantations. However, this expectation places an immense physical burden on the women, who are pressured to bear children from a young age continuously. This results in high rates of maternal mortality, stillbirths, and miscarriages due to the strenuous workload. The situation is particularly dire for the "ex-tea tribes" living in the labor lines. These groups are among the most vulnerable in the tea gardens, receiving minimal attention or support from management. Policy recommendations and welfare initiatives rarely reach their intended impact in these communities, leaving the ex-tea tribes especially neglected. The government of Assam has signed a series of MOUs with tea plantations to address the dire state of maternal and infant health among the tea tribal women in the gardens. Under these MOUs, tea gardens receive public funds to implement specific maternal and infant health services. However, these initiatives often fall short of their goals. The MOUs require the establishment of an NRHM committee to oversee budget allocation and the implementation of health services. Unfortunately, these committees are frequently controlled by tea garden management, who are not held accountable for budget expenditures. The lack of transparency, coupled with the misappropriation of funds and the absence of an effective grievance redressal mechanism, perpetuates a cycle of inadequate maternal health care and persistent violence against the tea tribal women. This mismanagement severely undermines efforts to improve maternal health, leaving tea tribal women in Assam vulnerable and without the necessary support during and after pregnancy.
The health challenges faced by tea tribal women in Assam's plantations are deeply rooted in systemic marginalization, lack of accountability, and socio-economic vulnerabilities. In a conflict-ridden state like Assam where ethnic violence is a recurrent incidence, lack of access to social, cultural and economic resources tends to have a disproportionate impact on women. As primary caregivers, such marginalization also often leads to a loss of autonomy and decision-making power, with women often becoming victims of intimate partner violence. Governmental initiatives, despite their intentions, often fall short due to the entrenched control of tea garden management over health committees, lack of transparency in fund allocation, and the absence of effective grievance redressal mechanisms. This mismanagement perpetuates inadequate maternal health care and ongoing violence against Tea Tribal women. The alarming correlation between crimes against children, and maternal deaths highlights the urgent need to improve educational access and quality. While education alone cannot resolve all issues, it is a vital part of a comprehensive strategy to uplift these communities. Enhanced educational opportunities can help break the cycle of early marriage and teenage pregnancies, which are significant contributors to maternal health complications. More importantly, there is a dire need for various departments and policymakers to work in tandem to address these challenges rather than working in silos. Coordinated efforts can ensure that the tea tribal women receive the comprehensive support they need, from healthcare improvements to educational and economic opportunities, ultimately leading to better health outcomes and reduced maternal mortality.
Gayatri Misra currently works as a Program Associate at The Udaiti Foundation. She holds a Master's degree in Sociology from the Delhi School of Economics and has previously worked at the intersections of public health, education, correctional reform, child rights, gender and development. She can be reached at gayatri.gits@gmail.com.
Vaishali Saikia is a doctoral student in the Department of Sociology at Pondicherry University. She holds a Master's degree in Sociology from Delhi School of Economics and her focus areas of research are gender and development, public health, and tribal politics in Assam. She can be reached at vaishalisaikia1@gmail.com.
To cite this essay, please use the entry suggested below:
Gayatri Misra and Vaishali Saikia, “Unveiling the Crisis: The State of Maternal Health among Assam’s Tea Tribal Women,” criticalasianstudies.org Commentary Board, June 18, 2024. https://doi.org/10.52698/BDEW1444.