Table 7 Results of thematic analysis of qualitative open-ended questions on impact of insufficient light or power

Panel A: Impact of Insufficient Light or Power

 In response to the questions:

Please comment on the aspects of your job where lack of overhead light impacts you the most

Please comment on any problems or difficulties resulting from your use of kerosene lanterns or candles such as: personal injuries, candle wax burns, problems with eyes from smoke, problems with breathing from smoke, burn marks on wall, etc.?

Please describe in detail a memorable situation when you were trying to care for a patient, and you did not have sufficient lighting

 Difficulty in providing care

More difficult procedures

Suturing an episiotomy or tears is difficult whereby the midwife has to hold a torch in the mouth and sometimes pierces herself in the process

Another point is when assessing to confirm PPH, it is difficult to distinguish fresh blood and the non-fresh because of lack of adequate light

Used instruments can only be cleaned in the mornings. It’s impossible to clean the floor in dim light

One time an infant was brought with severe malaria with convulsions and [the health workers] used the headlamps to pass an intravenous line and gave emergency treatment and he got better

During resuscitation of the baby, it’s hard to see the chest movements if there’s no overhead light and ruling which color of the skin is the baby

It was March and the midwife was giving routine care to a baby by cutting the baby’s cord and a torch which was put in her mouth fell down and stopped working. She tried to repair it and it refused so she had to cut the cord in darkness. If there was good lighting, she would have cut it without any delay

When attending multiple patients

It was one night when [the health worker] was conducting a delivery and she had positioned the torch in a place where it was focusing light very well to this mother on the delivery bed, meanwhile [the health worker] was called that another mother had come and also in second stage so she just rushed to go and help the other who seemed to be pushing at that time. However, [the health worker] forgot the torch in the delivery room and couldn’t carry it because she had gloved already. After reaching there, she couldn’t see very well and rushed back to get the torch. However, when [the health worker] came back, she found the baby was down on the floor. [The health worker] tried to do immediate care to the newborn and third stage but it would be different if she had adequate light: the baby wouldn’t have fallen on the floor because [the health worker] was around when the delivery began, but all changed when [the health worker] ran for the torch

Delayed care/procedures

It was a night delivery and the mother was nearing second stage when the lantern went off. The paraffin had been used up and [the health worker] didn’t realize that earlier to prepare for it. [The health worker] conducted the delivery without any light source since it was very late. [The health worker] did not assess for tears till morning, and yet the woman had sustained one, which [the health worker] repaired the following morning

Unnecessary referrals

Most prime gravida are referred due to fear that they may get tears because inadequate light would lead to poor suturing

Inadequate care

HIV positive mother got a tear. Because there was no light, she was left unsutured. If there were light, mother would be sutured

 Harm to health Worker

Anxiety, fear, stress, feeling bad/irritated, boredom

In case there’s no light during these scenarios it makes the health worker panic, nervous and feel like if something bad happens her job will be gone

So bad and disturbing, whenever night comes, [the health worker] thinks of work without power and prays that no mother comes in the night

Reduced job security

It’s a very bad situation. If it happens, midwife fears to lose her job in case a fatal situation happens

It has made some mothers not to come to the facility with fear of delivering in the dark. The midwife claimed that lack of reliable lighting has led to low generation of income to run the facility

Physical pain, infection, injury, tiredness

Giving treatment, calculating doses, and checking expiry dates are difficult because dim light makes the midwife’s eyes develop pain at night

During night deliveries, when [the health worker] has to use a phone torch to conduct a delivery and the torch is also dim, [the health worker] can end up suturing herself

Disrespect from patients

Very bad. It makes every care provided to the mother to be meaningless and vanishes the respect the mothers and the companion can give to the midwife.

Lower motivation/morale

It’s a terrible moment which makes [the health worker] feel like leave her job cause it puts the baby’s and mother’s life in danger as well as spoiling her career and dignity

It’s a condition that the health worker doesn’t like to work in. It makes her feel like she’s in a wrong profession especially at night

Lack of personal safety

One time, after delivery as the midwife was taking the placenta to the placenta pit, she almost stepped on a snake without seeing it. This is because there is no light around that area

Damage to personal phones

At 3am mother came in second stage and [the health worker] helped the mother to deliver with the help of a torch in the mouth so as to see, but along the way of cleaning, the phone fell into liquor and got damaged. It was difficult to replace it and yet if light were sufficient, it wouldn’t have happened that way

 Poor facility conditions

Worse facility hygiene

Soot makes the walls look nasty, giving the cleaning department more work. This would not have happened if lamps weren’t being used

Fire hazard from lanterns/candles

There can be risks of fire outbreak when using candles because they are the main source of light used in case electricity is off

 Harm to patients

Burden on patients/companion

In January, a mother was laboring when the husband fainted in the labor ward. Husband was told to help hold the torch for the delivery. He would have just waited for the baby in the postnatal ward

Loss of privacy

[The health worker] was conducting a delivery of a precious baby and was using a lantern. She had to call another person to help her position the lamp wherever she wanted so as to finish the delivery as well as to resuscitate but the privacy was compromised because the person was not even a health worker

