Measuring adult mortality in Brazil: improving quality of cause of death data

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1 Measuring adult mortality in Brazil: improving quality of cause of death data Ana Maria Nogales Vasconcelos (Universidade de Brasília Brazil) Elisabeth França (Universidade Federal de Minas Gerais Brazil) Introduction Mortality statistics on causes of death are one of the principal data sources for assessing a nation s health (Lopez, 1990) 1, and can help in determining public priorities. Although adulthood has been commonly regarded as a healthy time in life, in Brazil mortality among adults should be addressed as a priority because it has become relatively more important than mortality in other groups. Major shifts in health take place around 15 years of age as new health risks with potentially lifethreatening consequences (Gore et al, 2011) 2. Consequently, health profiles change from adolescence to adulthood. Reliable mortality data and detailed analyses of causes on adult deaths may improve our knowledge of patterns of ill health in Brazil, making it possible to assess the impact of interventions towards the reduction of major risk factors. In Brazil, despite the fact that the first law making it mandatory for the State to register deaths dates back to the XIX century, only in 1975 did the Ministry of Health (MH) create the Mortality Information System (MIS) with responsibility for compiling cause of death data (Vasconcelos, 1998) 3. Since then the death certificate has been issued by the attending physician according to the international model recommended by the International Classification of Diseases (ICD). MIS provides annual reports of deaths by cause, age, sex, place of residence and other key variables on the Internet and on CD_ROM (Brazil, 2003) 4. Although in the MIS the majority of deaths should get a death certificate (DC) completed by a physician, deaths coded to ill defined causes have been a challenge and still represent a substantial proportion of all deaths. Despite MIS continuous improvements, Brazil was categorized in 2000 according to international assessment as producing medium quality death registration data (Matters et al., 2005) 5. Moreover, there were important differentials in completeness and quality at sub national level (França et al., 2008) 6. Among the five administrative regions, the Northeast region, where 53 million Brazilians live (28% of the total population), and the North (8% of the national total) are the most underdeveloped, with the lowest Human Development Index (UNDP, 2003) 7. In contrast, the South and Southeast are the wealthiest and have the highest standard of living in the country. The Centre West region (7% of the population) has living standards intermediate between these two regional groups (UNDP, 2003) 7. Since 2005, the Brazilian government has focused on helping states and municipalities from the poorest regions targeting an increase in completeness and a 1

2 reduction in ill defined causes of death. Linkage between health information systems and active search in notary registry offices, healthcare facilities and the Family Health Program were performed to identify underreporting of deaths in relation to the MIS database. Adapted verbal autopsy questionnaires developed by the World Health Organization were adopted for the investigation of ill defined causes of death that occurred at home (Brazil, ; Brazil, ). Despite its importance, no comprehensive studies of death in people aged years old have been done in Brazil, and this group makes up around about 65% of the Brazilian population. The aim of this proposal is to evaluate the evolution of quality of causes of death data and the distribution of defined causes after investigation on adults (15 59 years) in Brazil. Methods Data collection on causes of death Data on deaths were provided by the Brazilian MIS (available on from 1980 to In this system, when a death occurs in a hospital or health facility, the attending physician should issue a death certificate (DC) according to the international form recommended by the International Classification of Diseases. Where there are suspicious circumstances surrounding the death, the DC should be filed by a coroner. For deaths that occur at home, the cause of death is certified by an attending physician if present, or another available physician, or by the civil registrar in which case the cause of death is assigned as an ill defined cause. The Brazilian MIS uses a standardized electronic program called SCB Sistema de Seleção de Causa Básica (Underlying Cause of Death Selection System for Microcomputers) to select and code the underlying cause of death, using codes from the Tenth Revision of ICD since Data cleaning and compilation is done at the municipal, provincial and state level, and an electronic data file is transferred to the national office every three months (Brazil, 2003) 4. After 2005, ill defined deaths were investigated by the health surveillance worker or the family health program professionals from the municipality to trace existing information about the disease or death, including data obtained from hospital, health departments, autopsy, family health program, or civil registry office records. For deaths occurring at home, verbal autopsy interviews were conducted with family members of the deceased. A standardized VA questionnaire was used after 2008 to elicit information on symptoms experienced by the deceased before death. This questionnaire was based on the Portuguese version of the WHO instrument previously used in Mozambique and adapted by the Ministry of Health for the Brazilian reality, including cultural differences and the most prevalent diseases. The underlying cause of death of each individual was assigned using both the VA and the medical records, or any other documented evidence available that might have 2

