Healthcare providers' views and perceptions on post-mortem procedures for cause of death

16 Pages·2017·0.75 MB·English

RESEARCHARTICLE
Healthcare providers’ views and perceptions
on post-mortem procedures for cause of
death determination in Southern
Mozambique
MariaMaixenchs1,2*,RuiAnselmo2,AriadnaSanz1,PaolaCastillo1,3,EusebioMacete2,4,
CarlaCarrilho5,6,JaumeOrdi1,3,ClaraMenendez1,2,7,QuiqueBassat1,2,8,9,
KhatiaMunguambe2,6
a1111111111
a1111111111 1 ISGlobal,HospitalClinic—UniversitatdeBarcelona,Barcelona,Spain,2 CentrodeInvestigac¸ãoem
Sau´dedeManhic¸a,Maputo,Mozambique,3 DepartmentofPathology,HospitalClinicofBarcelona,
a1111111111
UniversitatdeBarcelona,Barcelona,Spain,4 NationalDirectorateofPublicHealth,MinistryofHealth,
a1111111111
Maputo,Mozambique,5 DepartmentofPathology,MaputoCentralHospital,Maputo,Mozambique,
a1111111111 6 FacultyofMedicine,EduardoMondlaneUniversity,Maputo,Mozambique,7 ConsorciodeInvestigacio´n
Biome´dicaenReddeEpidemiolog´ıaySaludPu´blica(CIBERESP),Madrid,Spain,8 CatalanInstitutionfor
ResearchandAdvancedStudies(ICREA),Barcelona,Spain,9 PediatricInfectiousDiseasesUnit,Pediatrics
Department,HospitalSantJoandeDe´u(UniversityofBarcelona),Barcelona,Spain
*[email protected]
OPENACCESS
Citation:MaixenchsM,AnselmoR,SanzA,
CastilloP,MaceteE,CarrilhoC,etal.(2018) Abstract
Healthcareproviders’viewsandperceptionson
post-mortemproceduresforcauseofdeath
determinationinSouthernMozambique.PLoSONE
Background
13(7):e0200058.https://doi.org/10.1371/journal.
pone.0200058 Theminimallyinvasiveautopsy(MIA)isbeinginvestigatedasanalternativetothecomplete
Editor:AlexanderHeazell,Universityof diagnosticautopsy(CDA),goldstandardforCoDdetermination,insettingswhereCDAis
Manchester,UNITEDKINGDOM unfeasibleand/orunacceptable.Weaimedtoexplorehealthcareproviders’viewsandper-
Received:March9,2018 ceptionsontheoreticalandfactualacceptabilityoftheCDAandtheMIA.
Accepted:June15,2018
Methods
Published:July6,2018
Aqualitativestudy,combiningethnographicandgrounded-theoryapproaches,wascon-
Copyright:©2018Maixenchsetal.Thisisanopen
ductedwithinaprojectaimingtovalidatetheMIAtoolagainsttheCDAforCoDinvestigation.
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,which Wepresentdataonin-depthandsemi-structuredinterviewsof33healthcareproviders
permitsunrestricteduse,distribution,and operatingwithintheformalandinformalhealthservicesinSouthernMozambique.MIAper-
reproductioninanymedium,providedtheoriginal
ceptionwasanalysedthroughthetheoryofdiffusionofinnovations.
authorandsourcearecredited.
DataAvailabilityStatement:Thedataprovided Results
cannotbemadeavailableduetoethicalconstraints
fromtheHealthBioethicsNationalCommittee, AllparticipantsconsideredCDAusefulforCoDdetermination.CDAwasperceivedreliable,
Mozambique,asparticipantshavenotprovided buttheunpleasantnatureoftheprocedureanditsassociatedinfectionriskwerethemain
informedconsentfortheirdatatobestoredina
perceiveddisadvantages.ParticipantsconsideredtheMIAsimple,easyandquicktoper-
publicrepository.Datacanberequestedto
form;likelytomeetfamilies’expectationstoknowtheCoD,andabletoprovideevidence-
ISGlobal’sDataManagementandBiostatisticsUnit
(contacte-mail:[email protected]). basedknowledgefordiseasemanagement.Concernswereraisedonitsreliabilitycom-
paredtotheCDA.Family’semotionalstatusandaccessibilitytodecision-makersweremen-
Funding:TheCaDMIAresearchproject(Validation
oftheminimallyinvasiveautopsytoolforcauseof tionedasprincipalbarriersforMIAperformance.ThemainjeopardizingfactorsforMIA
PLOSONE|https://doi.org/10.1371/journal.pone.0200058 July6,2018 1/16
Healthcareproviders’viewsonpost-mortemmethodsinMozambique
deathinvestigationindevelopingcountries)was implementationweretheshortageofrequiredresourcesandthesignificantproportionof
fundedbytheBill&MelindaGatesFoundation peopledyingathome.KeyfacilitatorsforMIAacceptanceincludedtheneedforthesupport
(GlobalHealthgrantnumbersOPP1067522;QB)
fromcommunityandreligiousleaders,provisionofclearinformationtothecommunity,and
(http://www.gatesfoundation.org/)andbythe
SpanishInstitutodeSaludCarlosIII(FIS,PI12/ accompanimenttobereavedfamilies.
