Where There is No Light: A Mixed-Methods Exploration of Quality of Obstetric Care and Energy Access in Low and Middle Income Countries and the Impacts of a “Solar Suitcase” Intervention

Background/nMaternal and newborn mortality remain a pervasive problem in Sub-Saharan Africa and Asia; annually, as many as 300,000 maternal deaths occur worldwide from complications of pregnancy and childbirth. One million newborns do not survive their first day of life. Interventions to reduce facility-based maternal and newborn mortality often assume the presence of continuous light and electricity. In 2018, a detailed review of 128,000 health facilities in 78 low and middle income countries showed 59% lacked reliable electricity. This dissertation analyzes in-depth interviews of frontline health workers in 11 countries to examine the impact of unreliable electricity on emergency obstetric and neonatal services. It recounts the design and dissemination of a scalable solar electric intervention, called the Solar Suitcase, and examines its impact on maternal-newborn care./nMethods/nThe Solar Suitcase intervention was developed as a result of formative ethnographic research in 2008 by the author at a state hospital in Nigeria. The author described grim conditions in the hospital and her emerging conclusion that the lack of continuous electricity impaired the execution of life saving emergency obstetric and newborn care. She describes how she partnered with others provide solar power to one hospital, and later, how a compact rugged solar electric system tailored for maternal health care sparked an organization, We Care Solar that is dedicated to healthcare electrification in under-resourced health systems, as well as a movement to eradicate energy poverty in maternal healthcare./nThe research studies within this dissertation utilize an existing database of in-depth interviews obtained by We Care Solar and partner organizations in 11 sub-Saharan African and Asian countries over the course of 10 years (2010 – 2019). A total of 1,213 semi-structured interviews were conducted with health workers in energy-deficient facilities before and 3–18 months after a solar electricity intervention. Interviews focused on current and/or past experiences conducting maternal-newborn health services in energy-deficient facilities. Topics included electricity reliability, alternative lighting sources, routine and emergency care, referral patterns, financial burdens, health worker morale, and patient-provider relations. Responses were documented in written or audio formats, translated when necessary, transcribed, and coded using Atlas.ti. Analyses followed the principles of Grounded Theory./nResults/nHealth workers in energy-deficient facilities reported their dependence on suboptimal light alternatives including kerosene lanterns, candles, torchlights, and cell phone lights, prohibiting efficient and effective care. They recounted difficulties in routine activities (reading medicine records, writing notes, locating equipment, maintaining hygiene), and performing standard Emergency Obstetric and Newborn Care signal functions (treatment of hemorrhage, eclampsia, obstructed labor, sepsis, and newborn resuscitation). The lack of visibility reportedly affected patient health-seeking behavior and referral patterns. Health workers described personal frustration, fear, and lack of confidence working without reliable electricity./nBy contrast, health workers in facilities equipped with essential electricity and continuous medical lighting 3-18 months before their interviews reported a greater sense of confidence and efficiency, less fear of night time care, and a better ability to make decisions. With an improved working environment, health workers further described the provision of more timely procedures, enhanced management of obstetric emergencies and newborn care, improved sanitation and infection control, appropriate referrals, and improved mobile communication. Health workers perceived increased utilization of maternal services after the solar intervention, and cost savings for patients and health workers. /nConclusion /nMaternal health providers in health centers lacking adequate and reliable electricity face significant challenges conducting routine and life-saving care. The conditions they describe indicate that health facility electricity, and in particular light, plays a critical role in the perceived quality of care, health worker experience, and patient health-seeking behavior. Health workers provided with access to reliable light and electricity via a compact, rugged solar electric system, report greater confidence and ability to conduct routine and emergency obstetric procedures.  Access to reliable lighting and basic electricity are a necessary, but not sufficient, component of quality maternal and newborn care. Energy access programs must be included in any comprehensive approach to improving quality of care and should complement other interventions designed to improve maternal and child health.

Advisor: Minkler, Meredith