A baby girl born in the rural areas of Assam has lesser chances of survival in comparison to its male counterpart before reaching the age of five. Prabir Kumar Talukdar finds out why Assam has amongst the worst IMR and MMR.
Suman Mirdha is a 19 year old tea garden worker in Muttak Guttibari area of Dibrugarh District. Like any other day, Suman was cleaning her thatched house when suddenly she felt a pain in her stomach. Immediately, she went to the pharmacist and was administered a medicine for ringworm. The next day as Suman went to the tea estate to pick leaves, her friends found her lying unconscious. Doctors said that Sumanwas 3 months pregnant and suffering from chronic anaemia.
Assam, one of the eight northeastern states of India has recently had a new political dispenation. While, there were a number of issues on which the 2016 election was fought, the issue of gender disparity did not find mention. Assam is the 17th largest state of India and 2nd largest in the Northeastern region with an area of 78,438sq km. According to the 2011 census, the population of Assam is around 31,205,576 of which 15,266,133 are females. But he most glaring statistic the state has is the worst maternal mortality rates.
Aneeta Keesh is a 20-year-old girl living in the border town of Tinsukia and Dibrugarh district. Aneeta got married when she was just merely 18-years old. Her mother is a tea garden worker and her husband is a daily wage worker at an estate. Due to severe financial strain, Aneeta started selling incense sticks near a temple. She delivered a healthy girl when she was 19. Soon after the birth of her first child, Aneeta would frequently take ill. She was 4 months pregnant when doctors found that Aneeta was suffering from tuberculosis, a common disease in and near the tea estates. Aneeta delivered a healthy baby weighing 2.9 kg in the month of February 2016. But soon after the delivery, she had problems breastfeeding. In the next few weeks, she had no milk to feed her newborn baby. Eventually, Aneeta left her two infants at home with powder milk packed in the bottles before she ventured out to sell her stock of incense. In June 2016, Aneeta’s second child died barely four months after his birth.
India, a country that represents 16% of the world population accounts for 20% of maternal mortality ratio (MMR) worldwide. One of India’s millennium Development Goals (MDGs), MDG 5 was to reduce MMR by around three quarters- 560 in 1990 to around 140 in 2015. India failed to reach this number by a significant margin as the current MMR stands at 180. Assam, on the other hand, has the country’s highest maternal mortality rate with 347 per 1,00,000 births, almost double the nation’s average. The infant mortality rate (IMR) of Assam isn’t much better as the state is placed fourth after Madhya Pradesh, Uttar Pradesh and Orissa with 58 per 1,000 live births (2011) way worse than the nation’s average of 47. If one looks at the demographic distribution of the population in Assam, the IMR figure is quite distressing. Kokrajhar, a Bodoland Territorial Area Districts (BTAD) stronghold tops the list with a figure of 76 followed by Morigaon (72), Dhubri (72), Karimganj (69) and Darrang (69). Mr.Kumud Kalita, Director of Social Welfare, Government of Assam, says, ” Institutional delivery is the key to reducing infant mortality rate but till now we have been unsuccessful in controlling it in a much greater effect”. This might be in conjunction with the fact that there are certain areas of Kokrajhar and migrant population in Dhubri which is yet to be reached out along with crucial areas in the two autonomous hill districts of Assam. ”We have a total of 62,152 Anganwadis and 10,000 mini centers spread across the state. There is one helper and one worker assigned in the Anganwadis specifically trained to look after pregnant women and critical infant cases” said Mr. Kalita. Although boasting a greater number of Anganwadis in the state, one cannot simply rule out two most important facts that help in the rising figures of IMR. One is the seasonal heavy monsoon when communication and transportation of pregnant women to nearby clinic becomes impossible. Secondly, the home-based child birth is a major reason while considering the rising IMR figure. The figures become disturbing if one considers the rural female mortality rate.The 2012-2013 Health survey of Assam reflects that infant mortality rate in rural areas is 28 points higher than in urban areas wherein the female infant mortality rate is much higher than the male infant. In simpler terms, a baby girl born in the rural areas of Assam has lesser chances of survival in comparison to its male counterpart before reaching the age of five.While the Ministry and Welfare board can thump their chest on lowering the IMR figure by at least 11% compared to the 2009 figure, the reality on the ground remains unchanged.