00757;CM)(https://portalfis.isciii.es).Data
analysishasbeensupportedbytheCaDMIAplus
Conclusions
researchproject,fundedbytheBill&Melinda
GatesFoundation(Globalhealthgrantnumbers
HealthcareprovidersconsidertheMIAspotentiallymoreacceptableandfeasiblethan
OPP1128001;JO)(http://www.gatesfoundation.
CDAsinplaceswherethelatterhaveshownsignificantimplementationchallenges.Aclear
org/)andtheSpanishInstitutodeSaludCarlosIII
(AccionesCIBER;CM)(http://www.ciberisciii.es/). understandingofhealthcareprovider’sperceivedbarriersandfacilitatorsforconducting
QBhasafellowshipfromtheInstitucio´Catalanade post-mortemproceduresingeneral,andMIAsinparticular,willshedlightontheirfuture
RecercaIEstudisAvanc¸ats(ICREA)agency
fieldimplementationformorerobustmortalitysurveillance.
(cid:3)(https://www.icrea.cat/)(cid:3)<https://www.icrea.cat/>.
ISGlobalisincludedintheCERCAProgramme/
GeneralitatdeCatalunya(http://cerca.cat/en/suma/
).Thefundershadnoroleinstudydesign,data
collectionandanalysis,decisiontopublish,or
preparationofthemanuscript.
Introduction
Competinginterests:Theauthorshavedeclared
thatnocompetinginterestsexist. Inlowandmiddle-incomecountries(LMIC),significantchallengesexistinordertoaccount
forandestablishwhatthemaincausesofdeathattheindividualandpopulationlevelare.
Althoughmuchstrongerrecommendationsarenowinplacetostrengthenvitalregistration
systemsinthesesettings,therealityisthatinmanyruralareasofthepoorestcountries,acon-
siderablenumberofbirthsanddeathsarenotcapturedbythenationalregistrationplatforms.
Insub-SaharanAfrica,regionaldeathcertificatecoveragemaybeaslowas10%,andthequal-
ityofcauseofdeathdataremainspoor,essentiallyrelyingonverbalautopsyandclinicaldata
[1].Mozambique,aparadigmaticexampleofasub-SaharanAfricancountryisnoexceptionto
this,wherebymortalitydataarescarce,incompleteandoftenunreliable[2].
Theminimallyinvasiveautopsy(MIA)hasbeenvalidatedasastrongalternativeforcause
ofdeathdetermination(CoD)inLMICwherethegoldstandardmethod,thecompletediag-
nosticautopsy(CDA),isunfeasibletoimplement[3–6].Insuchcountries,CDAcanonlybe
performedintop-levelhealthfacilities,whereasinthecommunityverbalautopsiesarethe
commonlyusedmethodforCoDdetermination.However,VAhasimportantlimitationsand
poorspecificity[7].
TheMIAconsistsofaseriesofpost-mortempuncturesusingbiopsyneedlesaimingto
obtaintissuesamplesandbodyfluidswithinthefirsthoursafterdeath,whicharethensubmit-
tedforathoroughhistopathologicalandmicrobiologicalinvestigationoftheunderlyingCoD
[8].ThevalidationofthisnewMIAprotocolforCoDinvestigationinLMIChasbeencon-
ductedinMozambique,inahead-to-headcomparisonagainstthegoldstandardmethodology,
theCDA.Theresultshaveshown,inthedifferentagegroupsstudied,includingadults,chil-
dren,neonates,stillbirthsandmaternaldeaths,amoderatetosubstantialconcordancebetween
thetwomethods(Kappavaluesoftheconcordanceanalysesinthedifferentagegroupsrang-
ingfrom0.40to0.78)[3–6].Therefore,theMIAcanpotentiallyactasanalternativeforthe
CDAinthoseareaswherethelattercannotbeeasilyconducted,providedthattheprocedureis
acceptednotonlybythecommunitybutalsobyhealthcareproviders.
Healthcareprovidersareregularlyincontactwiththeeventofdeathandareoftenres-
ponsiblefortheinteractionwiththerelativesofdyingordeadindividuals(includinggrief
counsellingandconsentforpost-mortemprocedures).Additionally,someofthesehealthpro-
fessionalsmaybepotentialcandidatestoperformtheMIAinthefuture.Previousqualitative
studiesabouthealthproviders’perceptionsandattitudesrelatedtopost-mortemmethodsand
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
communicationwithbeaveredfamilies(includinginformedconsent)aremainlyfocusedon
High-IncomeCountries(HIC)[9–12].
