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Mortalidade infantil e classificação de sua evitabilidade por cor ou raça em Mato Grosso do Sul
Child mortality and classification of its preventability by skin color or ethnicity in Mato Grosso do Sul, Brazil

Mortalidade infantil e por cor ou raça
Child mortality by skin color or ethnicity

Renata Palópoli Pícoli - Fundação Oswaldo Cruz de Mato Grosso do Sul; Universidade Anhanguera – Uniderp. Campo Grande, MS, Brasil
Luiza Helena de Oliveira Cazola - Universidade Anhanguera – Uniderp. Campo Grande, MS, Brasil
Débora Dupas Gonçalves Nascimento - Fundação Oswaldo Cruz Fundação Oswaldo Cruz de Mato Grosso do Sul

RESUMO
Estudo epidemiológico que objetivou analisar os óbitos infantis em menores de um ano e seus critérios de evitabilidade por cor ou raça, em Mato Grosso do Sul, de 2005 a 2013, a partir dos Sistemas de Informações sobre Mortalidade e sobre Nascidos Vivos. Elaborou-se o coeficiente de mortalidade infantil anual e a descrição dos óbitos por componentes e por grupo de causas evitáveis, mal definidas e não evitáveis para os três triênios. Observou-se declínio do coeficiente de mortalidade infantil para todas as categorias de cor ou raça, com predomínio para as crianças pardas e pretas. O componente Neonatal precoce apresentou maior percentual de óbitos para todas as categorias, com exceção da indígena que registrou predomínio no componente Pós-neonatal. Os óbitos ocorreram, majoritariamente, por causas evitáveis e não foram homogêneos entre as categorias de cor ou raça. Os óbitos por causas mal definidas predominaram entre as crianças indígenas e pardas. A investigação dos óbitos apontou diferenças nos componentes de mortalidade e nas causas evitáveis segundo recorte étnico racial, o que poderá contribuir para o direcionamento de políticas públicas que qualifiquem a rede assistencial materno-infantil, sobretudo para as minorias étnicas.
Palavras-chave: Mortalidade infantil, Distribuição por raça ou etnia , Sistemas de informação, Saúde materno-infantil

ABSTRACT
The epidemiological study aimed to investigate the mortality of children under one year and the classification of preventability by skin color or ethnicity in Mato Grosso do Sul state in the period 2005-2013 retrieved from the Mortality and Live Births Information Systems. The annual child mortality coefficient and the description of deaths by components and by group of preventable, ill-defined and non-preventable causes for the three triennia were elaborated. The child mortality coefficient declined for all skin color or ethnicity categories, with a predominance of brown and black children. The early neonatal component had higher mortality rates for all categories, except for the indigenous population, which recorded predominance of the post-neonatal component. Deaths were mainly due to preventable causes, and they were not homogeneous among skin color or ethnicity categories. Deaths from ill-defined causes predominated among indigenous and brown children. The investigation of deaths pointed to differences in the components of mortality and preventable causes according to racial and ethnic contour, which could contribute to the direction of public policies that qualify the mother and child care network, especially for ethnic minorities.
Keywords: Child mortality, Race or ethnic group distribution, Information systems, Mother and child health.
INTRODUCTION
The Child Mortality Coefficient (CMC) is an important indicator for the assessment of children’s health and living conditions, since it shows the effectiveness of public health policies and the socioeconomic development of the country1.
Child deaths causes are mostly classified as either totally or partially preventable or reducible by effective and accessible actions of the health services in a given place and period2.
In view of its relevance, child mortality was one of the Millennium Development Goals (MDGs), with a commitment to reduce it by two thirds by 2015. This goal was achieved ahead of the deadline, falling from 47.1/1,000 live births (LB) to 15.3/1,000 LB in the period 1990-20113. However, social and economic inequalities and uneven access to mother and child health services are still found and may influence child mortality4,5.
In Chile, the reduction of child mortality rate in the last three decades has neared developed country rates, but there is still an increased risk of child deaths when analyzing the socioeconomic, ethnic-derived and unequal coverage of vital statistics6 aspects.