3 helped in determining the probable cause of death. Rules of the 10th revision of the International Classification of Diseases (ICD 10) were applied (Brazil, ; França et al, ). Data of the investigation process since 2006 are available on the Internet or CD ROM with micro data. Causes of death defined after investigation among deaths originally coded to the ICD codes for symptoms, signs and ill defined conditions (ICD 10 codes R00 R99) were calculated in and compared with the proportional distribution of causes of death before investigation. Assessing cause of death data quality and causes of death analysis For evaluating cause of death data quality in we considered the criteria of completeness and the proportion of ill defined deaths among all causes. For completeness, a revision of literature provided estimated levels based on demographic methods such as: 1) Growth Balance originally proposed by William Brass (1975) and their variants; 2) Synthetic Extinct Generation, initially proposed by Preston et al. (1980) and a variant proposed by Bennett and Horiuchi (1981). These methods are based on some properties of stable population and use population census data to evaluate completeness of death registration. Detailed data by age group is required for population and deaths. For their application some assumptions must be observed as: 1) closed population; 2) invariant levels of completeness by age; and 3) accurate recording of age for both population and deaths. Proportions of ill defined causes of death are calculated for the whole period From 1980 to 1995, the XVI chapter of ICD 9 th revision Symptoms, signs, and ill defined conditions ( Codes) was considered as the group of ill defined causes of death. From 1996 to 2010, the XVIII chapter of ICD 10 th revision Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00 R99 codes) gathered ill defined causes of death. For analyzing causes, deaths were categorized according to ICD 9 (1980 and 1990) and ICD 10 chapters (2000 and 2010) to allow comparison between the same groups of causes in the period. We also used the Brazilian List of Mortality ICD BR for ICD 9 and ICD 10 to include specific causes of death. Results Completeness Some studies based on demographic methods such as Growth Balance or Extinct Generation have indicated that the levels of completeness in Brazil have been increased and are tending to improve. From 80% to 87% for males and 75% to 86% for females in 1980, the level of completeness of MIS data increased to 87% to 98% for males and 80% to 96% for females in 2000 (Agostinho, 2009) 11 (Table 1). 3

4 Table 1: Estimated completeness of Mortality Information System (MIS) data by gender and method used. Brazil Method Source Male Female Brass' Growth balance Ortiz (1982) Brass' Growth balance Castilla Jardim (1988) Brass' Growth balance Sawyer & Castilla (1989) Brass' Growth balance Paes (1993, 2005); Paes & Albuquerque (1999) Brass' Growth balance Oliveira, Albuquerque & Lins (2004) Brass' Growth balance Agostinho (2009) Preston et al. (1980) Costa ( Preston et al. (1980) Agostinho (2009) Extinct Generation Agostinho (2009) Source: Agostinho, Estimates of levels of completeness by regions show huge differences in the first years of MIS implementation ( ) (Table 2). The Southeast and South regions presented levels of completeness of over 90%, while in the North, Northeast and Center West regions these levels were around 50% to 60%. The completeness increased in all regions, but mainly in the least developed, and also in the Center West region. Differences by gender occurred, with lower levels of completeness for females in all regions in (Yasak & Ortiz, ; França et al., ) In 2008, a nationwide research of completeness carried out by the MH showed that the completeness of MIS data considering all ages was 93% and for deaths occurred in the first year 81.7%. These results indicate that completeness for adult mortality data is higher than 93%, but the differences among regions persist (Table 2). In the South and Southeast, levels of completeness were approximately 97%. In contrast, in the North and Northeast these levels were 83.1% and 87.1%, respectively (Szwarcwald et al, ). Table 2: Estimated completeness of Mortality Information System (MIS) data by region. Brazil , and 2008 a Yazak & Ortiz, b França et al., c Szwarcwald et al., Proportion of ill defined causes of death The proportion of ill defined causes of death was 21.5% in 1980, and differed widely according to the regions, varying from 48.6% in the Northeast to 9.6% in the 4