Inthisanalysisweaimedtoexplorelocalhealthcareproviders’perceptionsandattitudes
regardingpost-mortemmethodsingeneral,andMIAsinparticular,andtheperceivedadvan-
tages,disadvantages,barriersandfacilitatorsofthistechniqueinthecontextoflowresourced
settings.Thetheoryofdiffusionofinnovations(DOI)introducedin1962byRogers[13]is
usefultounderstandwhyandhowrapidlynewtoolsandinterventionsareadopted(ornot),
despitetheevidenceoftheirpotentialbenefits[14].TheDOIfocusesonthemultiplefactors
thatcanaffectanyimplementation,takingintoconsiderationtheinnovationitself,thecom-
municationchannelsandthedecision-makingprocesses,timeandthesocialsystems[13].
Methods
Studysiteandpopulation
ThestudytookplaceinMaputocityandintheDistrictofManhic¸a,bothinSouthernMozam-
bique.Maputo,thecapitalofMozambique,isacitywithapopulationofapproximately2mil-
lionpeople,mostofthemlivinginperi-urbanareas.ThecityisservedbytheMaputoCentral
Hospital(HCM),whereCDAsareroutinelyconducted,aswellasthreegeneralhospitalsand
severalhealthfacilities.BesidesconductingroutineCDAs,fromNovember2013toMarch
2015,theHCMhostedaMIAvalidationstudy,inwhich282MIAswereperformedonadults
(includingmaternaldeaths),children,neonatesandstillborndeceasedatthehospital,and
comparedagainstCDAsasthegoldstandard[3–6].
Manhic¸aDistrictisaruralarea,located80KmnorthofMaputoCity,withapopulationof
183,000inhabitantscoveredbyaHealthandDemographicSurveillanceSystem(HDSS)ranby
theManhic¸aHealthResearchCentre,previouslydescribedelsewhere[8,15].Healthservicesin
Manhic¸aDistrictareprovidedbyadistricthospital,aruralhospital,and12primary-level
healthcenters,nonewiththecapacitytoconductpost-mortemproceduresatthetimewhen
thecurrentstudywasconducted[8].
FormalandinformalhealthsystemstructurescoexistbothinMaputoandinManhic¸a.
Informalhealthcareprovidersinclude,amongothers,traditionalhealers,herbalists,traditional
birthattendants,informaldrugprovidersandknowledgeableelders.Thetargetpopulationof
thisspecificanalysisincludedhealthcareprovidersfrombothgeographicalareas,definedas
thoseregularlyincontactwithdeathevents,bothwithintheformalandinformalhealthsys-
tem,andinvolvedornotinpost-mortemprocedures(includingtheperformanceofMIAs).
Thisincludedmedicaldoctors,nurses,midwives,communityhealthworkers(CHW),tradi-
tionalbirthattendants(TBA)andtraditionalhealers.
Studydesign
Thisarticlereportsfindingsfromaqualitativestudyconductedinthecontextofalargermulti-
centrestudy[ValidationoftheMinimallyInvasiveAutopsytoolforcauseofdeathinvestiga-
tionindevelopingcountries(CaDMIA)],aimingtoassesstheperformanceofaminimally
invasiveautopsytool(MIA)incomparisontotheCDA[3–6].Theoverallqualitativecompo-
nent,conductedin5countries(Gabon,Mali,Kenya,Mozambique,Pakistan),wasbasedona
combinationofethnographic[16]andgroundedtheory[17,18]approachestodatacollection
andanalysis.Theaimwastounderstandthephenomenonofdeathandpost-mortemmethods
fromthelocalcommunitiesperspectives(includinghealthcareproviders),andtocontributeto
theorybasedondatasystematicallyobtainedfromsocialresearch[17,18].Inconsequence,
therewerenopredeterminedspecifichypotheses,butbroadresearchquestionsfocusedonthe
areaofinterest.Theresearchquestionsaddressedbythisspecificstudy,focussedonlyin
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
Mozambicanhealthcareproviders,included:i)HowdohealthcareprovidersperceiveCDAs
andMIAs?ii)Whatarethebarriers,facilitatorsandrequirementsforMIAimplementation
accordingtohealthcareprovidersinSouthernMozambique?
