The global surgery blood drought: frontline provider data on barriers and solutions in Bihar, India

ABSTRACT

Background: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions.

Objective: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar – a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country’s blood transfusion system.

Methods: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility.

Results: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients’ families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention.

Conclusions: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought.

KEYWORDS:

• Blood transfusion system
• maternal mortality
• India
• health system strengthening
• obstetric hemorrhage
• global surgery

Responsible Editor Peter Byass, Umeå University, Sweden

Responsible Editor Peter Byass, Umeå University, Sweden

Acknowledgments

Dr. John Meara, Director of the Program and Global Surgery and Social Change, and Dr. Mark Shrime, Research Director of the Program and Global Surgery and Social Change, for their support of the entire research team.

Author contributions

Rachita Sood – Conception and design of study objectives and data collection material, data collection, primary writer. Rachel R Yorlets – Design of data collection material, data analysis, secondary writer. Nakul P Raykar – Conception and design of study objectives and data collection material, data analysis, critical revision of manuscript. Remya Menon – Design of data collection material, data collection. Hemant Shah – Design of data collection material, critical revision of manuscript. Nobhojit Roy – Conception and design of study objectives and data collection material, critical revision of manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

This study was approved by the Institutional Committee for Ethics and Review of Research of Ashirwad Ethics Committee, Ulhasnagar, India, and confirmed to be exempt from review by the Institutional Review Board at Boston Children’s Hospital in Boston, Massachusetts, U.S.A.

Paper context

Lack of timely, safe, affordable access to blood in many low-resource settings across the globe limits access to surgical care, leading to unnecessary patient deaths. This paper adds rigorous data from front-line providers’ experiences in an Indian state with a known deficit of blood. The innovative solutions identified by these providers meaningfully add local input to an ongoing multi-stakeholder, global process of integrating surgical care into national public health planning.

Additional information

Funding

This work, under Bihar Technical Support Unit project, was supported by a grant from the Bill and Melinda Gates Foundation (Grant ID# OPP1084426). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. RS was supported by a Fulbright-Nehru scholarship.