5 Southeast (Figure 1). In 1990, this proportion decreased slightly to 18.2%, maintaining huge regional differences. From 2000 to 2010 the proportion fell significantly to 14% and 7%, respectively; major decreases were observed in the Northeast, from 28% to 8%, and the North, from 24% to 13%. Figure 1 Proportion of ill defined causes of death by region. Brazil % 50% % ill defined causes of death 40% 30% 20% % 0% North Northeast Southeast South Center West Brazil Source: Ministry of Health, Mortality Information System, For adults (15 59 years old), the range of variation of proportions of ill defined causes of death is lower than for all deaths. Nevertheless, the same pattern observed for all ages are verified here (Figure 2). From very wide disparities among regions in the 1980 s, these proportions present in 2010 a slight variation. More precisely, the proportion of ill defined cause of death fell from 15.0% in 1980 to 6.4% in 2010 for the whole country, varying from 31% and 21% in Northeast and North, respectively, to 10% and 12% in Southeast and South. The year of 2005 marks a sharp decrease in the proportion of ill defined causes of death in the Northeast region. From this year until 2010, these proportions are even lower than in the Southeast, where we observe very little change in the whole period: from 10% to 7%. The ranges of variation in that period were wider in the others regions, reaching lower proportions in 2010, except for the North region. 5

6 Figure 2 Proportion of ill defined causes of death among adults by region. Brazil % 50% % ill defined causes of death 40% 30% 20% % 0% North Northeast Southeast South Center West Brazil Source: Ministry of Health, Mortality Information System, By gender, the patterns of variation from 1980 to 2010 are very similar (Figure 3), but the proportions of ill defined causes of death fell initially in the Northeast and North regions among males. After 2005, the fall was more intense among females, reaching lower levels in 2010 (6% for females and 7% for males). Figure 3 Proportion of ill defined causes of death among adults by gender and region. Brazil MALE FEMALE 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% North Northeast Southeast South Center West Brazil North Northeast Southeast South Center West Brazil Source: Ministry of Health, Mortality Information System, The investigation of ill defined causes of death Table 3 shows the proportions of investigated ill defined causes of death on adults by gender after starting the process of investigation of ill defined cause of death 6

7 implemented from 2005 to There was an increase on the proportion of deaths investigated, varied from 25,8% (n=7000) in 2006 to 35,7% (n=10503) in Differences by gender can be observed: in 2006, 23,3% of deaths with ill defined causes were investigated among males, while this proportion was 31,5% among females. The proportion of deaths investigated also increased for both genders: to 30,3% and 47,9% among males and females, respectively, in The increase was higher among females than males (Table 3). Table 3 Proportions of investigation among ill defined causes of death on adults by gender. Brazil, Total Ill-defined Investigated Year Gender causes (n) n % 2006 Male Female Both sexes Male Female Both sexes Male Female Both sexes Male Female Both sexes Male Female Both sexes Source: Ministry of Health, Mortality Information System, Differences by regions are also observed: 50% and 40% in the Center West and Northeast regions in 2010, respectively, 33% in the Southeast and South and 26% in the North. We observe differences by gender in all regions, but in the Center West and Northeast these differences were smaller than in the North and Southeast (Figure 4). 7

8 Figure 4 Proportions of investigation among ill defined causes of death on adults by gender and region. Brazil, % inves gated North Northeast Male Southeast Female South Center West Total Source: Ministry of Health, Mortality Information System, In 2010, it was possible to reclassify 61% of deaths with ill defined causes investigated in Brazil. For those coded originally as an ill defined cause (n=29,444), were investigated and 6,395 (22% of the total ill defined causes) had their cause of death reclassified after investigation into a defined group of causes (Table 4). The proportions of reclassified deaths after investigation were different according to regions: in the North, Southeast and South, those percentages were lower (14%, 18% and 19%, respectively). In the Northeast and Center West, where the proportions of investigation were higher, we also observe higher proportions of reclassified deaths (40% and 29%, respectively). Table 4 Percentage of ill defined causes of death reclassified after investigation. Brazil and regions Total Ill defined causes (n) Investigated (a) (b) (b/a) n n % North Northeast Southeast South Centre West Brazil Source: Ministry of Health, Mortality Information System, Region Defined after investigation ( c) (c/b) (c/a) n % % When comparing the proportional distribution of causes of death between ill defined causes investigated and the raw data before investigation, not including ill defined causes of death, very dissimilar patterns were observed. In 2010, raw data shows that external causes (32,1%) were the first leading cause of death among adults, followed by cardiovascular diseases (20,2%) and neoplasm (16,9%). However, cardiovascular diseases (32.2%) were the first among ill defined causes investigated, 8