Sampling
Aminimumsamplesizeof30participantswasdefinedbasedonsimilarstudies’experiencein
reachingsaturation(thenon-additionofnewconceptsafterthecontinuousrecruitmentof
moreinterviewees)[19,20].Purposivesamplingwasusedtoonlyenrolthosewhowereregu-
larlyincontactwithdeath(particularlycorpsesandbereavedfamilymembers),specificallyat
thetimeofdeathand/orshortlyafterthedeathevent.Thoseincludedwereformalhealthcare
providers(medicaldoctors,nurses,clinicalofficers,midwifes,healthfacilityadministrative
personnel,stafffromthehealthfacilitymorguesandcommunityhealthworkers),andinfor-
malhealthcareproviders(traditionalbirthattendantsandtraditionalhealers).Ofnote,some
oftheinterviewedhealthcareprovidersinMaputohadactuallywitnessedCDAsandMIAs
beingconducted,whilethoseinterviewedinManhic¸ahadgenerallyneverseenpost-mortem
techniquesbeingconductedandthus,theirperceptionswerediscussedfromatheoretical
pointofview.
Recruitmentstrategy
Formalhealthcareproviderswereidentifiedandrecruitedathealthfacilitiesbythestudysocial
scientistsandresearchassistants.Informalhealthcareproviderswereidentifiedandrecruited
byresearchassistantsthroughaseriesofcommunitymeetingsthatwereheldtoexplainthe
CaDMIAethnographicstudywithinthestudyarea[8].
Datacollection
Thirty-threesemi-structuredinterviewswereconductedwithhealthcareproviders(inrural
Manhic¸aandurbanMaputo)betweenNovember2013andFebruary2015.Datawerecollected
bysocialscientistsandlocalresearchassistantsbasedonaguideofopenquestionslinkedto
themainresearchquestions,butalwaysfocusingontherespondents‘trainofthoughts”,allow-
ingemergingthemestobecaptured.InterviewswereconductedinShangaanorPortuguese,
accordingtoparticipant’spreference,wereaudiorecorded(whenpermissionwasgivenby
participants)andtranscribed.Detailedfieldnotesweretakenwhennopermissionwasgiven
forrecording.
Analysis
Whiletheoverallqualitativestudyusedgroundedtheory,datafromthisspecificcomponent
werethematicallycodedusingNvivo10(QSRInternationalPtyLtd).Thiscodingprocess
entailsidentifyingpassagesoftextrelatedtothetopicsofinteresttotheresearchquestionand
labellingthemwithspecificthemesandsub-themes.Astranscriptsweregraduallyimported
intotheNvivoprojectandthoroughlyread,codeswererefined,addedoreliminated,depend-
ingontheirrelevancetothemainresearchquestion,thealreadycodeddata,andtheemergent
data.Bygroupingtogethersimilarlycodedtext,themeswereconstructed,discussionswere
builtaroundeachthemeandaroundlinksbetweenthemesandsubthemes,andfromthesedis-
cussions,themainconclusionsemerged[21].
Thetheoryofdiffusionofinnovations(DOI)[13],wasusedtoassesMIAsperceptions
fromthestandpointofaninnovation.Diffusionofinnovationsistheprocessbywhichanew
idea,practice,orobjectthatisperceivedasnew,iscommunicatedthroughcertainchannels
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
overtimeamongthemembersofasocialsystem.Thecharacteristicsofinnovations,asper-
ceivedbyindividuals,helptoexplaintheirdifferentrateofadoption.Theanalysisfocuseson
the5characteristicsorelements,describedinthetheory,namelyi)relativeadvantage;ii)com-
patibility;iii)complexity;iv)trialability;andv)observability[13].
ThisstudycomplieswiththeConsolidatedCriteriaforReportingQualitativeResearch
(COREQ)checklist[22].
Ethicalconsiderations
ThestudywasapprovedbytheManhic¸aHealthResearchCentre’sInstitutionalReviewBoard
(CIBS-CISM)andtheMozambicanNationalBioethicsCommittee(Ref.342/CNBS/13)in
Mozambique,andbytheEthicsCommitteeofBarcelona’sHospitalCl´ınic(File2013/8676)in
Spain.Writteninformedconsentwasobtainedfromallparticipants.Inthecaseofilliteracy,
participantsprovidedathumbprintthatwascountersignedbyanimpartialwitness,guarantee-
ingthatparticipationhadbeeninformedandvoluntary.Alldataweremanagedbasedon
uniqueidentificationnumberssoastoguaranteetherespondent’sanonymity.
Results
Atotalof33respondentswereinterviewed,39%(13/33)inMaputoand61%(20/33)inthe
Manhic¸astudyarea.Fifty-eightpercent(19/33)ofallparticipantsweremales,67%(22/33)
hadcompletedprofessionaltrainingorfurtherstudies,andthemajority(79%;26/33)was
Christian.Detailedsocio-demographiccharacteristicsofthestudyparticipantsareshownin
Table1.Allwhomwereapproachedbythestudyteamacceptedtoparticipate.
Table1. Socio-demographiccharacteristicsofparticipantsandexperiencewithcompletediagnosticautopsies
andminimallyinvasiveautopsies.
