CNN is committed to covering gender inequality wherever it occurs in the world. This story is part of As Equals, an ongoing series.

The names of laborers have been changed for their safety and job security.

Assam, India — Rama is scared. She's six months pregnant and increasingly worried about the health of her unborn child.

The 22-year-old casual laborer earns her living by picking tea leaves in India's north-eastern Assam state.

She does not take a break from the hard labor even if she is in pain.

"Sometimes I feel good, sometimes not so good," she said. "I am new to this, so, I don't know what to expect."

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Her hut in a village near Tezpur in Assam's Sonitpur district is one of dozens for workers within a fenced compound on the tea plantation that stretches for miles, surrounded by swathes of lush green fields making it beautiful, but extremely remote. "We are totally dependent on the tea garden," she told CNN from her village. Short and of slender build, Rama is struggling with the exhaustion that accompanies a pregnancy, made worse by working on her feet six days a week for nine hours a day. She worries about her baby's health. Recent blood tests show Rama's hemoglobin is low, she said, making her anemic and at high risk of bleeding excessively when she gives birth, a scenario not uncommon on the plantation. Numerous neighbors have suffered complications while giving birth, she said, sometimes with fatal consequences for both mother and child. This is fueled by poor working and living conditions, prolonged working hours and minimal access to health care during pregnancy, say experts. "I get afraid when they talk about surgery or some kind of cutting when there is (a) slight problem in delivery," Rama said. For every 100,000 live births in Assam state, 237 women die -- making this the most dangerous place in the country to give birth, according to government figures for the 2014-16 period. The situation has improved in recent years, falling from 480 per 100,000 in 2006, according to data released by the Indian government, but the state remains an outlier compared to the rest of the country. For India as a whole, the rate is 130 deaths per 100,000 live births and in developed nations like the US, the rate is 14, according to World Health Organization numbers from 2015. But statistics or stories won't stop Rama working. She can't afford to. World famous tea These tea plantations are the starting point for the world famous Assam tea, known for its strong flavor and aroma. India is the second largest producer of tea in the world, after China, with Assam its largest tea producing state, housing around 800 tea plantations. Assam's tea exports have an estimated value of $250 million, ending up in tea cups around the world, in countries like Russia, Iran, United States, United Kingdom and China. India itself is also one of the largest consumers of tea, representing 19% of the global market. The plantation where tea picker Rama works is not accredited by the Rainforest Alliance, which checks working conditions to make sure they comply with certain standards in terms of health and safety. Employees of the Rainforest Alliance audit the plantations registered with the NGO every year to ensure compliance. "Unless you make sure you meet all the criteria, you are out of the system," said Harkirat Sidhu, consulting program coordinator with the Rainforest Alliance in India. The world's biggest tea companies, Hindustan Unilever Limited and Tata Global Beverages, source the tea for their international brands like Yellow Label and Tetley from accredited plantations. But they have other, local brands that are not fully sourced from Rainforest Alliance-accredited plantations, like Hindustan Unilever's Taj Mahal Tea. A Hindustan Unilever spokesperson told CNN that 40% of its tea for the domestic Indian market comes from non-certified plantations. "For non-certified gardens, while we have traceability up to the factory level, but do not have traceability on green tea leaves sourced by the factory for manufacturing tea," read a statement sent to CNN. "Our endeavour is to move the remaining 40% to sustainably sourced plantations by 2020." Separately, a spokesperson for Tata Global Beverages told CNN, "In India, we are in the process of getting to 100% accreditation. Given the complexities in the supply chain, this is not a straightforward journey." "In our international markets, we are 100% Rainforest Alliance certified for our Tetley brand," the statement read.

Meanwhile, local health and social workers continue to raise significant concerns about the welfare of workers in Assam's tea gardens and a recent report by the World Bank's independent watchdog, Compliance Advisor Ombudsman (CAO), agreed.

To investigate the issues raised, CNN visited two un-certified gardens in Assam where workers, like Rama, shared experiences of poor access to health care and inadequate working conditions, particularly during pregnancy. Smaller plantations like these two form almost 50% of the Assam market.