Facility-acquired infection/injuries

The soot leads to respiratory infections especially for babies who are born under the dark and stay for 2 days in the department

Discomfort/pain

It happened around December 2016. The midwife was suturing a vaginal tear when grid light was off and the solar at the facility wasn’t reliable as it produces dim light. [The health worker] focused a torch to the mother which was in her mouth. [The midwife] said that the suturing took a long time and the local anesthetic drug wore off. The mother was in pain. The midwife pierced herself several times. If [the midwife] had good light, the suturing process would have been quick

Fistula

Due to the poor reliability and brightness of light used when the overhead light is absent, it puts the health worker at risk of possible cross infection. Poor suturing not in the respective layers might make the mother develop fistula

Neonatal death

Mother came in second stage with raptured membranes. 1^st baby was delivered with Apgar score of 5 at 1^st minute and at 5 min 0/10 (1.3 kg). Second baby came at 21:39 h with Apgar score of 0 (0.6 kg) at 1 min. Third baby at 22:00 with Apgar score of 6/10 at 1 min (1.3 kg) and was referred but also passed on after 2 days in Hospital. These babies would have been resuscitated well and if there were light and electricity, their lives would have been saved

Maternal death

There was a mother who came with a preterm pregnancy and she was already in second stage, so [the health worker] conducted the delivery, but because there was no sufficient lighting, [the health worker] didn’t notice the mother was anemic. [The health worker] referred the mother the next morning to [X] hospital but unfortunately, she died on the way. The story would have been different: if [the health worker] had adequate light, she would have referred her early

Panel B: Reasons Solar Suitcase Might Not Be Enough

 In response to the questions:

Please comment on any problems or difficulties you’ve had with using the Solar Suitcase or any of its components

How does lack of overhead light compare to other problems at this facility? Is it the most important problem, or are there other areas that you feel are more important to address?

 Problems with Solar Suitcase

Overhead LED light—does not last

When all 4 bulbs are switched on, sometimes when it has rained, lights go out very early in the morning at around 4:00am. Thus, if a mother comes that time, she delivers in the dim electricity. It has occurred once since it was installed

Overhead LED light—not bright enough

One night [the health worker] had a mother with a second-degree tear, yet the light from the solar was not enough and the mother was developing PPH [postpartum hemorrhage]. [The health worker] had to use the headlamp to repair the tear and then the bleeding also reduced

Doppler—unstable reading

Sometimes the fetal Doppler keeps disturbing [the health worker] by giving high and low reading some time

Doppler—gel running out

The only problem is when the gel gets done but other things are well and fine

Doppler—charging problems

One day [the health worker] had a mother and couldn’t use a fetal scope to check for fetal heart rate. The fetal Doppler also failed because it had not charged because the charger was faulty

Lack of training/

Midwife wasn’t trained on how to use it and admitted to have problems with charging the fetal Doppler, headlamp and the batteries separately, interpreting the charger lighting to detect any problems

Infrequent use

[The health worker] has hardly used the Solar Suitcase. She has only used it like once

 Other challenges

Lack of medical supplies/equipment

It’s not the only problem of the facility; there are other problems affecting the facility, including lack of mama kits to give out during antenatal visits or during delivery, lack of a resuscitation table, delivery bed, or equipment used in delivery (such as suture holders, episiotomy scissors, malfunctioning suction bulbs), lack of an incinerator or autoclave to sterilize equipment, low funds to purchase drugs (e.g., oxytocin and antibiotics) as the government supplies only class C drugs which are not the most needed at the facility

Lack of space

The maternity ward is very small with one delivery bed and one postnatal bed. Maybe those can be addressed first

Lack of clean water

[The health worker] stated that accessing water at the facility is her first priority and light problems would come second since at times they even have to postpone cleaning after delivery because of lack of water, especially in the dry season

Poor transportation/road conditions

Mothers came in second stage due to long distances and poor roads, which make them delay care. In addition, poverty in the community makes mothers go to traditional birth attendants and when it complicates, mothers are referred sometimes in second stage

Inadequate security

Lack of security personnel and fence for the health facility as well as staff quarters

Inadequate accommodation

The health worker feels the issue of accommodation should also be addressed because the staff quarters are not enough. Some of them improvised by sleeping in some rooms on the medical wing

Poor community relationship

Harsh community habits towards health workers, especially if there’s a stockout of drugs or equipment

Under staffing/heavy workload

Work overload, especially during clinic days for family planning, antenatal, HIV etc. There are usually only 2 midwives on duty

Improper waste disposal

Waste segregation bins are not enough and placenta pit is not in good condition

Patient poverty

Poverty has affected a lot of the health sector as some mothers are unable to provide baby clothes (babies are wrapped in cotton or men’s shirts). Some even fail to get a meal after birth

Late pay

The midwife said that she felt demotivated to work because she hasn’t received her salary for 4 months

Inadequate training/supervision

Inadequate continuous medical evaluation from supervisors. Poor supply of equipment. No in-service trainings