Poor power quality is a major barrier to providing optimal care in special neonatal care units (SNCU) in Central India

Background: Approximately 25% of all neonatal deaths worldwide occur in India. The Indian Government has established Special Neonatal Care Units (SNCUs) in district and sub-district level hospitals to reduce neonatal mortality, but mortality rates have stagnated. Reasons include lack of personnel and training and sub-optimal quality of care. The role of medical equipment is critical for the care of babies, but its role in improving neonatal outcomes has not been well studied. Methods: In a qualitative study, we conducted seven focus group discussions with SNCU nurses and pediatric residents and thirty-five key informant interviews and with pediatricians, residents, nurses, annual equipment maintenance contractors, equipment manufacturers, and Ministry of Health personnel in Maharashtra between December 2019 and November 2020. The goal of the study was to understand challenges to SNCU care. In this paper, we focus on current gaps and future needs for SNCU equipment, quality of the power supply, and use of SNCU equipment. Results: Respondents described a range of issues but highlighted poor power quality as an important cause of equipment malfunction. Other concerns were lack of timely repair that resulted in needed equipment being unavailable for neonatal care. Participants recommended procuring uninterrupted power supply (UPS) to protect equipment, improving quality/durability of equipment to withstand constant use, ensuring regular proactive maintenance for SNCU equipment, and conducting local power audits to discern and address the causes of power fluctuations. Conclusions: Poor power quality and its negative impact on equipment function are major unaddressed concerns of those responsible for the care and safety of babies in SNCUs in Central India. Further research on the power supply and protection of neonatal equipment is needed to determine a cost-effective way to improve access to supportive care in SNCUs and desired improvements in neonatal mortality rates.


Introduction
In India, 600,000 neonates die every year, mostly from preventable causes 1 . The proportion of neonatal deaths in children under age five years increased from 48% to 59% between 2000 and 2016 1 . The Indian Ministry of Health and Family Welfare aims to increase the proportion of births in health facilities and, beginning in 2003, established Special Neonatal Care Units (SNCUs) in district and sub-district level hospitals to reduce neonatal mortality for small and sick babies. SNCUs provide Level II care to neonates: 24-hour care by trained neonatologists, staff nurses, and support staff for infants born after 32 weeks' gestation and weigh more than 1500g at birth 2 . These infants are typically physiologically immature and moderately ill but expected to recover quickly; they also do not need subspecialty services on an urgent basis. Medical equipment in the SNCU includes radiant warmers, phototherapy units, devices that deliver continuous positive airway pressure (CPAP), and incubators 3 .
Previous research has focused on shortages of personnel in SNCUs 4 , the need for improvements in training of SNCU staff 5 , and improved quality of care, particularly compliance with evidence-based guidelines. A neglected opportunity for improvement is the role of medical equipment to optimize staff support and efficiency, a strategy that frequently benefits patient outcomes 6,7 .
Medical equipment is critical for the supportive care of babies in the SNCUs. Suboptimal functioning of equipment or inability to use the equipment has led to adverse outcomes in neonates 8 . The Indian Government recommends the following measures be adopted for general maintenance and optimal functioning of equipment: provide power back up, conduct regular SNCU power and equipment audits, train staff in equipment usage and preventive equipment maintenance, maintain technical support systems of equipment technicians and engineers, and outsource maintenance services when appropriate 8 . UNICEF's toolkit for establishing SNCUs provides specifications related to electrical supply, including ensuring that each piece of SNCU equipment has 24-hour uninterrupted stabilized power supply, a backup power supply, and a generator 9 . To date, there is little evidence as to whether these specifications are being implemented in SNCUs.
To address this gap in knowledge, we conducted a qualitative study in Maharashtra between December 2019 and November 2020 to better understand the barriers and facilitators to providing optimal care for neonates in the SNCUs and the gaps and future needs for SNCU equipment. This paper focuses on the quality of the power supply, its effect on the functioning of the equipment, and the specific equipment-related needs of front-line health care workers.

Design
To explore power quality and equipment-related barriers to care for neonates in the SNCUs, we conducted Focus Group Discussions (FGD) and Key Informant Interviews (KII) with care providers, hospital and government administrators, equipment manufacturers and maintenance contractors.