In Brazil, studies on child mortality according to the ethnic-racial contour point to the complexity and challenges of expanding coverage of health services to different ethnic groups5,7,8. Thus, it is worth noting the improvement of the skin color/ethnicity variable in the live births and deaths certificates, reflected in the quality and coverage of the Health Information Systems, which allows greater reliability of health indicators for the planning of health actions and policies for the population9.
In Brazil, in the period 1999-2002, comparative analyses showed that child mortality rates of brown children were close to white’s. However, rates for black and indigenous children were substantially higher than white skin color or ethnicity8.
Several studies10,11 address the issue of child mortality, but there are still gaps with regard to investigations concerning the coefficient and its criteria of preventability for the category of skin color or ethnicity, especially for the State of Mato Grosso do Sul. Thus, this study aims to analyze deaths of children under one year and their criteria of preventability by skin color or ethnicity, in the State of Mato Grosso do Sul.
METHODS
This is a descriptive epidemiological study on children’s deaths according to skin color or ethnicity, for the period 2005-2013 (full years), in the State of Mato Grosso do Sul, located in the Midwest of Brazil, which has an area of 357,145,836 km2, 79 municipalities and a population of 2,449,024 inhabitants12.
The characterization of skin color or ethnicity follows the categories defined by the Brazilian Institute of Geography and Statistics (IBGE) – yellow, indigenous, white, black and brown, and the skin color or ethnicity referred to by a relative or person responsible for the information concerning the child who was born and died9 is recorded in the Death Certificate (DC) and Live Birth Certificate (LBC). However, as of 2011, there was change in the recording of this variable in LBC, using mother’s skin color or ethnicity and not of the child13 anymore.
Children included in this study were selected from the database of the Mortality Information System (SIM) and the Live Births Information System (SINASC) during the study period, and skin color or ethnicity data category was ignored. Both systems showed adequate data quality (completeness and validity)14,15.

To calculate the annual Child Mortality Coefficient (CMC), according to the different categories of skin color or ethnicity, death and live birth frequency was used to compose the numerators and denominators, respectively.
The related variables according to components and preventable causes were reviewed based on the 2005-2007, 2008-2010 and 2011-2013 triennia, with the purpose of analyzing possible temporal changes in the child mortality level, according to skin color or ethnicity.
Deaths of children under one year of age were considered, according to the early neonatal (0-6 days of life), late neonatal (7-27 days of life) and post-neonatal (28-364 days of life) components, as recommended by the Child and Fetal Death Surveillance Manual and the Committee for the Prevention of Child and Fetal Death16.
Data on preventable death were retrieved from the classification of child death preventability, using the List of Preventable Causes of Death due to Interventions within the Brazilian Unified Health System2.
Child deaths investigated (with and without informed summary record) were shown, as well as those not investigated in the last two triennia, since this activity started in 200617.
Data were entered and sorted in Microsoft Excel 2016 Electronic Spreadsheet and shown in tables, initially with statewide information, followed by skin color or ethnicity categories.
The Research Ethics Committee of the Anhanguera Uniderp University approved the study under protocol no. 1222.763/2015.
RESULTS
There were 5,898 child deaths of mothers residing in the State during the period studied. The proportion of skin color or ethnicity deaths ignored was 2.1% (48/2,284) for the first triennium 2005-2007; 1.7% (35/2,049) for 2008-2010 and 1.0% (17/1,665) for 2011-2013. Regarding live births, 366,985 LBs were recorded for the period, with a proportion of ignored skin color or ethnicity field of 0.48% (575/119,560) for the triennium 2005-2007; 0.07% (90/121,635) for 2008-2010 and 0.9% (245/126,700) for 2011-2013.
CMC in Mato Grosso do Sul fluctuated in the first four years and declined in the following years. The coefficients for white children were less than 19/1,000 LB for each year. CMC for the indigenous skin color or ethnicity was around twice as high when compared to the State ratio for the study period. In the period 2006-2007, the yellow skin color or ethnicity did not report deaths and brown and black showed a marked fall for the last three years (Figure 1).
