This document summarizes a study that conducted a proactive search of deaths and live births in Brazil between 2000-2010 to improve the quality of vital statistics data. The study focused on the poorer North and Northeast regions which had less complete vital records. Researchers sampled 133 municipalities and searched various sources like hospitals, cemeteries, and registry offices to find unreported vital events from 2008. They estimated correction factors for underreporting by municipality completeness levels. Applying these factors, they corrected vital statistics from 2000-2010. The corrected data showed more pronounced decreasing trends in infant mortality, particularly in the Northeast, indicating the impact of recent health policies in improving outcomes.

1. 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

2. 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.

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

4. 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.

5. 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).

6. 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.
Death
Certificate 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.

7. Non official Cemetery, rural area, PI, Northeast
Non issued Death Certificates

8. 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.

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

10. 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

11. 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

12. 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

13. 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

14. Category of
ASMR*
Correction factors for
deaths Category of
LB Ratio**
Correction
factors for LB
Infants
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.

15. 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

16. 0 20 40 60 80 100
North
Northeast
Brazil
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Completeness (%) of infant death information.
North and Northeast regions, Brazil, 2000-10

17. Infant mortality rate (IMR) per 1,000 LB calculated using informed and
corrected vital data by macro-geographical region. Brazil, 2000-10
Corrected
Informed
40
35
30
25
20
10
5
IMR(/1000LB)

18. 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

19. THANK YOU!