Table 2.

Key themes identified in provider interviews.

Themes	Illustrative Quotes and Excerpts
Theme 1: Pervasive blood shortages force facilities to require replacement donation	‘That is why this whole problem of donor exchange is happening. [Blood banks] have no option but to ask for something in return. At some points they would have just 20 bags. So if you keep giving blood, your blood will be gone in a day’ [Participant number 3].
Blood availability is variable	When there are severe anemia cases like who come to us with hemoglobin 6 then it is important to transfuse on time. At that time, the blood bank doesn’t have it. We also can’t get a donor. So blood is not available [Participant number 9]. Blood availability is no longer an issue at our facility due to help from our support partners. We also have a tie-up with red cross, which provides our patients with blood when our blood bank is short of units, especially negative blood [Participant number 16].
Patient education and cultural norms	‘There is havoc among people that, I’ve given blood, I’m going to die… Twenty attendants will be there and then run away. …The lady [patient] herself will say, “Don’t call my husband, don’t call my son”’ [Participant number 4].
Theme 2: When blood is available, additional barriers delay or prevent transfusion	‘If we ask for blood in the morning, then we will get it by evening. It easily takes six hours. For educated patients, it can even take two or three hours. But the patients who are illiterate have a lot of problems’ [Participant number 9].
Geographic barriers	We usually don’t ask for blood transfusion prior to transfer as our blood bank is 30–45 minutes away (in old district hospital campus) and getting blood can be time consuming, which can further agitate the relatives [Participant number 14].
Infrastructure	So the first thing would be that there would be no bulbs – to collect blood from patient and send it to BB for cross matching [Participant number 3]. Our hospital is not well equipped to handle any blood transfusion reaction [Participant number 18]. No facilities for investigating patients’ hemoglobin levels, so that we can convince relatives for the need for blood transfusion. Also most patients are not registered and have no idea about their blood group and as we don’t have a 24-hour lab we cannot determine their blood group [Participant number 18].
Workforce	There is not adequate staff at the blood bank so there is a delay in the process [Participant number 6]. Our nurses are unaware of the blood transfusion protocols and are unwilling to transfuse blood during their shift fearing transfusion reactions. No blood transfusions are done after 5 pm at our facility [Participant number 19].
Protocols for coordination	‘There was no liaison between the hospital and the blood bank… no protocol in place to get blood quickly. Even if you send the relative to go to Red Cross blood bank he would be lost. So many times we would be waiting one and a half hours – where is the relative? There would be no one to show him the way to the blood bank. These people are coming from rural areas – they would get lost’ [Participant number 3].
Affordability of blood	‘The most important is cost. It costs 2000–2500 INR [30 to 38 USD] if replacement donation is not given. If replacement is given, then it costs 800 INR.’ The poor patients who come, for them the cost is too much and their hemoglobin is low. The educated patients who come. Their hemoglobin is good and the cost is also okay. Educated and poor patients come to my clinic. Both sometimes refuse blood transfusion [Participant number 11].
Theme 3: Disparities exist between public and private care settings	In private practice we have to own everything we do. Like if we don’t treat the patient well… in the district hospital there isn’t good treatment given [Participant number 11].
Theme 4: Providers work around blood shortages	‘Sometimes there is a delay so we give colloids to keep the blood pressure stable.’ Sometimes we give injectable iron. For elective cases: ‘On the operation day, the donor stays in [the medical college hospital] near the blood bank. If blood is required, we get it and there is no delay’ [Participant number 6].
Providers acquire blood without replacement in emergencies	If they are too poor to get blood, we have nowhere to send them. The post-graduate goes to the blood bank and writes ‘MND’ – money and donor not available. Every day there is one patient like this [Participant number 8].
Mutual vulnerability forces referral	For example: an unregistered multiparous woman was brought in an auto-rickshaw to our district hospital with antepartum hemorrhage and before the relatives could arrange for blood as ordered by the on duty doctor, the patient died. There was resultant mob violence and since then we have decided to refer all such complicated patients to higher center and not take any risks [Participant number 14].
Theme 5: Blood shortages affect patient care	A lot of times diagnosed case of placenta previa or uterine rupture… these cases would be referred to the district hospital and the surgeon would refuse to touch the patient without blood. And when you don’t get blood or you get blood within 3–4 hours either the patient is already dead or the doctor has already left [Patient number 3].