Most child deaths in the State and for most skin colors or ethnicities occurred in the early neonatal period, with a significant worsening for this component among brown children, 53.9%, 55.7% and 57.1%, respectively. It is worth noting that, unlike previous ones, the prevalence of deaths in the post-neonatal period for all three years was observed among indigenous children (Table 1).
The analysis of the triennia showed that most child deaths of residents in Mato Grosso do Sul were preventable, with a small reduction in their percentage. Deaths classified as not clearly preventable increased, recording 29% in the last triennium (Table 2).
The percentage of child deaths due to preventable causes was different in all triennia among the skin color or ethnicity categories. A decrease was noted for brown and indigenous children, while black children deaths increased in the second triennium, 90% (Table 2).
Regarding the criteria for avoidability of child deaths, a group of causes that were reducible by appropriate health promotion actions, linked to appropriate health care actions (42.9%, 31.2% and 38.5% respectively) prevailed for indigenous children when compared to the State and other categories (Table 2).
The highest proportions of deaths due to ill-defined causes were recorded among indigenous children, varying between 2.1% and 3.7%, and brown children, between 1.7% and 3.7%. Regarding the non-preventable causes, there were higher percentages in the triennia for white children, 27.5%, 32.2% and 32.7% (Table 2).
There was a significant improvement in the percentage of child deaths investigated by the State Committee for the Prevention of Mother and Child Mortality in Mato Grosso do Sul, recording 22.8% in the first triennium and 80% in the second (Table 3).
There was an increase in child deaths investigated with an informed summary sheet for all categories in the last triennium, with the lowest proportions recorded among indigenous (73.5%) and whites (80.2%) (Table 3).
DISCUSSION
The study evidenced a decline of the CMC in the last three years for the State of Mato Grosso do Sul and for the skin color or black and brown ethnic group categories, with emphasis on the early neonatal period, except for the indigenous. As for preventable deaths, there was decrease for all skin color or ethnicity categories, except for blacks.
The reduced number of non-completion of the skin color or ethnicity field in both information systems used in this study showed adequate quality (completeness and validity) of vital data and, therefore, there was no need to apply the correction factor to estimate the CMC18.
A study carried out in Cuiabá, State of Mato Grosso from 2006 to 2010 identified small fluctuations of its CMC, also for the State of Mato Grosso do Sul in the period 2005-2009 and decreasing trend in the last triennium11. However, this coefficient was significantly higher10 when compared to the CMCs of a Cuban study.
When analyzing the CMC according to skin color or ethnicity, we can affirm that their relationship alone is not a risk factor, but when it interacts with other markers of social status (education, income and gender), ethnicity can expose the group to situations of vulnerability, with a view to their adverse social REPLACEion19.
In this study, CMC for white children allows us to understand that they have better socioeconomic conditions and access to health services. A study conducted in the city of Rio de Janeiro (RJ) has identified that white women are able to have greater access to hospital services for childbirth care, which contributes to reduced child deaths20.
The indigenous population showed CMC higher than the other skin color or ethnicity categories. In Brazil, the CMC among indigenous children was higher and increasing when compared to the coefficients of white children, which showed lower and decreasing rates8.
The death of indigenous children seems to show that historical, socio-cultural, environmental and sustainability conditions interact in the child’s health process in its access to and the quality of health care, along with incipient death prevention strategies.
In this study, the lack of death records for yellow children may indicate a random variation of deaths for the years 2006 and 2007 or a underreporting that suggests weaknesses in the Mato Grosso do Sul SIM databases. The need to improve completion is evident and is associated to the adjustment of problems that include underreporting, since these measures are essential for a full knowledge of child deaths context21. The sharp fall in black and brown child deaths in the last three years indicates the need for studies that analyze this behavior and its possible correlations with social policies in the areas of health, education and fight against poverty.
Another contribution would be research in a timely manner, that is, closer to birth and death events, which will ensure information quality and consistency22. This setting shows health inequities in the Brazilian population, which is reflected not only in the data for the calculation of infant mortality, but also in the variation of their coefficients23.