A spokesperson from Hindustan Unilever said the company purchased "a small amount of tea" for its domestic market in India last year from these two plantations, while Tata Global Beverages said it did not source tea from these particular plantations.

Maintaining maternal health

One owner of a plantation visited by CNN, speaking via the telephone, refused to comment on the specific health issues facing his laborers, but said his estate provides ambulances, medical vans and transport to hospitals for women when needed.

"The medical issues (like excessive bleeding) that happen are problems which are not in our hands but whatever we can do, we do," he said.

The Indian Tea Association, meanwhile, told CNN that "workers are eligible for primary health care as per the Plantation Labour Act," with free medication provided to a worker and their family and maternity care provided to cover anemia treatment, immunization, institutional deliveries and mother and child care projects.

Human rights lawyer, Jayshree Satpute, who works with local plantation workers, disputes the claims that the medical facilities are available to most female workers. "If you look at the infrastructure on the ground, it is not enough," she said. "There are not enough doctors, the hospitals do not have enough facilities, not enough beds, the primary health centers do not have enough infrastructure, there are not enough doctors, there is not enough staff."

Rama says she has personal experience of the weak infrastructure, saying that while her plantation has one ambulance, it takes a long time to arrive and is not provided easily.

"It is always busy shifting patients to the hospital," she said. "Sometimes it even goes out of the town."

Lawyer Satpute said she has seen many of women in the later stages of pregnancy working on the plantation, with several having delivered their babies there. "Mostly these tea plantation workers are highly anemic and have not been able to access the health facilities or have (not) been able to register themselves."

Knowing her condition, this is what Rama fears -- that she won't have medical care for her child and herself.

Life on the plantation

With baskets strapped to their heads, throngs of women set out each day moving from one patch to another -- circling the same plantation -- typically taking a break just once a day, even when heavily pregnant like Rama.

Rama earns about Rs 1000, or $14, a week and is expected to gather around 24 kilograms of leaves each day. If she and others like her don't meet these targets, their daily wage is cut, she and other workers told CNN. At the end of each day, they drag their bags of leaves to be weighed, recorded and collected by plantation managers.

Workers are split into two groups: temporary and permanent, with the majority of the 1.5 million tea plantation workers in the region being temporary, according to Satpute. More than 70% of the workforce are women, she added.

Eligibility for maternity benefits do not discriminate against temporary workers, the Indian Tea Association told CNN. And according to the country's maternity benefits act, a woman is eligible for paid leave if she has worked for more than 80 days in the last one year, before going into labor.

But not all workers appear to be aware of these laws.

Rama, for example, says she was under the impression that only permanent workers are entitled to health benefits such as maternity leave. It's a common misconception, says Satpute.

Casual laborers often work throughout their pregnancy and rarely attend hospital appointments because they cannot afford to give up even a day's wages.

"It is difficult, but work is work, I have to do it," said Rama, adding that taking breaks is frowned upon and often results in a scolding from her supervisor.

She explained how she walks slowly to work these days, but with caution. "When they see us resting, they ask, 'who will pay for your wages?'"

Rama admits she is largely unaware of the health care needed to keep her baby healthy.

And officials believe that local habits add to this unawareness to make situations worse.

"Some of these populations have salt in tea, where the normal population uses sugar, they have a high salt consumption," said J.V.N Subramanyam, Director of the National Health Mission in Assam. "There is high amount of alcoholism and low availability of nutritious food at the labor lines," he said, pointing to the prevalence of anemia.

Women are often in need of supplements and blood transfusions, but are just too far away to get it, or to be informed.

"No one has told me what to do," says Rama. "What can we do?"

In theory, a lot.

An array of initiatives by the Indian government are meant to be making pregnancy safer for India's poor.

Since 2005, the government has been providing free pre-natal care, blood tests and cash payments for each baby that is delivered in a government hospital, registered with the state and given their first cycle of shots.

It has also launched nutrition-based programs where pregnant mothers are entitled to free meals at local community centers. Each state government then typically adds more benefits.