Participants MaputoCity Manhic¸aDistrict TOTAL
n(%) n(%) N(%)
Gender
Male 9(69) 10(50) 19(58)
Female 4(31) 10(50) 14(42)
Agegroup,years
18–29 5(38) 2(10) 7(21)
30–49 7(54) 10(50) 17(52)
>50 1(8) 8(40) 9(27)
Education
Noschooling 0(0) 0(0) 0(0)
Primary1 3(23) 8(40) 11(33)
Secondary 0(0) 0(0) 0(0)
ProfessionalTraining 2(15) 11(55) 13(40)
Universityorhigher 8(62) 1(5) 9(27)
Occupation
MedicalDoctor 6(46) 1(5) 7(22)
Clinicalofficer 2(15) 4(20) 6(18)
Nurse 0(0) 3(15) 3(9)
Midwife 0(0) 2(10) 2(6)
Pathologyassistant 2(8) 0(0) 1(3)
HospitalRegistrar 0(0) 1(5) 1(3)
Mortuaryassistant 3(23) 1(5) 4(12)
(Continued)
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
Table1. (Continued)
Participants MaputoCity Manhic¸aDistrict TOTAL
n(%) n(%) N(%)
Communityhealthworker 0(0) 2(10) 2(6)
Traditionalbirthattendant 0(0) 3(15) 3(9)
Traditionalhealer 0(0) 3(15) 3(9)
Religion
Christian2 9(69) 17(85) 26(79)
Muslim 1(8) 1(5) 2(6)
Animist 0(0) 2(10) 2(6)
Atheist 1(8) 0(0) 1(3)
Unknown 2(15) 0(0) 2(6)
Experiencewithpostmortemprocedures
Hasconducted/seenCDA
Yes 12(92) 7(35) 19(56)
No 1(8) 13(65) 14(42)
Hasconducted/seenMIA
Yes 6(46) 0(0) 6(18)
No 7(54) 20(100) 27(82)
TOTAL 13(39) 20(61) 33(100)
Valuesaren(percent)unlessindicatedotherwise
1Includesthreeparticipantswithincompleteprimarystudies
2IncludesCatholic,ProtestantorEvangelist,orChristianundetermined.
https://doi.org/10.1371/journal.pone.0200058.t001
ViewsandperceptionsofhealthcareprovidersregardingComplete
DiagnosticAutopsies(CDA)
TwelveoftheparticipantsfromMaputo(12/13)hadbeeninvolvedintheperformanceofat
leastoneCDA.Allbuttwo(11/13)wereworkingattheMaputoCentralHospital,ofwhichsix
(6/11)conductedCDAsaspartoftheirroutineactivities.NoCDAswereperformedinMan-
hic¸a,wherelessthanhalfoftheparticipants(7/20)reportedanypreviousparticipationin
post-mortemmethods,alwaysinthecontextoftheirprofessionaltraining.
ParticipantsfromMaputoexplainedthattheCDAisaprocedureconsistinginopeningthe
body,conductingavisualexaminationoftheorgans,collectingsamplesforhistologyand,
finally,stitchingtheincisions.Thedescriptionalsoincludeddetailsonthenatureandlocaliza-
tionoftheincisions,themainorgansobserved,andthematerialused.
AmongformalhealthcareprovidersfromtheManhic¸aarea,theCDAwasdefinedasatech-
niqueconsistinginopeningthebody,exploringtheorgansandobtainingsamplesforanalysis.
NeitherthethreeCHWsnortheinformalproviders(threeTBAandthreetraditionalhealers)
wereabletoexplaintheprocedure.AtraditionalhealerreferredtotheCDAastheopeningof
thehead.
SomeparticipantsexplainedthattheCDAwasnoteasytoperform,unpleasant,andcaused
physicalandmentaldiscomforttothestaffperformingit.Additionally,itwassaidthatspecial-
izedtrainingwasneededtoconductaCDAsandthatthestaffinchargehadtobepsychologi-
callypreparedtofacetheprocess.Thestrongsmell,thelargeincisions,theexposuretothe
organsandthebloodwereothermentioneddisturbingissues.
Participantsalsoexpressedconcernsregardingreturningasignificantlydisfiguredbodyto
thefamilies,anditsimpactontheiremotions,aggravatingtheexistingshockfromthedeathof
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
abelovedone,andcausingadditionalstress.Healthprovidersreportedthediscomfortrelated
torequestingconsentorinformingthefamiliesaboutCDAs,particularlyifinfluencedby
rumorsabouttheprocedure,althoughfamiliesnormallywereopentoreceivinginformation
aboutthemethodandthereasonsforrequestingtheCDA.
“Theyjusthaveheardofit(CDAs)fromothers.That’s whytherearesomepeoplewhoreject
theautopsy(CDA)buttheydonotknowreallywhatitis,theythinkautopsy(CDA)istotake
organsawaytobestoredforstudyingthem.Itisastheyweretakinghomeanemptybody.”