Data collection Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs).
The research team purposively selected nine hospital facilities including district general hospitals, sub-district hospitals, trust hospitals, and medical colleges with SNCUs, Neonatal Intensive Care Units (NICUs), and Specialized Newborn Units (SNBUs). Participants in the focus group discussion (FGD) and key informant interviews (KII) included pediatricians, pediatric medical residents, medical officers, and nurses who consented to be interviewed and were over the age of 18. KII participants also included SNCU/NICU equipment distributors, annual maintenance contractors, equipment designers, and equipment manufacturers who worked in the study districts and were over the age of 18. A total of 66 individuals (35 key informants and 31 FGD participants) participated in the study (please see Table 1 below for more detail). The research team conducted seven FGDs (two with pediatric residents (three and four participants) and five with SNCU staff nurses (four to six participants in each). One in-charge nurse at one facility refused to participate in a KII and did not give a reason. While two FGDs were planned for another facility, these were cancelled due to a staff shortage caused by COVID. FGDs and KIIs explored perspectives on equipment function and use, gaps and needs for medical equipment for different types of newborn units, and the impact of power quality on optimal function of the equipment The research team developed, pilot-tested and revised FGD and KII guides. FGDs and KIIs were conducted on site at each facility by trained study staff (one interviewer, co-author Cherryl Kohle, MSc, MPH, LMRF Research Associate, and a notetaker) with expertise in qualitative research methods and analysis. Initial meetings between the research staff and the hospital staff were initiated to build rapport and schedule interviews at convenient times. At each site, the newborn care unit director or his/her designate determined which staff were eligible for interviews based on the eligibility criteria above. The research team arranged meetings with eligible participants where the study goals and procedures were explained. Participants were introduced to the study interviewer who is an experienced qualitative researcher in the healthcare field. Participants were informed that there would be no adverse consequences of not participating. Those interested underwent informed consent procedures and, if they agreed to participate, they were asked to sign the written study consent form. FGDs and KIIs were conducted in private areas at each facility and audio taped. Participants were compensated for their time with a payment of approximately USD 10. The interviewer and notetaker met after each interview to write a summary of the interview process. Each participant participated once, and no repeat interviews or FGDs were conducted. All transcripts were de-identified for analysis.

Data analysis
The study team used a Grounded Theory 10 approach to understand SNCU staff perspectives on the use and functionality of the newborn care unit equipment in India. Interviews were conducted in English or Marathi and audio-recorded for transcription. All interviews in Marathi were transcribed and translated verbatim from Marathi to English. Each transcript was uploaded into NVivo V.12 (RRID:SCR_014802) (An open-access alternative is R Stats (R Project for Statistical Computing, RRID:SCR_001905)) and coded using line-by-line coding followed by focused coding to identify major themes emerging from the data, a common approach using Grounded Theory. Three coders (one PhD medical anthropologist and two Master's level public health research assistants) read through the initial 10 transcripts to develop a codebook with parent, child, and grandchild codes and to ensure consistency across coders. The team updated and revised the codebook after reviewing all transcripts and then used the final codebook to code all the transcripts. The team used the constant comparative method to establish analytical distinction and make comparisons throughout the analysis. The team identified themes, patterns, and relationships between themes, and as themes emerged from the data, compared them across transcripts. We used the socio-ecological model as a guiding framework to identify themes, patterns, and relationships between themes regarding equipment and power-related barriers and facilitators to providing optimal care for neonates in the SNCUs at the individual, interpersonal, facility, and systems levels (underlying data 11 and extended data 12 can be found on Zenodo). Due to study procedures and the Covid-19 lockdown, transcripts were not shared with participants for corrections and findings were not presented to participants for feedback. Table 1 provides the number of participants by facility type, participant type, and method (either FGD or KII). A total of 66 individuals participated in the study, including 35 key informants and 31 participants in seven FGDs.

Results
The participants in our study discussed several equipmentrelated barriers and facilitators to providing optimal care for babies in the newborn care units.
Major themes: equipment-related barriers to providing optimal care for babies in the newborn care units The following two major themes emerged from the KIIs with equipment manufacturers, AMC contractors, and Ministry of Health personnel as well as KIIs and FGDs with clinical staff and administrators working in the nine study facilities: • Power sags, surges, and spikes lead to equipment compromise and malfunction. In-charge sister 2 Maintenance contractor Ministry of Health personnel • Poor quality equipment and constant use lead to frequent breakdowns and need for repair.