Tea Plantation Workers :
Assam is the largest producer of tea which churns around 620 million kgs annually, almost half of the nation’s annual production of 1200 million kgs. There are about almost 800 registered big tea estates in Assam along with around 1,00,000 small tea growing estates whose land area is less than 10.12 hectares. They contribute around 35% of the total tea production in the state. In this huge tea production cycle, there are almost 5,00,000 permanent tea workers and an equal number of casual workers are working under the tea estates. Interestingly, tea-plucking business in Assam is mostly a women dominated affair and they are more than 50% of the total workforce.The tea garden workers belong to different tribes namely, Santhals, Oraons, Gonds, Mundas brought by British from different parts of the country to work in the estates. They are collectively termed as ‘Adivasis’. But unfortunately in comparison to their counterparts in other tea growing states in India, these Adivasi tea workers don’t enjoy the Schedule Tribe status, which they have been demanding since a long time.
Health Issues :
Assam enjoys a humid subtropical climate and therefore the tea-plucking season is best during May to October. The plucking is more productive during the second flush of the monsoon that sweeps the state during the month of July to October where the quality of the leaf is at its prime. This whole stretch of around 5 months is when the women workers work the hardest. The Plantation Labour Act of 1951(PLA), regulates the wages of the ‘permanent’ tea workers, duty hours and maintain their authority on the management, who then have to provide the basic amenities of healthcare, education, drinking water, housing, child care facilities, maternal care and accident cover. But such basic needs are not adequately provided. Not surprisingly, the major tea growing areas have shocking MMR figure of 436, much higher than the state average of 347 and 2.4 times the national average. Their dependence on the industry leaves them vulnerable to exploitation. ”If we become educated, ultimately we can fight our own battle and this is what the estates don’t want” said Jhumli, one of young tea workers in a Dibrugarh-based tea estate. Child marriage, nonexistent maternal healthcare, poor diet are some of the crucial reasons for the situation. According to UNICEF, consumption of tobacco based substance and alcohol is higher among tea workers. In general, tea women workers put the tobacco under their lower lips and continue to work as the substance helps them to go for hours without food. Alcohol and salt lead to complication in pregnancy often characterized by high blood pressure and organ damage, in medical terms,it is referred as eclampsia, one of the main reasons for high maternal mortality rate across the world. Due to unavailability of any nearby hospitals and healthcare facilities, patients often bleed to death, a risk known to the world as Postpartum hemorrhage (PPH). PPH accounts for 28% of maternal death in the developing countries.
Reasons for high maternal mortality and infant mortality isn’t always because of not receiving proper immunization or medication but the problem starts early when a woman conceives as pointed out by Bhaskar Bhuyan of Brahmaputra Radio Centre(BRC). Brahmaputra Radio Center of C-NES is a specialized club which has its own radio line transmitting in 90.4 Mhz delivering continuous programs in Assamese, Bhojpuri, and Chadri, a local dialect among tea workers. He said ‘’Prime Minister Jan-DhanYojana(PMJDY), a flagship scheme by the Government of India to enroll 75million households to open bank accounts states that the Dibrugarh district has a 100% coverage record. This is an absurd lie’’. The truth is that the central and state government has inaugurated two programmes for pregnant mothers which are, Janani Suraksha Yojana (JSY) and Mamoni Scheme respectively. Under JSY, a pregnant mother receives a sum of Rs.1400 for an institutional delivery. In the Mamoni Scheme launched by Govt. of Assam, three ante-natal checkups (ANC) are encouraged to determine any warning signs during pregnancy. After a pregnant woman registers herself for the Mamoni Scheme, she will receive two account payee checks of Rs.500 each during the 2nd and 3rd ANC. This aid is provided by the Government so that a pregnant woman can have a nutritious diet. But to receive the sum, a bank account is required and according to the beneficiaries banks hardly entertain them.
Durga Karmakar, a 20 year old tea worker has suffered four miscarriages in less than three years of her marriage. Ms. Tulika Goswami Mahanta, Asst. Professor of Community Medicine at Assam Medical College points out Durga’s condition is supplemented by the delay in decision-making and low priority on maternity. She said ‘’Hiding pregnancy is very common among tea women workers as they fear losing their jobs. Assam is facing a deficit of around 30,000 doctors and about 60,000 nurses. Lack of medical infrastructure means overcrowding leading to infection.
Ravi Tanti, a worker of BRC specializing in woman and child health care said survival of babies weighing very less during birth is quite low’’. Chaya Karmakar, a 21 year old tea worker worked in the estate until the 7th month of her pregnancy. She took rest for a month before delivering a baby weighing 1.70 kg. The baby’s lips were cracked at birth. Though the baby survived the infant mortality period of 0-5 years, but he now weighs merely 10 kg at the age of 5 years and 4 months. Ravi continues to ensure women in these tea gardens know how to use a simple Mother and Child Card (MCP) where they can check the health of their child.