9 with external causes (17.5%) and neuropsychiatric conditions (12.3%) in the second and third rank (Table 5). We also compared these proportions by regions in 2010 (Table 5). Higher proportions of external causes were observed in raw data in the North and Northeast regions (44% and 39%, respectively), while in the Southeast and South neoplasm was the top cause of death (18% and 21% of all observed causes, respectively). In the South, neoplasm is the second leading cause in importance after external causes, while in all other regions circulatory diseases are placed in second. The patterns of ill defined causes reclassified after investigation are, nevertheless, very different according to regions, revealing possible differences in the process of certification of causes of death before investigation. Despite this, circulatory diseases were the first cause of death reclassified after investigation (over 30% for all regions, and reaching over 36% in the North and Center West). External causes ranked in the second place, except for the Center West region. This proportion in the Southeast region was strikingly different, however, showing 23,5% of reclassified causes as external causes, a proportion higher than the observed in other regions (from 12% to 17%). Interestingly, neoplasm (ICD 10 Chapter 2) was not reclassified among investigated ill defined causes as it was in raw data before investigation, but the differences between these two proportions among regions are very important. In the North and Northeast, 11,3% and 9,2%, respectively, were reclassified as neoplasm while in South, Southeast and Center West the proportions were around 5%. It is important to highlight the higher proportion of neuropsychiatric conditions (ICD 10 Chapter 5) among investigated ill defined causes. The proportions of this group of causes varied from 0.9% to 2.2% in raw data, and increased to 5% (Center West region) and 17% (South) among reclassified ill defined causes. Also some other causes were more frequent among reclassified ill defined causes: diseases of nervous system (ICD 10 Chapter 6) in all regions; endocrine, nutritional and metabolic diseases (ICD 10 Chapter 4); respiratory diseases (Chapter 10); digestive diseases (Chapter 11) mainly in Center West and, more importantly, pregnancy, childbirth and the puerperium (ICD 10 Chapter 15), i.e. maternal deaths, for all regions, except the Center West (Table 5). 9

10 Table 5 Comparison of causes of death between observed data and ill defined causes investigated. Brazil and regions, Cause of death ICD 10th Chapter Causes of death in observed data before investigation (%) North Northeast Southeast South Center-West Brazil Certain infectious and parasitic diseases Chap Neoplasms Chap Diseases of the blood Chap Endocrine, nutritional and metabolic diseases Chap Mental and behavioural disorders Chap Diseases of the nervous system Chap Diseases of the eye and adnexa Chap Diseases of the ear and mastoid process Chap Diseases of the circulatory system Chap Diseases of the respiratory system Chap Diseases of the digestive system Chap Diseases of the skin and subcutaneous tissue Chap Diseases of the musculoskeletal system.. Chap Diseases of the genitourinary system Chap Pregnancy, childbirth and the puerperium Chap Congenital malformations, deformations.. Chap External causes of morbidity and mortality Chap Causes of death reclassified after investigation of ill-defined causes (%) Certain infectious and parasitic diseases Chap Neoplasms Chap Diseases of the blood Chap Endocrine, nutritional and metabolic diseases Chap Mental and behavioural disorders Chap Diseases of the nervous system Chap Diseases of the eye and adnexa Chap Diseases of the ear and mastoid process Chap Diseases of the circulatory system Chap Diseases of the respiratory system Chap Diseases of the digestive system Chap Diseases of the skin and subcutaneous tissue Chap Diseases of the musculoskeletal system.. Chap Diseases of the genitourinary system Chap Pregnancy, childbirth and the puerperium Chap Congenital malformations, deformations.. Chap External causes of morbidity and mortality Chap Source: Ministry of Health, Mortality Information System, Cause of death data available on the Internet ( which include the reclassified deaths after investigation since 2006, indicated that injuries and neoplasms increased their relative participation among all causes from 1980 to 2010 (Table 6). Inversely, cardiovascular diseases decreased from 25.3% in 1980 to 19.2% in On the other hand, the proportions of infectious diseases were 6.0% in 1980 and 4.5% in 1990, and this decrease was due in special to Chagas disease mortality. With the change in the ICD revision used (9 th to 10 th in 1996), this group of causes increased to 6.8% in 2000, probably due to the HIV Aids related causes, but decreased to 6.3% in 2010 (Table 6). 10