But due to a lack of awareness, rampant illiteracy and inaccessibility, women in the tea plantations aren't aware of these options, say social workers, leaving many with fatal outcomes.

A number of factors contribute to the problem: excessive bleeding during labor, the expense of medical fees at city hospitals or because they're unaware that their pregnancy might be high risk. They reach hospitals too late, or not at all, and any facilities they make it to have minimal equipment and expertise, said local social workers.

Living a legacy

The tea plantations in Assam are a legacy bequeathed to India by the colonial-era government where local tribes were employed, or in some cases got into indentured servitude, in the gathering of tea leaves. Entire generations have resided in the plantations, passing on the legacy of servitude and human rights violations on over time.

The men and women working today, see the same future for their children.

The plantations work under the 1951 Plantations Labour Act -- written to encompass practically all plantation workers in the country and to ensure their rights -- which set a standard wage that experts like Satpute say haven't kept pace with broader labor market rates.

The average wage for an unskilled laborer in agriculture in India is Rs 320 or about $4.50 per day. An individual working in Assam's tea plantations earns about half that, at Rs 167 or $2.27 per day, local plantation workers told CNN.

Satpute says that some plantation owners even restrict the movement of their workers -- a claim that's denied by local authorities.

"They are free to go everywhere," said Manoj Kumar Deka, Deputy Commissioner of the Sonitpur District in Assam. "They go to the markets, they go to the haats (local festivals). They enjoy. There is no issue."

Desperate for care

"The government is aware that this is a major human rights (issue)," said Subramanyam from the National Health Mission, referring to problems that workers have in accessing healthcare.

There are 35 tea plantations in the district of Sonitpur alone and more than 800 in Assam, all in need of sustained effort to their health facilities, he says.

There has been some progress. Over the last five to six years there has been a sustained effort by the state government to improve healthcare access, explained Deputy Commissioner Deka.

The state government has deployed new ambulances, more dispensaries and even mobile medical units -- small vans equipped with emergency medical care -- as well as doctors and nurses, he said.

But resources remain inadequate, one medical dispensary supervisor, who declined to be identified, told CNN.

Local social workers described how some of the existing dispensaries are dilapidated sheds served by a visiting doctor who comes a couple of times a week to work for just two hours. The result: a woman arriving at the dispensary will be seen by the nurse and a non-medical supervisor, while the doctor is called in, according to the supervisor.

"If something (medical facilities) is provided within the tea garden things might become more convenient and the conditions might improve a lot," one social worker told CNN.

Plantation hospitals should have a doctor, a nurse, a midwife and a pharmacist there every day but they only come once a week, according to Satpute, who in addition to her legal work co-founded Nazdeek, an NGO working in Assam and across India to promote the welfare of tea garden workers.

Labor rooms often have rusty gurneys on which women are expected to deliver. With a few shelves filled with medicines and no equipment like an oxygen tank or an ultrasound machine present, the women depend on the skills that the doctors possess, which often isn't enough, one social worker said.

It's common for the women to need blood transfusions, and, according to a national entitlement initiative, pregnant women are entitled to free blood during delivery. But the practice is hard to implement due to the shortage of blood banks in the gardens of Assam, according to Subramanyam, who is in-charge of all government-funded medical schemes in the state.

A healthy level of hemoglobin is 12 grams per deciliter of blood, but many of the pregnant women who come to the hospitals in Assam have just one third of that, with just 3-4 grams per deciliter, said Dr Reena Dutta Ahmed, former associate professor at the Assam Medical College (AMC). "Somehow, they are still walking around"

Of the women who die of childbirth in Assam, most die due to anemia and hypertension, added Ahmed.

Rama fears a similar fate for herself, having heard of a few women who died during their delivery.

She's sought help. To increase her strength, she says she's tried asking local medical workers for more food -- something that she says can't afford on her own. The response? Go buy your own food.

And she also worries about getting the medical supplies she will need. "When we need blood etc. it should be provided," she said.

"We receive no help."