Power sags, surges, and spikes lead to equipment compromise and malfunction.
Disturbances in power quality such as sags (rapid short-term voltage decrease), surges (rapid shortterm voltage increase), spikes or impulses (extremely high increase in voltage within a duration measured in microseconds), and outages (complete power loss for any period of time) can lead to the breakdown of equipment over time (https://www. gradianhealth.org/). While unit staff do not perceive the quality of the electrical supply to be a problem, AMC contractors and equipment manufacturers are concerned that sags, surges, and spikes in the power, especially frequent outside of metropolitan areas, can damage equipment. These events are particularly dangerous for warmers that can cause short circuits. A power supply card is an electric board that provides wiring for sensor inputs and power outputs. These electric boards or boxes come at a price and size depending on the type of electrical load expected. The 207 power supply card the participant mentions is a system used mainly for industrial applications and under certain non-explosive environmental conditions. Given the limitations of the power supply card, the participant is suggesting that they have used a Surface Mount Technology System (SMTS) that allows a circuit board to have customized circuits. The advantage of the SMTS is that because the circuit board is customized the manufacturer can adjust the power threshold of the circuit depending on the type of electrical work. However, the participant suggests that even the SMTS posed its own limitations which made them switch to a combination system of Electromagnetic Interference (EMI) sockets and Switch Mode Power Supply (SMPS). EMI sockets are small circuits that contain these voltage fluctuations. SMPS is a type of electric circuit and uses power from devices that are frequently turned on and off at a high frequency to maintain a desired level of voltage required by a piece of equipment. The participant is saying that a combination of EMI sockets and SMPS has worked most effectively in addressing equipment voltage. The above participant indicates that when the warmer is not in use, it is not switched off from the electrical source (outlet switch). Rather the on/off switch on the equipment itself is used instead of the button where the equipment is plugged in. This implies that the power is not completely off, and therefore the equipment is susceptible to potential voltage fluctuations.
Other participants mentioned the load is too much for the age of the electrical lines within the hospital.
There are a lot of problems.

Facilitators
Major themes: Power quality and equipment-related facilitators to providing optimal care for babies in the SNCU The following major themes were identified as power quality and equipment-related facilitators to optimal care for babies in the SNCU: • The power supply is stable due to generators.
• Equipment is user-friendly.
• The central government is investing in the power supply at the state and local levels, including the support to power audits.
The power supply is stable due to generators. Clinical staff at one trust hospital were not concerned about the electrical supply because of the use of generators and stabilizers at this facility. All health facilities included in the study had working generators. However, these staff do not have a background in electrical engineering and many facilities do not have biomedical engineers on staff. • Procure stabilizers to ensure equipment does not get damaged.
• Improve quality/durability of equipment to withstand constant use.
• Organize local power audits to discern and address the causes of power fluctuations.

Discussion
Neonatal equipment to monitor and treat certain conditions is critical to the survival of babies in neonatal units worldwide.
Our study found several barriers to the function and effective use of medical equipment in neonatal care units, the most important of which were poor power quality straining old and poor-quality equipment and inefficient and/or poor-quality equipment repair that resulted in limited unavailability of critical equipment. Facilitators of neonatal equipment use included reliable and steady power, user-friendly equipment, and the ability of the state to conduct power audits at the state and local levels.
Recommendations focused on what could be done to improve the quality of the equipment by manufacturers, the quality and timeliness of maintenance and repair by AMC contractors, and the quality and stability of the power supply by the facilities and the government.
There is a paucity of data on the effects of poor quality and unstable power on the proper functioning of neonatal care equipment in India. To our knowledge, this is the first study to document the understanding among stakeholders of these effects on crucial neonatal equipment. Much can be done in the short term, including provisioning each unit with its own generator, uninterrupted power supply, and power conditioners, regular training on equipment use, proactive repairs, and power audits. However, overall improvements in the quality of the power at local and district levels will take time. Manufacturers play an important role in fully comprehending the real-world challenging circumstances in which their equipment will be used. Manufacturers must build equipment that is safe and able to tolerate constant use, sags, surges and spikes in the power supply.
While hospital staff did not perceive the quality of the electrical supply to be a problem, AMC contractors, bioengineers, and equipment manufacturers indicated that the frequent sags, surges and spikes may be compromising the integrity of the equipment. Equipment manufacturers and AMC contractors recommended uninterrupted power supply (UPS) and stabilizers be installed in all facilities to protect equipment. Surges, spikes, swells, sags or brownouts, noise and outages, all common in low-and middle-income countries, can damage sensitive medical equipment and put patients at risk (https:// www.gradianhealth.org/). Facilities need to invest in protective devices such as UPS, stabilizers, and power conditioners to mitigate and prevent damage to neonatal care equipment. State power audits would help to determine how best to address the power quality problem.
Other studies have reported poor quality equipment, frequent breakdowns, and slow repairs of equipment in the neonatal units in India 4 . Consequences of fewer functioning pieces of equipment include sharing of equipment between infants that increases the risk of nosocomial infection. AMC contractors must understand how unstable power can damage each piece of equipment and proactively monitor the equipment to ensure small shocks are addressed before the equipment fails completely. AMC contractors also need to be held accountable for regular maintenance and timely repairs, and government facilities need to invest in procuring safe and reliable equipment.
Equipment end-users in the clinic must be properly trained to use the equipment and to detect under-functioning and stress on the equipment. Our study agreed with other studies that have reported that lack of training is a key barrier to proper use of equipment and optimal care for neonates 4,[13][14][15] .
Training staff on the correct and optimal use of neonatal equipment prior to caring for sick neonates needs to be prioritized, as does a new focus on retraining to ensure staff are up to date on the latest equipment.
Other studies in India have documented the improvements in the quality and reliability of neonatal equipment over time 3 as well as the expansion of access to care at SNCUs throughout India 4,9 . However, compared to government facilities, trust and private hospitals appear to have better access to higher quality equipment and conduct more regular training on the proper use of the equipment.
This study has a number of strengths. First, our interviewers were highly trained and have several years of experience conducting qualitative research in the Indian context. Our analytical team systematically coded and analyzed the data using an intensive Grounded Theory approach to identify the major themes, patterns, and relationships between themes that focused on power quality and SNCU equipment. This study also has a few limitations. First, the results of this study cannot be generalized to other types of neonatal facilities (e.g., neonatal intensive care units (NICUs) or to facilities beyond our study catchment area in a district of Maharashtra State. The majority of our participants were clinical staff and their knowledge of power quality was limited. We interviewed two biomedical engineers (working for equipment manufacturers) regarding power quality and efforts to maintain that quality in the face of sags, surges, and spikes, in part due to the impact of the COVID-19 pandemic that limited time available during the grant. In addition, since SNCU directors selected eligible staff to participate in interviews and focus group discussions, it is possible that the individuals deemed eligible might not represent the opinions of other staff who were not selected.