11 Table 6 Cause specific proportional mortality according to ICD 10 chapters and specific codes for adults. Brazil, 1980 and Chapter ICD 10th North Northeast Southeast Certain infectious and parasitic diseases Neoplasms Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Pregnancy, childbirth and the puerperium Symptoms, signs and abnormal clinical and External causes of morbidity and mortality All others causes Total South Center West Brazil Certain infectious and parasitic diseases Neoplasms Endocrine, nutritional and metabolic diseases Mental and behavioural disorders Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Pregnancy, childbirth and the puerperium Symptoms, signs and abnormal clinical and External causes of morbidity and mortality All others causes Total Source: Ministry of Health, Mortality Information System, 1980 and Discussion The findings of this study indicate that there has been an important improvement in levels of completeness and proportions of ill defined causes of death among adults in Brazil, especially after 2005 with the strengthening of expertise in death investigation of ill defined causes. Differences in quality of data among regions were reduced in 2010 allowing a more reliable comparative analysis of cause of death profiles. In general, any discussion on cause specific mortality statistics has to be conducted in the context of completeness of data; otherwise one would never be able to gauge the extent to which cause of death patterns in unregistered deaths could bias the observed cause of death patterns. Such bias from incompleteness needs to be assessed before going into other biases arising from cause of death ascertainment, coding, classification and statistical tabulation etc. Even though we cannot precisely estimate the level of completeness of death registration among adults, application of indirect demographic methods suggests that those levels have been improved and are now generally satisfactory in Brazil, more so in the South and Southeast. Death registration is less complete in the North and Northeast, a finding consistent with the results of higher proportions of illdefined causes of death in these regions. 11

12 Indirect demographic techniques to assess completeness of death registration are influenced by factors related to characteristics of the study population, specifically in terms of accuracy of enumeration, and patterns of migration. In the case of Brazil in particular, whose population have experimented a huge and fast demographic transition in recent years, some assumptions of these methods are strong enough to cause concern and take their validity in account. There are no set criteria for judging the plausibility of estimates of missing deaths, hence it is difficult to assess whether the absolute levels of incompleteness estimated are reasonable, although the relative pattern across regions appears to be. The proportion of ill defined deaths has been a significant problem in reported causes of death from 1980 to 2004 for the country and almost all regions. There has been an important decrease in the proportion of ill defined causes from all regions over time, especially in , with improvements both in terms of magnitude and the reduction of differentials across regions. It is likely that this improvement was due to the effort made by the Brazilian government focusing on helping states and municipalities from the North and Northeast regions strengthening expertise for household interviews and health service investigations targeting a reduction in illdefined causes of death (Brazil, 2006) 8. Interestingly, these reductions were more pronounced for females than males, probably due to the higher proportion of investigation among females than males, a pattern seen in all regions in Since 2006, investigations on maternal deaths have been carried out systematically in the country by the maternal mortality committees from municipalities through an active search for deaths among women of fertile age (Brazil, 2007) 14. It is probable that this initiative has made possible a more effective investigation of ill defined causes in females. Health service investigation of ill defined causes of death reclassified 61% (n=6,395) of the causes investigated (n=10,503) in 2010 in Brazil. From those, cardiovascular diseases, external causes and neuropsychiatric conditions were the leading causes of death. Meanwhile, there is a different cause distribution relative to the observed data before investigation, i.e., the proportions of causes of death among ill defined causes investigated were different, relative to defined causes on raw data. In particular, deaths of neuropsychiatric conditions specifically associated with alcohol use disorders occurred with a higher frequency in all defined causes investigated (12.3%) and were underreported in raw data (1.8%). More importantly, we found a higher proportion of maternal deaths among ill defined causes (1.2%) than on observed data (0.4%). On the other hand, cancer was recorded more accurately in registration data, and is much less likely to be classified to ill defined categories, when compared with other natural causes, as previously reported (Mello Jorge et al., ), taking into consideration that theses causes are 50% less representative within the ill defined than other natural causes (Gamarra et al, ). Health service investigation also confirmed the likelihood of injuries being miscoded to ill defined diseases, as detected in previous research (Mello Jorge et al., ; 12