This study evidenced that deaths occurred in the early neonatal period had a higher number of records and slight growth, which reflects weaknesses in the quality of health care of women in prenatal care and delivery and the newborn, unlike records found in Brazil and the Midwest in the period 2001-2011, which fell steadily24.
Among the categories, indigenous children had high child mortality rates in the post-neonatal period, consistent with a study on child mortality by skin color and ethnicity in the state of Rondônia (RO)5. These values may be linked to the social and economic determinants that directly affect the child’s health in the first years of life. These deaths are related to access to and quality of mother and child health care, as well as territorial, social and economic sustainability determinants that directly affect the health of the indigenous child in the first years of life and can lead to malnutrition and possible infections24,25.
The analysis of child mortality according to preventable causes allows a more precise identification of the child’s health situation in a given context, besides subsidizing actions more appropriate to the needs of the most vulnerable groups26.
For the triennia analyzed, there was a decreasing trend of preventable child deaths and an opposite situation regarding non-preventable deaths. Different behavior was found in a study conducted in Belo Horizonte (MG) in the period 2006-2011, which identified stable rates of non-preventable deaths, 31.2% in the first triennium and 31.3% in the second27.
Preventable infant deaths according to skin color or white and yellow race recorded smaller percentages when compared to the others that, despite showing a decreasing trend, still show high values. A study carried out by the Committee for the Prevention of Child Mortality in the State of Paraná found that white and yellow children had the lowest percentages (74.5%), while blacks, browns and indigenous had the highest (84.2%)28.
The group of causes “reducible by adequate care to women in gestation and delivery and the newborn” had the worst results for the State and all categories of skin color or ethnicity, except for indigenous women. These deaths could be prevented with improved clinical resolubility, but also with regard to the organization of care in care networks, in order to ensure access to and the quality of services timely provided to pregnant woman and the newborn29, in addition to the adequate use of scientifically proven procedures during childbirth, which may reduce the child’s death risk30.
However, when the preventability criteria were analyzed, deaths of indigenous children for the group of causes “reducible by adequate health promotion actions, linked to health care actions” evidenced the need to improve health care services for the indigenous child, with investments in training professionals to work in an interethnic context, in the articulation of the Indigenous Health Care Subsystem (SASI-SUS) with medium and high complexity levels, together with the importance of increasing coverage of water supply and sanitary sewage network adequate to the specificities of indigenous people.
In Brazil, in 2012, the two main causes of death for ethnicities / white, black, yellow skin colors were congenital malformations and prematurity, which are classified as causes that can be reduced by adequate care to women during pregnancy and delivery and to the newborn. On the other hand, the profile of the causes of child deaths was differentiated for the indigenous, in which child’s infections continued to prevail over the other causes9.
The percentage of not clearly preventable deaths showed an increase for all three years analyzed, with emphasis on skin color or white ethnicity. This behavior is to be expected, since preventable deaths are decreasing in the State and non-preventable deaths prove to be difficult to diagnose and prevent for the mother and child care network.
In this study, the proportion of deaths due to ill-defined causes among indigenous and brown children may indicate difficulties of access or poor care of these groups, besides indicating reduced information quality, unlike that identified among indigenous children of the State of Rondônia (RO), where high percentages (13.6%) of ill-defined causes are described5.
The significant improvement in the rate of child deaths investigated in the State is due to the establishment of the Committees for the Prevention of Mother and Child Mortality (CPMMI), improving the information of the summary records and providing better training for professionals conducting the investigation in loco.
One of the strategies that can contribute to the improvement of the definition of the cause of death would be the active participation of the CPMMI, so that actions are more effective, in order to reduce deaths and contribute to quality records and official health statistics.
One of the limitations of this study is the fact that its findings are based on secondary data, due to the underreporting in the completion of the Death Certificate and the lack of clarity in the classification of the skin color or ethnicity category. However, the results clarify the situation of child deaths according to skin color or ethnicity in the State.
