Why do women in tea gardens face higher reproductive health risks?
Ramdulari Kairi, a tea leaf picker at of Satgaon Tea Estate in Sreemangal, died on May 28, 2021, at the age of 48. She had cervical cancer, and was in severe pain in the final days of her life.
A private doctor in Moulvibazar had diagnosed Ramdulari in November 2019. Her days were numbered since then. However, she kept working in the tea garden despite the pain. Her last day of work was December 29, 2020. From January 2, 2021, she was bedridden until her death.
Her son Babul Kairi (27) took care of his mother and paid her medical expenses of Tk 150,000 (USD 1,660), a big sum for a tea worker's family. "I tried to save my mother. We gave her ten sessions of chemotherapy," said Babul. "She had breathing difficulties during this time. She stopped talking 12 hours before her death."
Babul knows from experience that women with cervical cancer in the gardens, like his mother, generally hide their diagnosis. By the time it reaches an advanced stage, it's too late for surgical treatment. "The cost of cancer treatment is high, which the garden management does not bear. The tea workers or their families generally bear the medical expenses when one has a serious illness, such as cancer," laments Babul.
"Tea workers are generally unaware and ignorant of cervical and breast cancers," says Dr Zainal Abedin, division chief of the Institute of Public Health and Nutrition (IPHN) and former Upazila Health and Family Planning Officer in Sreemangal.
According to him, the best precaution for this fatal disease is screening, which is done in upazila health complexes. Visual Inspection of Cervix with Acetic Acid (VIA) camps are also run in the tea gardens to detect cancer. "When we run visual tests, two to four percent come back positive," he said. The positives are then sent to Sylhet Osmani Medical College Hospital for confirmatory testing.
"To protect women tea workers from cancer, the government should run special camps, and both tea garden management and tea workers should come forward. Surgery at the primary stage can heal one diagnosed with such cancer," suggests Dr Abedin.
Obstetric fistula, vesico-vaginal fistula (VVF) and recto-vaginal fistula (RVF), prevalent among poor women, mostly in low and lower-middle income countries like Bangladesh, is another serious health concern, particularly in the tea gardens. Those married at an early age are more vulnerable to fistulas, since they give birth to children before they are physically ready to do so. This leads to complications at birth, although those who develop fistula have a tendency to hide it.
A 2018 study, conducted in 10 tea gardens in Moulvibazar district by the Centre for Injury Prevention and Research (CIPRB), identified 20 suspects with fistula. Fourteen were initially screened as positive using a primary diagnosis questionnaire, and were sent to a primary healthcare centre. Five of them were then identified as confirmed cases. All of these five women were married before 16 years of age and became pregnant the following year. This is seen as a key factor for developing obstetric fistula. Home childbirths with untrained birth attendants or long delays in delivery are other key factors behind this.
Fistulas can lead women to suffer through physical and social ordeals. Continuous urination or leakage is not only uncomfortable and embarrassing; it can lead to women being abandoned by their husbands, shunned by their community, and can even make them vulnerable to violence. The five women with fistula initially hid their symptoms, ignoring their discomfort and believing it would go away by itself, even though the only solution is surgery.
The Directorate General of Health Services (DGHS), with the support of UNFPA and CIPRB, initiated a fistula elimination programme in Sylhet division in January 2019. They identified 34 fistula cases in the tea gardens, and sent the patients to a specialised hospital in Dhaka for treatment. Twenty-one of them were completely healed after surgery, and 15 tea gardens were declared fistula free in 2022.
While research-based information on cervical cancers and fistula in tea gardens are scanty, leading to a lack of awareness, there are other reproductive health risk factors for women that are more widespread. These are miscarriage, stillbirth and maternal death, which continue to be huge challenges in current conditions. Women leaf-pickers, in particular, work very long hours, walk many miles to travel to and from their workplaces, and are on their feet all day. Pregnant women keep working till the end of their pregnancy, and experience various health risks.
Anika Munda (29), a tea leaf picker of Jagcherra Tea Estate, is one such woman. Pregnant for seven months, she delivered a stillborn baby on November 16, 2018. She walked four hours to return home after picking tea leaf the day before. Then, she felt pain in her belly. Anika's mother-in-law Taramoni Munda realised that the fetus was no longer moving. She began massaging Anika's belly with oil, and the next morning, she delivered Anika's deceased child. This was her sixth pregnancy.
Anika, who has a 14-year-old daughter and eight-year-old son, has had two miscarriages before, at five and seven months of pregnancy. Another child of hers died of haemoptysis at 1.5 years old.
During Anika's two miscarriages and the stillbirth, Taramoni Munda, an untrained birth attendant, took care of her. Anika never visited a hospital or dispensary. But she is finally determined to consult a doctor about family planning methods. "I don't want to get pregnant again. I want to be happy with my two surviving children," she said.