Medicaldoctor,36yearsold,female
OneofthemajorconcernsregardingCDAsamonghealthprofessionalswithexperienceof
CDAperformancewastheriskofinfection.
“There(whendoingautopsies)theriskis...Sometimes,well,mostofthetime,weworkwith
seropositive(HIVpositive)bodies,soonecanneverbetoocareful.”Pathologyassistant,27
yearsold,male
Despitetheabovementionedconcerns,themajorityofformallytrainedhealthprofessionals
consideredthattheCDAwasausefultoolforgettingtoknowtherealCoD,especiallywhenit
wasnotclear,andthatlearningfromtheresultscouldhelpimprovingdiseasemanagement
anddiagnosisinthefuture.
“[CDA]isawaywehavetoclarifyspecificcausesthat,whenthepersonwasalive,wewerenot
abletoidentify.(...)Ontheotherhand,wemayhavethoughtwewereinfrontofacertain
diseaseandwhenwehavetheresultsfromhistology,fromtheautopsy,itrevealsotherthings,
andsoweenduplearning.Yes, weenduplearning.”Medicaldoctor,35yearsold,female.
“ThefirsttimeIsaw(aCDA)itwasreallyshocking.Butafterthis,Irealizeditwasnecessary
toknowtherealcauseofdeath.We sawischemiacases.Thosethingsgounnoticed,youjust
discoverthemwhentheheartisdirectlyobservedandyoucanseethechangesoccurringinthis
organ.”Medicaldoctor,33yearsold,female
However,healthprofessionalswerealsoawarethatpostmortemexaminationscouldeluci-
datetherealunderlyingCoD,potentiallyquestioningtheclinician’sdiagnosticandprognostic
capacity.
“Iamafraidpeoplewillsay“no” [toCDA],becausewhenyouexplaintothefamilythatyou
wanttodotheautopsy,thatyouwanttoconfirm,todiscoverthecauseofdeath...the
patients,whentheycometoyou,theyexpectyoutoknow.So,conveytothemtheideathat“I
donotknow”,“wedonotknow”isdifficult.”Medicaldoctor,38yearsold,female.
Finally,someparticipantsexplainedthathealthprofessionals’negativeconnotationsto
CDAsshouldbedemystifiedthrougheducationandinformation.Workingatthepathology
departmentoratthemortuaryoftheMaputoCentralHospitalinvolvedstigmatization,
accordingtosomeparticipants,particularlyforassistantsandmortuarypersonnel.Oneof
themrevealedthatpathologydepartmentandmortuarystaffmemberswereuncomfortable
withdisclosingtheirprofessionordetailsofworkplace(i.e.,thepathologydepartmentorthe
mortuaryservices)because,otherwise,theywouldbeperceivedascrazyordrugaddictsoreven
asbadpersons.Thesameparticipantmentionedthat,evencolleaguesfromthesamehospital
mighttreatthemdifferentlywhenfindingouttheywereworkinginthisarea.
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ViewsandperceptionsofhealthcareprovidersregardingMinimally
Invasiveautopsies(MIA)
SixparticipantsinterviewedinMaputo(6/13)wereinvolvedinconductingMIAsaspartof
theirroutineactivities.AllofthemwerealsofamiliarwithCDAs.AttheManhic¸aarea,nopar-
ticipanthadeverseenorparticipatedinaMIA.
TheMIAwasviewedbyallparticipants,includingthosewithoutpreviousexperiencewith
theprocedure,asasimple,easyandquicktechniquethatanyonecouldperformafterappropri-
atetraining.Intheiropinion,theMIAscouldbeperformedanywhere,evenintheabsenceof
formalpathologyfacilities,oratthehouseholdlevel.
“We (healthprofessionals)needsomethingquick,thatdoesnottakeusalotoftime.So,itis
preferablewedoMIA(thanCDA),afteranappropriatetraining.”Clinicalofficer,33years
old,male.
ParticipantswhohadpreviouslyconductedaMIA,consideredthatthemethodwas
cheaper,lessunpleasantandlesstimeconsumingcomparedtoCDAs,withadurationof
about30–45minutes,asopposedtothe~2hoursrequiredforCDAs.Concernsdidhowever
ariseregardingthecostoftheneedlesandadditionallaboratorytests.
ThemainadvantageforthoseperformingMIAwasthatthetechniquedidnotinvolve
majorincisions:ononehand,thisallowedtheproceduretobeclean,therewasnobloodand
mess,therewaslessdisgustingsmell,andtheriskofinfection(althoughitremainsaserious
concern)wasbelievedtobesignificantlylower.Ontheotherhand,returninganapparently
intactbodywouldremoveadditionalstresstothefamily,allowthebodytobeshownduring
theceremoniesandavoidsuspicionsregardingorgansremoval.