Finally, it was pointed out that the study facilitated the identification of color or race categories of the most vulnerable children population in relation to the analyzed variables, with the purpose of intensifying efforts to complete official documents with a view to improving data quality and qualifying professionals involved. The investigation of deaths from preventable causes according to racial ethnic contour can contribute to guide public policies that qualify the care network and improve living conditions, especially for ethnic minorities, in order to ensure differentiated care for each segment of the population of Southern region of Mato Grosso State.













BIBLIOGRAPHY
1. Victora CG, Aquino EML, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Saúde das mães e crianças no Brasil: progressos e desafios. Lancet 2011;6736(11):60134-60138.
2. Malta DC, Sardinha LMV, Moura L, Lansky S, Leal MC, Szwarcwald CL, França E, Almeida MF, Duarte EC. Atualização da lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2010;19(2):173-176.
3. Organização das Nações Unidas (ONU). Relatório sobre os Objectivos de Desenvolvimento do Milénio. Nova Iorque: ONU; 2014. [Access on Feb 20, 2016]. Available from: http://www.onu.org.br/img/2014/07/relatorioodm2014.pdf
4. Victora CG, Matijasevich A, Silveira MF, Santos IS, Barros AJD, Barros FC. Socio-economic and ethnic group inequities in antenatal care quality in the public and private sector in Brazil. Health Policy Plan 2010;25(4):253-61.
5. Gava C, Cardoso AM, Basta PC. Mortalidade infantil por cor ou raça em Rondônia, Amazônia Brasileira. Rev Saude Publica 2017;51(35):1-8.
6. Barría MP, Vanegas JL. Aproximaciones metodológicas al estúdio de lamortalidad infantil en Chile. Rev Chil Pediatr 2012;83(1): 33-41.
7. Caldas ADR, Santos RV, Borges GM, Valente JG, Portela MC, Marinho, GL. Mortalidade infantil segundo cor ou raça com base no Censo Demográfico de 2010 e nos sistemas nacionais de informação em saúde no Brasil. Cad Saude Publica 2017; 33(7): 1-13.
8. Cardoso AM, Santos RV, Coimbra CEA. Mortalidade infantil segundo cor ou raça no Brasil: o que dizem os sistemas nacionais de informação? Cad Saude Publica 2005;21(5):1602-1608.
9. Brasil. Ministério da Saúde (MS). Indicadores de Vigilância em Saúde, analisados segundo a variável cor ou raça. Bol Epidemiol. 2015;46 (10):1-35. [Access on Jul 20, 2016]. Available from: http://portalsaude.saude.gov.br/images/pdf/2015/abril/22/Boletim-raca-cor-09-04-15-v2.pdf.
10. Elejalde DY, Uría RMA. La mortalidad infantil, indicador de excelencia. Rev Cubana Med Gen Integr 2008;24(2):1-8.
11. Lima JC, Mingarelli AM, Segri NJ, Zavala AAZ, Takano OA. Estudo de base populacional sobre mortalidade infantil. Cien Saude Colet 2017; 22(3):931-939.
12. Instituto Brasileiro de Geografia e Estatística, Sistema IBGE de Recuperação Automática – SIDRA. Censo demográfico e contagem da população, Brasil 2010. [Access on Aug 16, 2016]. Available from: http://www.ibge.gov.br/estadosat/perfil.php?sigla=ms
13. Brasil. Ministério da Saúde (MS). Consolidação do Sistema de Informações Sobre Nascidos Vivos – 2011. Secretaria de Vigilância em Saúde, Coordenação Geral de Informações e Análises Epidemiológicas. Brasília; 2013 [Access on Oct 01, 2017]. Available from http://tabnet.datasus.gov.br/cgi/sinasc/ Consolida_Sinasc_2011.pdf
14. Oliveira MM, Andrade SSC, Dimech GS, Oliveira, JCG, Malta, DC, Rabello Neto, DL, Moura L. Avaliação do Sistema de Informações sobre Nascidos Vivos. Brasil, 2006 a 2010. Epidemiol Serv Saúde 2015;24(4): 629-640.