Conclusion
Our study puts a new focus on the consequences of poor power quality, not just power availability as a cause of compromised equipment, e.g., micro-and macro-level damages to the equipment that are not detected by the end users. Generators are increasingly available and may ensure the power goes back on, but most SNCUs do not have uninterrupted power supply /power conditioners and stabilizers to prevent shocks to the equipment from sags, surges and spikes. Further research is needed to understand a cost-effective way to improve power quality at the central and/or facility level and whether this translates to reductions in neonatal mortality in at-risk babies in SNCUs. For more information, please see website: https://sites.bu.edu/BB4B

Data availability
Underlying data Zenodo: Underlying data for 'Poor power quality is a major barrier to providing optimal care in special neonatal care units (SNCU) in Central India', https://doi.org/10.5281/zenodo.5737387 11 .
This project contains the following underlying data: -Quotes matrix_BB4B.xlsx The audio transcripts are not openly available for data protection reasons because, despite removing identifiable information such as names and organizational affiliations, we risk revealing individual identifies through the interview responses. As part of the written consent agreement with participants, we assured them of anonymity when presenting synthesized findings. Requests for data must be provided in writing and should include a detailed rationale. All requests must be made by email to Lisa Messersmith at ljmesser@bu.edu. Access may be granted for legitimate research purposes. The Boston University Medical Center IRB will review all requests.

Julia Johnson
Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA The authors present their work on identification of barriers to care delivery, with a focus on medical equipment, in special neonatal care units in central India, which involved focus group discussions and key informant interviews with frontline clinical staff and Ministry of Health personnel, as well as contractors and manufacturers of such devices and equipment. The methods section clearly describes the study's approach, using Grounded Theory. Major themes identified included equipment-related barriers, including the impact of an unstable power supply and poor equipment quality/needs for repair. Focus group and key informant interview participants provided recommendations to improve care, to include procurement of stabilizers, improvement of equipment quality, conduct of regular equipment maintenance, and use of local power audits.
The inclusion of contractors and manufacturers in this qualitative study addresses a gap in the literature, as the focus of neonatal care delivery is often on the clinical aspects of care, rather than the infrastructure required to ensure care delivery. The authors recognize a disconnect between barriers identified by this important group of stakeholders and those identified by healthcare workers, as unit-based staff were less likely to recognize or identify the impact of electrical supply quality on care delivery.
A strength of this study is the inclusion of concrete action items to address some of the identified barriers. However, the capacity to implement these changes is of course resource-dependent and will partially depend on support by the government and other entities outside of the healthcare facility, in particular for improvement of electrical supply quality. Innovative approaches to reducing dependence on local power supply and improving quality of equipment for healthcare delivery will be needed while larger infrastructure improvements are addressed.
There are of course other barriers related to the use and functionality of equipment in neonatal care delivery and the authors could consider a summary of these, if they were identified during the focus groups or key informant interviews. Additionally, how these barriers may interact with the larger work system and other aspects of neonatal care delivery could be presented visually to aid in contextualizing this work.
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