“WithMIA,youmanagetodoakindofautopsythatpeopleathomemightnotnotice.I
mean,everythingisfine.Becausethewaytheautopsy(CDA)isdone....Itisnotpossibleto
openthecoffinandstaythere,seeingthedeceased,thatway...thehead...all...Imean,peo-
pleendupcryingtwice.WithMIA,peopledonotnoticethatastudyhasbeendoneandyou
mightreachadiagnosisaswell.”Pathologyassistant,38yearsold,male
AdisadvantagehighlightedbyintervieweesoftheMIAincomparisontotheCDAwasa
potentiallyreducedperformanceofthetoolintermsofreachingadiagnosis,astheprocedure
consistsjustontheanalysisofsmallsamplesanddoesnotallowanopen-eyedmacroscopic
analysis.
“A disadvantage(ofMIA)isthatyoucannotvisualizethewholeorgan.Becausetoreacha
diagnosis,insomecases,justforthemerevisualizationofthelesions,wereachthediagnosis.”
Medicaldoctor,26yearsold,male.
Facilitators,barriersandrequirementsforMIAimplementationfrom
healthcareproviders‘perspective
TheinterestinknowingtheCoDwasmentionedbyalmostallparticipantsasafacilitatorfor
MIAstobeperformedinthefuture.Accordingtohealthcareproviders,familieswouldclearly
wanttoknoworclarifytheCoDoftheirdeceasedrelatives.TodiscovertheCoDthroughthe
MIAwouldallowtakingmeasuresincaseofcontagiousorfamilydiseases.Further,themere
factofknowingthecauseofdeathwouldremoveuncertaintiesaboutthecircumstancesofthe
death,includingtheavoidanceofwitchcraftaccusations,provisionofpeace,andreleasefrom
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
distressamongfamilymembers.Thenatureofthetechnique,notimplyinglargecutsascom-
paredtotheCDA,wouldavoidrumorsaboutorganstealingortraffickingaswellasitwould
minimizethevisualshockofthedeadbody.
“FamilieswouldacceptMIA.Theywillbereassuredaboutthecauseofdeath.Forexample,
whathappens(isthat)ourbrotherscomebackfromtheborder,fromSouthAfrica,
Swaziland...Peopledonotknowwhichconditions,whatkindoflifehe/shewasleading.(He/
She)arriveshere(home)ill,anddies.”Nurse,38yearsold,male.
“This(MIA)isimportant,becausethereisnodiscussionaboutsomeonebeingkilled.Theper-
sondiedbecauseofanordinarydisease.”CHW,48yearsold,female
Besidesthefamily,healthcareproviders,bothwithintheformalandtheinformalhealthsys-
tem,alsorevealedtheirpersonalinterestinknowingtheCoDoftheirpatientsandtheircom-
munities.Themethodwasconsideredasacontributiontosciencebecauseitmayprovide
betterknowledgeaboutdiseases,assistonfuturediagnosesandtreatments,andsavelives.
Additionally,amidwifefromruralManhic¸amentionedthatMIAswouldbeagoodtoolfor
evaluatinghealthprofessional’sperformanceandqualitycontrolatthehealthfacilities.
“H/She(thedeceased)hasTB(tuberculosis),HIVassociated...all...inanadvancedstage.
WhytoperformaMIA?You havenoneed.Justinthecaseofsuspecting...épa!...notknow-
ingthecause,isn'tit?Ormaybebecauseofdoctor'scarelessness,Idon’t know.Then,yes.It
couldbeadrugpoisoning;theygavethewrongmedicine.Yes. Inthiscase,yes”.Midwife,34
yearsold,female
Participantswithhigherlevelofformaleducationreportedmoreconcernsaboutthemar-
ginoferroroftheMIAtoolthantheotherparticipants.Somedoctorsstressedthatthetech-
niquehadnotbeenvalidatedyet,thereforeforthemitwastoosoontoacceptitsreliability.
“Quitefrankly...forinfectiousdiseasesmaybewecouldhavereliableresults(withtheMIA),
butfornon-infectiousdiseasesIdon’t thinkso.Theconsistentonethereis“theclassicone”
(CDA)becauseweareseeingtheorganandwearesure...wearethere!Justtocollecta
sample...Idon’t knowifthisissoreliable.”Medicaldoctor,27yearsold,female
OneofthebarriersforMIAimplementationreportedbyinformalhealthcareprovidersand
thoseworkinginisolatedareasofManhic¸aDistrictwasrelatedtothefactthatmanypeople
dieathomeandareburiedinthecommunity,intheabsenceofanycontactwiththehealth
system.This“invisibilityatdeath”[23]iscommonforallagegroups,butevenmoreforstill-
birthsandearlyneonataldeaths,forwhomtheburialritualsareoftenkeptsecret,andper-
formedbyjustacoupleofrespectedelderwomenofthecommunity,atnightordawn,making
thetrackingofthosedeathsevenmorecomplex.
