Correction of vital statistics based on a proactive search of deaths and live births, Brazil 2000-2010

Célia Landmann Szwarcwald, Otaliba L de Moraes, Paulo Frias and Paulo R B. de Souza

Seattle, GHME, June 18, 2013

celials@cict.fiocruz.br

Background Brazil is politically and geographically divided into five

distinct regions (North, Northeast, Southeast, South and Center-West) with varied physical, demographic, and socioeconomic characteristics.

The North and the Northeast have the worst levels of socioeconomic development and the Southeast and the South the most developed regions.

There is also important regional inequality in the completeness of death registration.

The Mortality Information System has a coverage of 94% of the total number of deaths and of 85% of the infant deaths but in only 8 of the 27 states, all from the Southern half of the country, birth and death information are considered universal.

Distribution of the municipalities according to completeness of death information. Brazil, 2008

Background

In the 1990s, many health programs were implemented focused on reducing infant mortality. The Family Health Program became the national policy for primary care, giving priority to municipalities with the worst socioeconomic levels located in the North and Northeast regions.

In view of the limitations of survey-based demographic techniques for mortality estimation, specially at the municipality level, the strategy of Brazil was to improve vital information.

This work presents recent progress in the improvement of national databases in Brazil and a method for correcting vital statistics based on a proactive search of deaths and live births in the Amazonia (North) and Northeast regions.

Estimation of infant mortality and monitoring of time trends became essential in very poor areas with deficient vital information.

Proactive search of deaths and live births

A proactive search of live births and deaths was carried out in the Amazon and Northeast regions to find vital events occurred in 2008 and not informed to the Ministry of Health.

A random sample of 133 municipalities located in 17 states of the Legal Amazonia and Northeast regions was selected.

The sample was stratified by the population size of the municipalities (1 to 20,000 inhabitants; 20,001 to 50,000 inhabitants; 50,001 to 200,000 inhabitants; more than 200,000 inhabitants) and by the adequacy of the vital information (deficient; unsatisfactory; satisfactory).

Proactive search of deaths and live births

• In the selected municipalities, we carried out a proactive search process of vital events occurred in 2008 to identify both the live births and death certificates issued but not reported to the vital information systems, as well as the live births and deaths for which the certificates were not issued.

DeathCertificate Local Health

Department

The death certificate was issued but not informed to the Ministry of Health due to local problems in the implementation of the Mortality System.

Non official Cemetery, rural area, PI, Northeast

Non issued Death Certificates

Sources of information

• Registry Offices• Unified Registry of Federal Social Benefits• Hospitals and other health care establishments• Institutes of Forensic Medicine • Official and unofficial cemeteries (burial sites) and funeral

houses

The proactive search was carried out in registry offices and hospitals located in the sampled municipality and in neighboring municipalities, where births and deaths of the residents of the sampled municipality are likely to occur.

Deaths Live BirthsSources n % n %Hospitals and other health facilities 2,551 30.7 9,377 53.5Institutes of Forensic Medicine 402 4.8 - -Registry offices 2,588 31.1 7,397 42.2Cemeteries 1,368 16.5 - -Funeral houses 960 11.5 - -Registry of social benefits 83 1.0 578 3.3Other 360 4.4 175 1.0Total 8,312 100.0 17,527 100.0

Distribution of deaths and live births found in the active search according to information source. Northeast and Legal Amazonia Regions, 2008

To characterize the level of completeness of death information, the age-standardized mortality rate (ASMR) was calculated by municipality, in the period 2000-2010. Values above 5.5 per 1000 inhabitants indicate satisfactory coverage while values lower than 3 per 1000 inhabitants indicate important underreporting.

Due to the large proportion (45%) of municipalities with fewer than 10,000 population, the age-standardized mortality rate was calculated by triennium, by considering the average number of informed deaths every three years so that the indicator would be more stable (1999-2001 up to 2009-2011).

Adequacy of death information

For the triennium corresponding to 2008 (year of the proactive search), municipalities were grouped into categories according to the age-standardized mortality rate per 1,000 population:

In each category, the underreporting correction factors were estimated by the ratio of the sum of the number of deaths corrected by the active search process and the sum of informed deaths.

Correction factors for underreported infant deaths were estimated separately.

Correction of the number of reported deaths

<2; ≥2 and <3; ≥3 and <4; ≥4 and <5; ≥5 and <5.5; and ≥5.5

To characterize the adequacy of the live birth (LB) information, the ratio between the reported and estimated LBs was calculated by municipality. The estimated number of LBs was based on the projected population of children less than one year of age.

A live birth ratio (LBR) above 0.9 indicates satisfactory LB information coverage while values lower than 0.7 indicate relevant underreporting.

Similarly to the mortality data correction, the average number of informed LBs per triennium was used (1999-2001 up to 2009-2011).

Adequacy of life birth information

For the triennium corresponding to the year 2008, the municipalities were grouped into categories according to the live birth ratio.

In each category, the underreporting correction factors were estimated by the ratio of the sum of the number of LB corrected by the active search process and the sum of informed LB.

Correction of the number of reported live births (LB)

<0.5; ≥0.5 and <0.6; ≥0.6 and <0.7; ≥0.7 and <0.8; ≥0.8 and <0.9; and ≥0.9

Category of ASMR*

Correction factors for deaths Category of

LB Ratio**Correction

factors for LBInfants

1 year and over

<2 7.17 2.76 <0.5 2.30≥2 to <3 3.17 2.08 ≥0.5 to <0.6 1.74≥3 to <4 2.11 1.50 ≥0.6 to <0.7 1.40≥4 to <5 1.52 1.23 ≥0.7 to <0.8 1.19

≥5 to ≤5.5 1.24 1.12 ≥0.8 to <0.9 1.08≥5.5 1.10 1.06 ≥0.9 1.05

Correction factors for infant deaths, deaths of individuals one year of age and older and LB per level of information coverage of the municipalities. Amazonia and Northeast Regions, 2008

*Age-standardized mortality rate per 1000 population.** Ratio of informed to estimated live births.

For the generalization of the death correction procedure in the period 2000-10, in each triennium, the municipalities were categorized according to the age-standardized mortality rate.

The correction factors were estimated from the active search according to the level of completeness of death information and were kept constant in the period.

In each municipality, the informed infant deaths in each year were corrected by the corresponding correction factor. So, if a municipality improves death registration in the period, data will be corrected by decreasing factors along the decade.

Similarly, for each category of the LB ratio, the informed LBs in the period 2000-10 were corrected by the corresponding correction factors estimated from the active search project.

Correction of vital information from 2000 to 2010

North

Northeast

Brazil

0 10 20 30 40 50 60 70 80 90 100

20102009200820072006200520042003200220012000

Completeness (%) of infant death information. North and Northeast regions, Brazil, 2000-10

Infant mortality rate (IMR) per 1,000 LB calculated using informed andcorrected vital data by macro-geographical region. Brazil, 2000-10

CorrectedInformed

40

35

30

25

20

10

5

IMR

(/10

00 L

B)

The proactive search of vital events was shown to be a good strategy both in terms of understanding local irregularities as well as for correcting vital statistics.

Due to the increase in mortality reporting over the decade, the comparison of the infant mortality rate calculated with corrected and informed vital information showed more pronounced decreasing trends after correcting the data.

The infant mortality rates estimated in 2000-10 indicated a continuous reduction, with an annual decreasing rate of 4.7% in Brazil, higher than the required rate for achieving the Millennium Development Goal.

The corrected estimates of the infant mortality rate in the period 2000-10 and the largest reduction in the Northeast certainly show the impact of recent health policies.

Conclusions

THANK YOU!