What can be done :
Measures regarding effective controlling of MMR and IMR figures require a proper diagnosis of health issues, meticulous planning and proper implementation of schemes. It is obligatory to mention here that the Plantation Labour Act 1951 only covers the permanent workers and not the casual workers which has a strength of almost 5,00,000. ”Northeastern Tea Association(NETA) has proposed to the Ministry of Labour and Employment, Government of India regarding the implementation of Employee’s State Insurance Act 1948, (ESI)” says Mr. Bidyananda Barkakoty, Vice-Chairman(Tea Board of India) and Advisor, NETA. The Union Labour Minister has promised to set up ESI Hospitals which will cover the complete workforce working in the Tea gardens. Under this scheme the employer has to contribute an amount of 4.75% and the employee 1.75% of their salary to ESI to avail the benefits. Implementation of ESI Act isn’t that easy. ”Normally ESI doesn’t cover seasonal work as tea plucking is a seasonal business. But having said that, to address the present issue of tea workers certain amendments have to be made in the ESI Act which can then only be implemented by us” said Mr. Sutradhar. A Parliamentary Standing Committee visited the tea gardens of Assam in the month of May 2016 to review the situation. Mr. Sutradhar also pointed out two things that are mandatory in implementing the act. First, the Cabinet has to approve the amendments in Section-1 Sub-3 of ESI Act 1948 and pass it. Secondly, the State Government has to demarcate land for setting up the ESI Hospital facilities. Under ESI there are two main acts: workman compensation and maternity benefit. The issue of poverty and unavailability of good healthcare infrastructure for maternity can be sorted out by the implementation of ESI.
The next step is to address the severe health issues related to working in the tea gardens. Anaemic, hypertension, substandard food habits are some of the critical issues that need an eye to look at. Almost 87%-90% of young workers working in the tea gardens are anaemic. Anaemic conditions are caused by nutritional deficiency or low iron storage resulting from a previous pregnancy and heavy menstrual blood loss. This results in pre-labour dates and having a baby with a low birth weight. In most of the anaemic pregnancy cases, PPH is an inevitable truth. Lancet Global Health data reflects that worldwide prevalence of anaemia in pregnancy is around 38% compared to 28% in non-pregnant women. The other factor that can be looked at is the high-salt induced tea that is served in tea gardens for the women workers as an energy drink to combat dehydration and extreme fatigue due to heat buildup. ”Pregnant woman should avoid having tea especially with salt as it leads to less iron absorption and high pressure due to higher consumption of sodium’’ describes, Mr. Mridul Hazarika, Vice Chancellor, Gauhati University and a renowned Tea Scientist(Tocklai Tea Research). Mr. Bhuyan of BRC said ‘’Proper coordination between Anganwadi Centres and ASHA workers is the need of the hour as they have the source to reach out to maximum population’’. In 2006, UNICEF entered into a five-year long partnership with Assam Branch of Indian Tea Association (ABITA), a federation of 276 tea garden companies in starting the Integrated Young Child Survival (ICYS) programme aimed at addressing issues of healthcare and basic needs for survival of pregnant mothers and adolescent children. Although India increased a whopping 57% of skilled and trained health attendants responsible for child birth, it’s still lacking in infrastructure facilities. Secondly, there is an urgent need to map rural flood affected areas where recent cases of pregnancy can be detected. These women can then be shifted to proper healthcare home or nursing care.Workplace intervention is another way to address the maternal problem as pointed by Ms. Mahanta. She said ‘’ AMC has opened up Adolescent girls Club with the help of UNICEF where we impart the knowledge of nutrition and child healthcare in addition to kitchen garden concept where they can grow green leafy vegetables right at their step’’. Tea workers common diet includes mostly rice, dry fish pickle, chillies. A recent study has found out that they consume around four times more salt than others which has contributed to the rise of pressure strokes and hypertension.Lastly, active male participation is required especially in programmes like Village Health Nutrition Day (VHND) where issues of general healthcare, nutrition, and reproductive health are discussed. There is no reason why a state responsible for one-sixth of the global production of Tea should not be able to take basic care of its workforce.
- Population of Assam according to Census 2011. http://www.census2011.co.in/census/state/assam.html
- India’s Millennium Development Goals in MMR : http://pib.nic.in/newsite/PrintRelease.aspx?relid=123669
- Chief Minister’s Vision for Women and Children, published 2016
- Annual Health Survey 2012-2013, Assam published by Census of India, Vital Statistics Division
- Tea Board of India’s Estimated production 2015-2016 : http://www.teaboard.gov.in/pdf/stat/Production_Monthly.pdf
- Dibrugarh district scores 100% record in PMJDY : http://pmjdy.gov.in/statewise-statistics
- Global, regional, and national trends in hemoglobin concentration and prevalence of total and severe anemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Glob Health.2013 : http://goo.gl/5n4O95
- UNICEF partnership profile with Assam Branch of Indian Tea Association(ABITA), 2012 : http://goo.gl/dKqeBD