Table 3 Illustrative quotes from identified themes

Theme 1: Shortages of supplies, infrastructure, and staff mean CPAP is not always available and/or of the highest quality

“With that budget we can use, say 10 circuits (per 3 months), whereas we have 6 new cases who need CPAP per week. So, we are obliged to reuse circuits, humidifiers, and prongs. These are not autoclavable, we disinfect them but this is not ideal.” (Consultant Neonatologist, medical college, IDI 6)

“Equipment is not available, I mean the sizes of the prongs, sufficient caps and all that equipment are not available. We haven’t been able to use it (CPAP) as much as we should.” (Medical Officer, medical college, IDI 17)

“We only have three CPAP machines. Sometimes more than five babies need CPAP at the same time” (Nurse, medical college, FGD 1)

“We have 20 CPAP machines, but only five or six are working. If we get more preterm babies, we have a shortage.” (Senior Resident, medical college, IDI 18)

“The main problem is the number of babies compared to the number of personnel. At times, we are not able to deal with cases needing urgent care. Sometimes we have three babies in a serious condition and only one doctor to take care of them.” (Senior Resident, medical college, IDI 1)

“Our main issue is shortage of staff in nursing. We are sometimes rotated to other wards and we face emergencies especially in the evenings and nights. We may have to deal with 20–30 babies and there will be just the two of us. Feeding has to be done at almost the same time. How can two of us do it?” (Nurse, medical college, FGD 6)

“We put him under CPAP, he improved but then we had a power cut which lasted for many hours, 6 h, and he immediately deteriorated. We had to intubate him to refer him but the vehicle for transfer took too much time to come. Then he died before we could refer him” (Medical Officer, district hospital, IDI 4)

“I don’t think we had a case of pneumothorax, but as I mentioned we don’t do x-rays as we had no mobile X-ray machine.” (Doctor, district hospital, IDI 4)

“Because of lack of monitoring, some babies go into (cardiac) arrest or apnoea, and nobody is there, if apnoea is not corrected they go into arrest and babies die immediately, within a fraction of seconds. So, if more staff was there, babies could be monitored better.” (Senior Resident, medical college, IDI 17)

“Because there is a rush of cases and the shortage of staff, and the fact that CPAP requires continuous monitoring, we are not able to focus on non-CPAP cases.” (Nurse, medical college, FGD 1)

Theme 2: Poor organisation support hinders optimal implementation of CPAP and neonatal care

“If they were guidelines on how to use the money, then the Head of Department and the supplier would communicate better. We need a better process of stock management and supply delivery.” (Consultant Neonatologist, medical college, IDI 6)

“Some of the nurses rotate after 3–6 months to other wards (internal medicine, psychiatry), and so, in this short period of time they do not gain enough confidence to enjoy using this device (CPAP).” (Senior Resident, medical college, IDI 3)

“I was alone one day in the ward and there was a power shut down for nearly 5–6 h. There was a baby on CPAP. I began giving oxygen through ambu (bag and mask). There was a security guard outside. He was helping me with other things, but to ventilate with ambu, you need to be trained technically. I asked my superiors for help, to send my colleagues (who were in OT or labour room) or any other nurses to assist me. They told me to manage with the security guard. When I told them that he does not know how to use the ambu, they told me that I should have anticipated this situation and should have trained him in preparation.” (Nurse, district hospital, FGD 5)

“Whenever we get into a crisis because of a baby dying, no one comes to support us. If it happens, the administrators tell us that they cannot be responsible for what we have done. There is absolutely no support. Everyone treats the newborn unit as an external unit.” (Nurse, district hospital, FGD 5)

“We don’t know who will solve our problems, whoever we ask, they blame each other, they say they are not responsible as we are under the jurisdiction of the central government.” (Nurse, medical college, FGD 6)

“The entire hospital does not value our services. By this I mean that nobody supports us. Not even the nursing superintendent understand us. We feel isolated. They say since we are from the National Health Mission and they are from the state government, we have to go to the National Health Mission to deal with our problems. There is no one to represent us in the hospital.” (Nurse, medical college, FGD 1)

Theme 3: Healthcare providers feel powerless to provide better care for neonates’

“The power in our hospital comes and goes every 5–15 min. At times, we run out of oxygen cylinders and we have to rush to place an indent and order it. Sometimes, the cylinders are not available even in the store. We become so helpless. We lose our confidence, especially when we are alone.” (Nurse, district hospital, FGD 5)

“The night can be quite hectic, because if three emergency cases are admitted, at least one nurse should be with the doctor to resuscitate the baby, otherwise how can we do it? how can the sisters cope?” (Medical Officer, district hospital, IDI 7)

“The work load is very high and in the afternoon, we are tired and we are not able to offer 100% of the care. In the long term this may have an impact on our motivation.” (Consultant Paediatrician, medical college, IDI 2)

“Sometimes we are alone. The rest of us must go to OT and labour ward. There is so much pressure to give EBM, monitor vitals, handle admissions, sometimes deal with oxygen shortage, giving ambu, connect to ventilator, etc. It is so much stress.” (Nurse, district hospital, FGD 5)

“When the power goes off, there is no air flowing. We ourselves feel frustrated. We can only imagine how the babies must be feeling.” (Nurse, district hospital, FGD 7)

“Yes. Everything of CPAP, we reuse: nasal prongs, circuits, caps. We do not have the choice (…) We are happy to see the baby is given CPAP but also fear and pray that there should not be any infections because of reusing the prongs.” (Nurse, district hospital, FGD 7)

Theme 4: Healthcare providers perceive CPAP as a beneficial intervention

“We are still using CPAP (despite all the constraints), we don’t want to lose the babies” (Consultant Neonatologist, medical college, IDI 13)

“Definitely, I would recommend it, it (CPAP) has a positive impact on preterm and term babies, but still we have to improve the quality of our work” (Senior Resident, medical college, IDI 18)

“There are more advantages than disadvantages of using CPAP” (Nurse, district hospital, FGD 7)

“It prevents the need for mechanical ventilation, prevents the complications of mechanical ventilation, the comfort of the baby is better” (Medical Officer, district hospital, IDI 9)

“Earlier, when we got babies with severe respiratory distress, we used to refer them to other facilities. Now we can manage it ourselves.” (Nurse, district hospital, FGD 2)

“CPAP is an easy procedure, we can use it here in a safe way” (Medical Officer, district hospital, IDI 10)

Theme 5: CPAP enables nurses to work independently

“It is easy to place, easy to remove; it is not difficult to use CPAP.” (Nurse, medical college, FGD 6)

“We have no problem in connecting the CPAP and we are well trained and are able to operate the machine with ease.” (Nurse, district hospital, FGD 7)

“Using CPAP is very simple and [nurses] can do it independently, they don’t need to ask us, whereas the monitoring of mechanical ventilation needs a lot of technical expertise. With CPAP, [nurses] can take their own decisions and act very well.” (Senior Resident, medical college, IDI 3)

“We do not need doctors to operate CPAP. Doctors are very busy and mostly not available. We can operate the CPAP by ourselves. We cannot do the same with ventilators” (Nurse, medical college, FGD 1)

“We, nurses, operate the machines on our own, many times without the help of doctors- be it identifying the baby who requires CPAP or placing the prongs, positioning the baby, or recording the Silvermann score. We do it by ourselves” (Nurse, medical college, FGD 8)