Table 6. Reasons for refusing MITS based on direct observation and health staff accounts of refusal cases (n = 18).

Themes and categories	Notes from observations and/or informal conversation and quotes from IDIs
Decision making complexity	“The first family member (an older sister of the child) showed interest but they waited for the father who was in South Africa. They ended up taking the body because the father arrived very late in no time to consenting to MITS before the already set up burial time.”–observer’s notes
	“The mother agreed with the procedure, but it was the father, who was martially separated from the mother, who had to provide formal consent. The father, who had moved to Boane district, delegated this mandate to his sister, but she did not feel comfortable to be responsible for the consent, because for that to happen the child should not have been residing with a stepfather…so if anything strange was done to the child (including MITS), the child should be taken to Boane district afterwards”—observer’s notes
	“According to the consent taker, the mother said that she could not decide on anything, and had to wait for the other family members, who took the child’s body as soon as they arrived at the hospital.”–field notes on informal conversation with project’s staff
	“The mother explained that she was not able to consent because the father was not there at the hospital. However in practice she took the child immediately back home without waiting for the father.”–observer’s notes
	“I accepted my husband’s family´s refusal because there was urgency to bury the child.”- IDI with child’s mother
Conforming with the norm of burying the child immediately
	“The family had urgency in taking the child back home to comply with the timings for the burial.”–observer’s notes
	“The parents did not deny MITS. They initially showed interest to consent to it. But the MIA was not performed because the morgue table was busy with another body, a case of drowning, and on which the police [forensic department] was running some tests to ascertain the cause of death. Hospital staff explained to me that traumatic deaths were a priority for tests which were run by the police investigators.”–observer’s notes “The mother sat down and waited for the next steps, however the consent team members were busy with preparations and took some time to get back to the mother with the paperwork…the time they begun the [consent] process, the mother said that it was too late. She was in a hurry to take the foetus for burial.”–observer’s notes
Health facility unpreparedness
	“The grandmother agreed with the procedure, but it was not done because there were no conditions for that in the morgue (the fridges were full, there were bodies on the table, and there was a bad smell of unclaimed bodies). The municipality had not responded to the hospital’s formal request to remove the bodies. After consideration that MITS could not be done on that day, the body was released to the family.”–observer’s notes “There was a failure on the side of the health facility staff, who followed the family’s instructions to discard the foetus instead of taking the body to the morgue, not knowing whether the family would eventually consent to a post-mortem procedure. By the time they [MITS team] traced the body it was too late…the samples could not be obtained, therefore the family was not formally requested to consent.”–observer’s notes
Practical transportation requirements	“The family refused because they wanted to take the body while still fresh to enable to carry [the body] using the public transport, therefore they wanted to take the body immediately.”–CRF abstractions, confirmed by IDI with child’s mother
Incompatibility with family values	“The child’s father alluded that in their family it is not acceptable the manipulation of the body after the death, including obtaining samples from internal organs.”–observer’s notes
Unknown reason	“The family refused and gave no reason.”—observer’s notes