A young woman is comforted by her mother-in-law while in labor in the maternity ward at the Dhekiajuli Community Health Center in Assam, India. April 8, 2015.Lynsey Addario—Getty Images Reportage
Nazreen Khatoon, a 25-year-old farmer in the eastern Indian state of Assam, gave birth to a boy in March. Just two weeks later, she returned to a local government hospital suffering from severe anemia. Khatoon’s condition is all too common in Assam, one of India’s poorest states, where the last national family health survey in 2006 showed that 70% of women suffered from anemia. The crucible: the state’s tea plantations, which produce a sixth of the world’s tea supply, and where anemia as well as malnutrition are endemic.
During the harvesting season, workers fan out across the plantations to pick more than 20 kg of tea leaves per person for wages that in 2014 stood as low as $1.50 a day. To keep earning, female workers carry tea leaves in baskets or bags slung over their backs months into their pregnancies. Already weak, and with few public-health resources to draw on, too many of these women die from complications during pregnancy or childbirth.
As a result, Assam has the highest maternal mortality rate in India, a country that, overall, accounted for some 50,000 of the 289,000 maternal deaths worldwide in 2013. From 2011 to 2013, 167 Indian women died for every 100,000 live births. In Assam the figure was nearly double that at 300.
Yet many of these deaths could have been prevented, but for lack of resources. Even as India’s economy expands, the World Bank estimates that from 2010 to 2013, the country spent less on public health as a proportion of GDP than poorer nations like Sierra Leone, Cameroon and Nepal.
The consequences were clear to photographer Lynsey Addario when she arrived in Assam in April with Nazdeek, an Indian human-rights nonprofit backed by the U.S. charity Every Mother Counts. The government hospital where Addario met Khatoon was desperately understaffed. Patients in need of medical attention sprawled on the floor in the ward and hallways, and there were only nurses to look after them—the doctors came just twice a day.
A veteran of war zones from Afghanistan to Syria, Addario has witnessed similar scenes of desperation before. But somehow Assam was worse. “I do see those things in postconflict countries or in places that are rife with war—but the excuse is, they’re at war, so their infrastructure is broken,” she says, recalling a hospital in Somalia where she saw “people strewn out on the floor across the ward.” In Assam, the scene at Khatoon’s hospital “depressed me,” says Addario.
As for Khatoon, she was eventually treated at a private hospital after her relatives pooled their money. For too many other women like her, though, the outcome is not recovery, but death.
Lynsey Addario is a photojournalist represented by Getty Images Reportage. Her memoir, It’s What I do: A Photographer’s Life of Love and War, is published by Penguin Press.
Alice Gabriner, who edited this photo essay, is TIME’s International Photo Editor.
Nikhil Kumar is a reporter and TIME’s South Asia Bureau Chief.
Indian families rest in a room reserved for women recovering from cesarean sections, at the Tezpur Civil Hospital in Tezpur, Assam, India. April, 2015. Assam has the highest rate of women dying in childbirth and from pregnancy-related causes in all of India. The conditions in many of Assam's state-run medical facilities are often overcrowded and unhygienic, with an insufficient number of doctors, and patients sprawled out in the floors and hallways due to a limited number of beds. Lynsey Addario—Getty Images ReportageNazreen Khatoon is comforted by her mother as she lies gravely ill, suffering from severe postpartum anemia, at the Tezpur Civil Hospital in Tezpur, Assam, India. April 2015. Khatoon delivered her son, Kashari Pam, three weeks prior, and returned to the hospital two weeks after delivery when her condition worsened. In dire need of both blood and iron, she was not receiving either from the Tezpur Hospital. She was eventually referred to a private hospital, where she was able to receive better care, but at a great expense to the family. Lynsey Addario—Getty Images ReportageNazreen Khatoon winces in pain as she lies gravely ill, suffering from severe postpartum anemia at the Tezpur Civil Hospital in Tezpur, Assam, India. April 2015. Lynsey Addario—Getty Images ReportageNasuran Begham, 30, sits in the dark during an electricity cut holding her third child, four days after giving birth, in the a postnatal ward. Assam, India. April, 2015. Lynsey Addario—Getty Images ReportageIndian families sleep outside a postnatal ward, where women are in labor and recovering from delivery, accompanied by their families. Tezpur Civil Hospital, Tezpur, Assam, India. April, 2015. Lynsey Addario—Getty Images ReportageIndian women wait to weigh their tealeaves at the end of a workday on a tea plantation in the Tinkharia garden in Assam, India. April 8, 2015.
Many families in Assam work on the tea plantations, where there is a high rate of pregnant and lactating women. Women are severely anemic due to poor diets and little to no prenatal care, which leads to a high number of pregnancy complications. Lynsey Addario—Getty Images ReportageBabita Hemrom picks tealeaves while holding her child alongside other Indian women on a tea plantation, in the Tinkharia garden in Assam, India. April 8, 2015. Over years, women working on the plantations have been subjected to long hours with little accommodation of their basic needs for food, hygiene, latrines, and lesser workload for pregnant and lactating women. Lynsey Addario—Getty Images ReportageResonate Bhumi sits over her severely deformed infant hours after giving birth at home, in the village of Holing Kata, in the Tinkharia plantation. Bhumi's son was born with no arms and a cleft palate. Many women from the village came to look at the mother and child. Assam, India. April 8, 2015.Lynsey Addario—Getty Images ReportageSosana Gowala holds up her severely deformed nephew for the doctor to see, in the Dhekiajuli Community Health Center, hours after her niece, Resonate Bhumi gave birth to a baby with no arms and a cleft palate in the village of Holing Kata, in the Tinkharia plantation, Assam, India. April 8, 2015.Lynsey Addario—Getty Images ReportageA young woman is comforted by her mother-in-law while in labor in the maternity ward at the Dhekiajuli Community Health Center in Assam, India. April 8, 2015. Lynsey Addario—Getty Images ReportageSarasoti Bauri, 22, lies on a stretcher after she delivered her second child in a taxi en route to the hospital. She lost a relevant amount of blood prior to arriving at the Dhekiajuli Community Health Center in Assam, India. April 8, 2015. Lynsey Addario—Getty Images ReportageA young woman kneels with labor pains in the hallway of the maternity ward at the Dhekiajuli Community Health Center in Assam, India. April 8, 2015. Lynsey Addario—Getty Images ReportageThe delivery room in the clinic at the Sapoi Tea plantation in Assam, India. April 9, 2015. Lynsey Addario—Getty Images ReportageIndian women walk to work with their children to pick tealeaves on a tea plantation in the Panbari Tea Estate in Assam. India, April 9, 2015. Lynsey Addario—Getty Images Reportage