The case of Mithila Nayek (22), a tea leaf picker from Hossainabad Tea Garden in Sreemangal, further points to the deep-seated issues that pregnant women face in the gardens. She gave birth to a baby on October, 6 2018, at Sreemangal Health Complex, after having three miscarriages before. An hour and a half after giving birth, Mithila was found sitting on the thick root of a mahogany tree in front of the upazila health complex. Her newborn did not cry at birth, and was having trouble breathing.
These are miscarriage, stillbirth and maternal death, which continue to be huge challenges in current conditions. Women leaf-pickers, in particular, work very long hours, walk many miles to travel to and from their workplaces, and are on their feet all day. Pregnant women keep working till the end of their pregnancy, and experience various health risks.
The health complex authority referred her to Moulvibazar District Hospital. While her family members struggled to find a transportation to Moulvibazar, the mother and child spent 45 minutes waiting on the roots of the mahogany tree. Finally, the family found a CNG to take them and, thankfully, the baby cried 20 minutes after their arrival in the district hospital and survived.
Most mothers in the tea gardens give birth in the garden's labour lines. Mithila only went to the upazila health complex because she had delivery-related complications, and she was able to return home with her baby. Had her family managed an ambulance to take her from Sreemangal to Moulvibazar, she would have suffered less, but there is no ambulance in Hossainabad Tea Garden to take patients in critical condition to hospitals.
Mithila travelled to the health complex by a CNG – an hour-long journey made even more difficult by the bumpy roads. She returned home from Moulvibazar along the same bumpy road, spending an hour and a half in a rickety CNG with her new baby.
Compared to other parts of the country, tea workers and their family members, especially women, face greater health risks, mainly due to malnutrition and other factors. Fifty-one percent of around 138,000 tea workers in 160 tea gardens in Sylhet and Chattogram divisions are women, as are 95 percent of the tea leaf pickers, who engage in the hardest labour in the tea industry. The sufferings of women workers are only exacerbated when they are pregnant, especially since most of them continue to do their heavy work throughout their pregnancies.
A general tendency among women workers is to take maternity leave only after child birth. Before birth, they sometimes take their earned sick leave and stay home for two to three weeks. Miscarriages and stillbirths are unavoidable consequences of this practice. Besides, most women in the tea gardens deliver their babies on beds set on floors in unhygienic environments, which endanger both mothers and their newborns.
The fact that many women and girls are married off at an early age only adds to the dangers. In these scenarios, it is always the women who adopt birth control methods. In a 2018 survey on 60 pregnant women, the Society for Environment and Human Development (SEHD) found that 29 were forced to marry early, and 29 adopted birth control methods. But none of their husbands ever adopted any birth control method. These, and many other factors, lead to more miscarriages and maternal deaths in the tea gardens than the national average.
According to the Department of Health, there were 120 maternal deaths in Moulvibazar district in 2014, of which 48, or 39.1 percent, occurred in the tea gardens, despite there being a much smaller population who live here. This means the health condition of female tea workers is worse than the national average.
It is true that government health services have reached the community level, and there are also some non-state initiatives. But the reality is that most tea gardens are still largely secluded, and the tea workers and their communities have many social and cultural barriers in taking full advantage of health services provided by state and non-state facilities.
According to a 2020 report from Bangladesh Tea Board (BTB), there are 78 hospitals and 162 dispensaries run by garden owners. The workers, however, are very unhappy with the services they get from these health facilities, which are unable to provide treatment for critical diseases, including tuberculosis and cancer. Prenatal and postnatal care that the company facilities provide is also very inadequate.
The tea workers, however, can go to the government hospitals, such as the District Sadar Hospital, upazila health complex, union health and family welfare centre, and community clinic, which are close to the tea gardens. However, few of them visit these public health facilities. The tea workers usually remain busy in the gardens, six work days a week, and do household chores on the one day of the weekend. Traveling all the way to health facilities outside the gardens is also costly for them.
Access to proper sexual and reproductive health care is a fundamental right, and extremely important for the physical and mental well-being of women and girls. This right is protected by a number of international charters and laws, including the Universal Declaration of Human Rights. Women and girls in the tea gardens are deprived of sexual and reproductive health rights to a great extent due extreme poverty, lack of awareness and knowledge about government health services, ignorance about family planning, poor hygiene and sanitation, indecent work conditions, violation of labour laws and rules by employers and withholding of the benefits they are entitled to, inadequate access to health workers, lack of education, and various other factors, including social and cultural practices in the tea gardens.
It is true that government health services have reached the community level, and there are also some non-state initiatives. But the reality is that most tea gardens are still largely secluded, and the tea workers and their communities have many social and cultural barriers in taking full advantage of health services provided by state and non-state facilities. Economic hardship, which leads to malnourishment and lower literacy, is a key factor that has multiplier effects on the lives and livelihoods of tea workers. All of this means that special attention to ensure proper sexual and reproductive healthcare for women and girls in the tea gardens is now a necessity.
Philip Gain is a researcher and director at the Society for Environment and Human Development (SEHD). Fahmida Afroze Nadia, SEHD researcher, assisted the author in collation of information on fistula.