13 Campos et al., ; França et al., ). Miscoding of injury to ill defined causes is indicative of the necessity to consider injury in the redistribution rules of illdefined causes to estimate levels of cause specific mortality. The Global Burden of Disease results do not include any data on ill defined causes, which according to the methodology are redistributed to communicable and non communicable diseases as more complete registration of deaths from injury is expected (Murray & Lopez, ). Thus, our results confirm that injuries among adults in Brazil were not as well reported as expected. Among both men and women, the most striking finding relates to the growing importance of injury mortality, responsible for one third of all deaths from ages years in The leading cause of injury deaths was homicide, followed by road traffic accidents and suicide. Homicide was responsible for 7% for all adult deaths in 1980, but this increased to 13% in In conclusion, our results confirm that the differences in cause specific data among ill defined and defined causes of death must be taken into consideration when making cross regional and temporal comparisons to increase the usefulness of data nationwide for health situation assessment and priority setting. References 1. Lopez AD. Who dies of what? A comparative analysis of mortality conditions in developed countries around Wld htlh statist quart. 1990; 43: Gore, F. et al., Global burden of disease in young people aged years: a systematic analysis, Lancet, 2011, 377(9783): Vasconcelos AMN. [Quality of mortality statistics in Brazil]. R Bras Est Pop. 1998; 15(1): Brazil, Ministry of Health. [Procedures from the Mortality Information System Manual]. Brasília: Fundação Nacional de Saúde, Available from: http//portal.saude.gov.br/portal/arquivos/pdf/sis mortalidade.pdf. 5. Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from: an assessment of the global status of cause of deah data. Bul World Health Organ 2005; 83(3): França, E. et al Evaluation of cause of death statistics for Brazil, , International Journal of Epidemiology 2008;37: UNDP United Nations Development Programme, Atlas do Desenvolvimento Humano no Brasil, 2003, (available on 003). 8. Brazil, Ministry of Health. [Reorganization and qualification of health information systems.] In: Ministry of Health [Health Surveillance in the Brazilian Unified System (SUS): Strengthening the reply capacity to old and 13

14 new challenges]. Brasília: MH, p Available from: http//portal.saude.gov.br/portal/arquivos/pdf/livro nova vigilancia web.pdf. 9. Brazil, Ministry of Health. Manual para investigação do óbito com causa mal definida. Brasília; Available from: [http//bvsms.saude.gov.br/publicacoes/manual_investigacao_obito.pdf]. 10. França E, Afonso DCC, Guimarães MDC, Sousa FM. Use of verbal autopsy in a national health information system: effects of the investigation of ill defined causes of death on proportional mortality due to injury in small municipalities in Brazil. Population Health Metrics., v.9, p.1 9, Agostinho, C. Estudo sobre a mortalidade adulta, para Brasil entre 1980 e 2000 e Unidades da Federação em 2000: uma aplicação dos métodos de distribuição de mortes, Doctoral thesis, UFMG, Brazil, 2009 (avaible on Yazak L & Ortiz P. "Estudo da mortalidade por causas nas regiões brasileiras com base no registro civil tábuas de múltiplo decremento, 1979/1980", Anais do IV Encontro Ortiz, P., "Estudo da mortalidade por causas nas regiões brasileiras com base no registro civil tábuas de múltiplo decremento, 1979/1980", Anais do IV Encontro Nacional de Estudos Populacionais, São Paulo, Szwarcwald CL, et al., Busca ativa de óbitos e nascimentos no Nordeste e na Amazônia Legal: Estimação das coberturas do SIM e do Sinasc nos municípios brasileiros and Busca ativa de óbitos e nascimentos no Nordeste e na Amazônia Legal: Estimação da mortalidade infantil nos municípios brasileiros, Saúde Brasil 2011, Brasília, Brasil, Ministério da Saúde. Manual dos comitês de mortalidade materna. 3. ed. Brasília; Mello Jorge MHP, Gotlieb SL, Laurenti R. [The national mortality information system: problems and proposals for solving them. II Deaths due to natural causes]. Rev Bras Epidemiol 2002; 5(2): Gamarra CJ, Valente JG, Silva CA. Correction for reported cervical cancer mortality data in Brazil, Revista de Saúde Pública 2010, 44 (4): Campos D, França E, Loshi RH, Souza MFM. Uso da autópsia verbal na investigação de óbitos com causa mal definida em Minas Gerais, Brasil. Cadernos de Saúde Pública 2010, 26(6): Murray CJL & Lopez AD. Estimating causes of death: new methods and global and regional applications for In: Murray CJL & Lopez AD. (eds). The global burden of disease. Boston: Harvard School of Public Health, p ,