Participant(P):“Ifhe/shediesathome...Thereisnootherway,wehavetowait.When24
hourshaspassed,he/sheisburied.Thereisnothingelsetodo.”
Interviewer(I):“Don’tyoubringhim/hertothehospital(morgue)?”
P-“No,wedon’tbringhim/hertothehospital”
I–“Andwhenishot,thebodydidnotgetdamaged?”
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Healthcareproviders’viewsonpost-mortemmethodsinMozambique
P-“Yes. That’s why,if24hourshavepassed,he/sheisburied.Sometimes,ifthepersondiesat
night,whentherearenorelativescomingfromMaputoorfromfaraway,attheendoftheday
he/shecanbeburied.”CHW,female,42yearsold
“Whengivingbirthandthebabyturnsbackwards(dies)wejustburyhim/her.Thewaywe
buryhim/her...Itisnotthesameasanadult,youdonotneedacoffin,itcanbejustabasin.
(...)We lookforashadyplace,underthetrees,aplacethatisfresh,isdark(...)becausethat
childdoesnotdeservetoburnbythesun.”TBA,female,64yearsold
AlmostallparticipantsreportedthattheMIApersemightnotclashwithtraditionalbeliefs.
Conversely,fewparticipantsexplainedthatMIAcouldconflictwithreligiousbeliefs,specifi-
callywithIslam.ThefactthatMuslimsmustburythebodyassoonaspossible,preferably
withinthefirst24hoursafterthedeath,couldjeopardizeacceptanceoftheprocedurefromthe
Muslimcommunity.Additionally,thebeliefthatthedeathwasGod'swill,accordingtomost
religions,couldalsocompromiseacceptanceofMIAs.Somehealthcareprovidersalso
expressedthisfatalisticnotionofdeath,asafewreportedthattheinformationobtained
throughtheMIAwouldnotofferanyadditionalvaluesincethepersonwasalreadydead.
Pooraccesstofamily’sdecisionmakersbythehealthpersonnelaskingforconsenttoMIA
couldconstituteabarrier.Afewparticipantsreportedthatthedecisionmakerswereoften
notavailableimmediatelyafterthedeath,astheystayathometoreceivecondolencesorto
takecareoffuneralarrangements.Moreover,someparticipantsmadeclearthatiftheMIA
implieddelaysinfuneralsandceremonies,familymemberswouldbereluctanttoacceptthe
procedure.
Familystateofmindaroundthedeathandfamilyemotionswereraisedbyparticipants,
bothfromMaputoandManhic¸aareas,asanimportantconcernregardingMIAacceptance.
Somehealthprofessionalsconsidereditmaybechallengingtoapproachfamilymembers,to
discussandexplaintheMIAandtoaskforconsentinsuchanearlyandacutemomentofpain
andgrief.Somehealthcareproviders,mainlyfromtheinformalhealthsystem,stressedthe
needforhealthpersonnelconductingMIAstobekind,sensibleandempathicwiththefamily
ofthedeceased,andopentorespondtoanydoubtatanytime.Inalignmenttothisissue,a
participantinMaputo,whowasfamiliarwithMIAs,statedthatrespectwascrucial;emphasiz-
ingthatprofessional’sactionsshouldstaytruetowhatispromisedtothefamily.
“You mustcomplywithwhatissaid.You cannotsaytosomebodyyouaregoingtohandthe
bodyat1pmandtheydonotreceivethebodyat1pm.Orthatthebodywillhave3punctures
andattheendthereare5.Whendealingwithpatients,theytrustyou(...)Ifyousayyouare
adoctor,theytrustyou.Theytrustyou.Iwouldtrust!”Medicaldoctor,33yearsold,female
ParticipantsfrombothsettingsfeltthatthehealthsystemmaynotbepreparedfortheMIA
implementation,onaccountofpotentialshortagesofmaterialandhumanresources,andinad-
equacyofequipment.Personnelfromtheprimaryhealthcarecentresreportedthatdeathsat
theirfacilitieswererare,asallthepatientswithasevereorlife-threateningdiagnosiswere
referredtohigher-levelfacilities,limitingtheutilityofconductingMIAsattheprimaryhealth
centres.
IntermsofrequirementsfortheMIAstobeembracedbythehealthsystemandthecom-
munities,allparticipantsreportedthatinformationandcommunicationwerecrucialfor
futureMIAimplementation.Thisinformationshouldhavetobeclear,detailedandinan
understandablelanguage,andshouldbedeliveredtothefamily,thecommunityandthecom-
munityandreligiousleaders.Thisinformation,accordingtoparticipants,shouldincludethat
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