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.
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.