Tinsukia, Assam: Hemanti Dhara Das was severely underweight and anaemic at the time of her pregnancy. Her weight had dropped to 32kg and her haemoglobin level had dipped to 6 gm/dl. While she managed to deliver her baby, she died three months later because of complications arising out of childbirth.

Das, who stayed in the Tinsukia district in Assam, is not alone to meet such a cruel fate. Hundreds of women die in Upper Assam every year because of anaemia, blood pressure and malnutrition. In fact, according to the latest National Family Health Survey report, Upper Assam records the highest number of maternal deaths in the country — 229 per 1,00,000 births. This tally is double the national average.

But a group of women from 20 villages of Upper Assam are on a mission to save their kind from the clutches of death and promote institutional — and safer — deliveries. Since 2014, their intervention has brought down the number of maternal deaths in these villages from 18 to 2 last year. The instances of home delivery have also reduced from 134 to one in the same period. They are all homemakers, who volunteer in their free time.

Attitudes changed, lives saved
It’s the job of the government-affiliated ASHA (Accredited Social Health Activist) workers to supervise the health and hygiene issues in rural India. One ASHA worker is mandated to look after a population of 1,000. But in Upper Assam, “they are more often swamped with work,” says Nitumoni Gogoi, a resident of Nagajan village in the Tinsukia district.

That’s why women from the community decided to step up in 2014. They were acting on intervention by Schoolnet, a social organisation that works in the area of health and women empowerment. It had trained female volunteers from 20 villages of the Tinsukia and Dibrugarh districts over a week under a CSR program called Arogya. After the training, these women took an exam, post which they were entrusted with the responsibility of tracking the health of pregnant, newlywed and adolescent women in their villages.

These women haven’t replaced ASHA workers — they are complementing their efforts. Volunteers such as Gogoi assist the ASHA workers in spreading awareness on women's health and maternal care in her village Nagajan, which has a530 males and 554 females. Nitumoni is responsible for monitoring the health of 14 pregnant women, 38 adolescent girls and 42 children.

However, these ‘field workers’ have an advantage over ASHA workers. They are familiar with the women and their families because they live in the same neighbourhood and have known each other for years.

Despite this, the unwritten rules of patriarchy that tend to govern women’s bodies and their reproductive rights posed a big challenge for them. They faced resistance every time they tried to recommend vitamin supplements to women. A lot of elderly members, particularly in-laws, in the region believed that the consumption of vitamin tablets and immunisation may complicate the pregnancy. Eating banana flower prevents the birth of twins and other myths are also prevalent here.

"In the beginning, it was difficult to convince them. But since we have been interacting with the families for many years now, they listen to our advice now," says Nandita Baideu, a field worker from Tinsukia's Bapuhola village.

It also took them some time to drive proper menstrual hygiene practices among young girls and married women — from how to use sanitary pads to how to dispose of them. Either they used to wear the same cloth pad without washing and drying it properly or they would use a store-bought sanitary pad for over 24 hours. These would give rise to vaginal infections and other hygiene-related issues among them.

Their intervention spanning nutrition to hygiene has saved the lives of women such as Monisha Manjhi. "My weight was 30kg when I was pregnant. At that time, these women would visit my home regularly and prescribe me tablets and healthy food like colocasia, ferns, moringa leaves, guava and amla.”  Manjhi gave birth to a healthy child in a tea garden hospital last September.

360° monitoring

Going door-to-door is one of the many ways how these ‘field workers’ interact with women and their families. They also organise meetings with women and girls to discuss the issues related to anaemia, hygiene, nutrition and pregnancy. These meetups are called ‘Saathiya Club’. 

These women were trained to become field workers in 2014. Credit: Monika Mandal

They also track the health of the children and pregnant women using an app. Nivedita Barathakur, the zonal program head of the Schoolnet initiative informs 101Reporters, “Around 1,467 pregnant women in Tinsukia and 789 in Dibrugarh are constantly monitored by the field workers using an in-house app called Survey CTO. Apart from this, 1,323 children in Tinsukia and 721 in Dibrugarh have been tracked to administer immunisation on time. We have seen exceptional changes [in the health] of these families.”

Trouble over tea 

While these women are doing their bit with full enthusiasm, the challenges ahead of them are multi-dimensional. The high maternal mortality in Upper Assam is a result of a host of financial, historical and cultural reasons.

With over 800 tea estates and 1,00,000 smaller tea gardens, Assam is the second largest tea producer in the world after China. Which means, a large population of Upper Assam works in tea estates. The violation of labour rights on these estates, in terms of the lack of water and proper pay, has been widely reported.  This leaves women and girls with poor sanitation facilities and inadequate nutrition, making their growth delicate and pregnancy fragile.

Add to this, the tea workers drink saltwater and salty tea, locally called nimok sah, multiple times a day to fight lethargy and dehydration. This habit was introduced by the British and has been detrimental to the health of the tea-farming communities. “As a result, high blood pressure, abnormal haemoglobin levels and weight loss are common in this region. During pregnancy, the problem of hypertension and anaemia aggravates,” says Sumi Dowarah, who’s a project consultant with the said social organisation.

So acute is the salt tea-drinking habit that the Assam government in its 2019-20 budget had proposed to distribute free sugar to the lakhs of its tea workers to help them transition.