15. Braz RM, Oliveira PTR, Reis AT, Machado NMS. Avaliação da completude da variável raça/cor nos sistemas nacionais de informação em saúde para aferição da equidade étnico-racial em indicadores usados pelo Índice de Desempenho do Sistema Único de Saúde. Saúde debate 2013; 37(99): 554-562.
16. Brasil. Ministério da Saúde (MS). Manual de vigilância do óbito infantil e fetal e do comitê de prevenção do óbito infantil e fetal. Brasília; 2009. [Access on Jan 15, 2016]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/vigilancia_obito_infantil_fetal.pdf
17. Brasil. Ministério da Saúde (MS). Sistema de Informações sobre Mortalidade – SIM. Óbitos fetais - a partir de 1996. Notas Técnica, 2012a. [Access on Apr 10, 2016]. Available from: http://tabnet.datasus.gov.br/cgi/sim/Obitos_Fetais_1996_2012.pdf.
18. Frias PG, Szwarcwald CL, Souza Junior PRB, Almeida, WS. Lira, PIC Correção de informações vitais: estimação da mortalidade infantil, Brasil, 2000-2009. Revista de Saúde Pública 2013; 47(6), 1048-1058.
19. Batista LE, Escuder MML, Pereira JCR. A cor da morte: causas de óbito segundo características de raça no Estado de São Paulo, 1999 a 2001. Rev Saude Publica 2004; 38: 630-636.
20. Leal MC, Gama SGN, Cunha CB. Desigualdades raciais, sociodemográficas e na assistência ao pré-natal e ao parto, 1999-2001. Rev Saude Publica2005; 39(1): 100-107.
21. Frias PG, Vidal SA, Pereira PMH, Lira PIC, Vanderlei LC. Avaliação da notificação de óbitos infantis ao Sistema de Informações sobre mortalidade: um estudo de caso. Rev Bras Saude Matern Infant 2005;5(Supl 1): S43-S51.
22. Maia LTS, Souza WV, Mendes ACG. Diferenciais nos fatores de risco para a mortalidade infantil em cinco cidades brasileiras: um estudo de caso-controle com base no SIM e no SINASC. Cad Saude Publica2012; 28(11): 2163-2176.
23. Andrade CLT, Szwarcwald CL. Desigualdades socioespaciais da adequação das informações de nascimentos e óbitos do Ministério da Saúde, Brasil, 2000-2002. Cad Saude Publica 2007; 23(5): 1207-1216.
24. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília; 2014. [Access on Feb 10, 2016]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2013_analise_situacao_saude.pdf
25. Brand AJ, Pícoli, RP. Mortalidade infantil entre os Kaiowá e Guarani de Mato Grosso do Sul. In: Ricardo B, Ricardo (Ed.). Povos indígenas no Brasil 2001/2005. São Paulo: Instituto Socioambiental, 2006, p. 795- 798.
26. Nascimento SG, Oliveira CM, Sposito V, Ferreira DKS, Bonfim CV. Mortalidade infantil por causas evitáveis em uma cidade do Nordeste do Brasil. Rev Bras Enferm 2014; 67(2): 208-12.
27. Menezes ST, Rezende EM, Martins EF, Villela LCM. Classificação das mortes infantis em Belo Horizonte: utilização da lista atualizada de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Rev Bras Saúde Matern Infant 2014;14(2):137-145.
28. Mathias TAF, Assunção AN, Silva GF. Óbitos infantis investigados pelo Comitê de Prevenção da Mortalidade Infantil em região do Estado do Paraná. Rev Esc Enferm da USP 2008; 42(3):445-453.
29. Lansky S, França E, Leal MC. Mortalidade perinatal e evitabilidade: revisão da literatura. Rev Saude Publica 2002; 36(6):759-772.
30. Dias BAS, Santos Neto ET, Andrade MAC. Classificações de evitabilidade dos óbitos infantis: diferentes métodos, diferentes repercussões? Cad Saude Publica 2017;33(5):1-14.