Death, Culture, and Conflict: A Qualitative Study on Sociocultural Practices and Their Implications for Maternal and Perinatal Death Surveillance in Eastern Democratic Republic of Congo

Technical Summary: Death, Culture, and Conflict in Eastern DRC

Problem Statement
Maternal and perinatal deaths remain critical public health challenges, particularly in low- and middle-income countries. While medical causes are well-documented, the socio-cultural dimensions of these deaths—specifically how communities interpret, mourn, and report them—are often overlooked. In conflict-affected settings like the Eastern Democratic Republic of Congo (DRC), these dynamics are exacerbated by insecurity, displacement, and mistrust of health systems. Cultural beliefs regarding witchcraft, spiritual causality, and the varying social value assigned to stillbirths, neonatal deaths, and maternal deaths directly influence whether families disclose losses to formal health structures. Consequently, these factors contribute to significant underreporting, undermining Maternal and Perinatal Death Surveillance and Response (MPDSR) systems which rely on accurate data to identify preventable factors and implement interventions. Despite national guidelines for MPDSR in the DRC, implementation in Eastern provinces remains weak due to a lack of understanding of these local socio-cultural barriers.

Methodology
This study employed a phenomenological qualitative design to explore socio-cultural practices surrounding death in two conflict-affected health zones: Mweso (North Kivu) and Mulungu (South Kivu). Data collection occurred between December 2022 and July 2023.

• Participants: A purposive sample of 49 participants was interviewed, including bereaved family members (mothers, fathers, or husbands), community leaders, and health providers (obstetricians, nurses/midwives, and community health workers).
• Data Collection: In-depth interviews (IDIs) were conducted in French or Swahili, based on participant preference, using semi-structured guides. Interviews took place in private locations chosen by participants to ensure confidentiality.
• Analysis: Interviews were transcribed verbatim and analyzed using inductive thematic content analysis. The analysis was iterative, employing triangulation across the three participant groups to identify emergent themes regarding burial practices, mourning traditions, and the rationale for these practices. Reflexivity was practiced throughout the process to address researcher positionality and power dynamics.

Key Findings
The study identified four primary themes characterizing socio-cultural practices and their implications for MPDSR:

1. Differential Burial Practices: Burial customs vary significantly by the type of death. Maternal deaths are treated with adult burial rites, often requiring the separation of the fetus from the mother (via C-section in facilities or by community leaders/chief in the community). Unique rituals include burying the mother near a banana tree or crossing a river to separate the spirits of the mother and fetus. In contrast, stillbirths and neonatal deaths are often buried immediately, frequently by women only, in separate cemeteries or near health facilities, and are sometimes wrapped in specific clothing (e.g., a grandmother's) to prevent spiritual harm to the mother's fertility.
2. Mourning and Bereavement Traditions: Maternal deaths typically involve a 2–4 day mourning period involving community gatherings, dowry discussions, and condolence gifts (often goats). Conversely, mourning for stillbirths and neonatal deaths is often non-existent or minimal. Some cultures view the loss of a first child or a child without teeth as not warranting formal mourning. For neonatal deaths, financial constraints often dictate the length of mourning. Specific taboos exist for twin deaths, where the surviving twin must be protected from grief (e.g., anointed with animal blood) to prevent their own death.
3. Rationale and Social Valuation: The disparity in mourning is rooted in the socio-cultural valuation of life. Maternal deaths are seen as significant losses requiring communal support. Neonatal deaths and stillbirths are frequently perceived as having less social value because the child had not yet "shared life" or contributed to the community. Some participants noted that grief for a child is not accorded the same significance as for an adult.
4. Impact of Insecurity: Ongoing conflict disrupts customary practices. Violence limits movement, preventing families from gathering for funerals or adhering to specific burial rituals (e.g., night vigils). In extreme cases, corpses are discarded without proper burial due to safety concerns or lack of resources (e.g., coffins). This insecurity erodes community trust and further inhibits the disclosure of deaths.

Sense-Making and Attribution of Blame
The study found that communities construct meaning around these deaths through specific lenses:

• Witchcraft and Sorcery: Deaths are frequently attributed to spells, adultery, or the mother being a witch. This is particularly common for stillbirths and repeated neonatal losses.
• Blame Dynamics: Mothers are often blamed for negligence, non-adherence to medical advice, or consuming traditional products. Husbands are blamed for neglect or adultery. Health providers are frequently accused of causing deaths, leading to fear of retaliation and sometimes flight from the district. Inter-ethnic tensions further complicate these blame dynamics.
• Religious Beliefs: While less dominant than witchcraft, some deaths are attributed to "God's will."

Implications for MPDSR
These cultural and conflict-related factors create significant barriers to MPDSR:

• Underreporting: The low social value assigned to perinatal deaths, combined with stigma and fear of blame, leads to non-disclosure.
• Case Identification Gaps: Standard surveillance often misses community-based deaths because families do not report them to health facilities.
• Trust Deficits: Accusations against health providers and the attribution of deaths to witchcraft or spiritual causes undermine the credibility of the health system's role in death review.

Significance and Contributions
The paper argues that effective MPDSR in conflict-affected settings cannot rely solely on standardized reporting frameworks. Instead, it requires culturally responsive adaptations that:

1. Engage Specific Community Actors: Case identification should involve key informants who participate in burial rites, such as village chiefs, parents of the deceased, and elderly women who handle the burial of stillbirths and neonates.
2. Utilize Cultural Markers: Surveillance systems should consider specific burial locations (e.g., near banana trees, rivers, or in secluded forest areas) as indicators of unreported deaths.
3. Address Cultural Beliefs: Interventions must include education campaigns to address misconceptions about the causes of death (e.g., witchcraft vs. medical causes) and reduce stigma. Collaboration with traditional healers and religious leaders is essential to improve reporting.
4. Adapt to Context: MPDSR policies must be flexible enough to accommodate the disruptions caused by conflict and the specific mourning practices of the community.

The study concludes that integrating social and cultural analysis into surveillance system design is not optional but essential for generating reliable mortality data and reducing preventable maternal and perinatal deaths in the Eastern DRC.