Abstract

Introduction

According to a study based on World Health Organization (WHO) estimates, from 2010 to 2014, there were approximately 55 million abortions worldwide, 45% of which were considered unsafe ¹1. Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu A, Temmerman M. From concept to measurement: operationalizing WHO's definition of unsafe abortion. Bull World Health Organ 2014; 92:155.. Africa, Asia and Latin American concentrate 97% of unsafe abortions. The study further showed that restrictive laws increase the occurrence of these abortions. The illegal status of abortion, however, does not deter the practice, which is related to social inequality and remains a global problem ²2. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde)..

The WHO defines unsafe abortion as a procedure for terminating a pregnancy carried out by persons lacking the necessary skills or in an environment lacking the requirements for performing medical procedures, or both ¹1. Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu A, Temmerman M. From concept to measurement: operationalizing WHO's definition of unsafe abortion. Bull World Health Organ 2014; 92:155.. Despite scientific advances capable of enabling safe abortions, unsafe abortions continue to take place, leading to an increase in health system costs, maternal complications and deaths ³3. Say L, Chou D, Gemmill A, Tunçalp Ö. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2: e323-33..

In Brazil, abortion is a public health problem, both because of its magnitude and because of its persistence ⁴4. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. Over the years, several studies, in different regions and with different methodologies sought to estimate the number of annual abortions, both induced and miscarriages. These studies were based on interviews, data collection through the ballot box method, research based on procedure and hospitalization records, and estimated very different percentages of abortion prevalence in the country ⁴4. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.^,55. Heilborn ML, Aquino EML, Bozon M, Knauth DR, organizadores. O aprendizado da sexualidade: um estudo sobre reprodução e trajetórias sociais de jovens brasileiros. Rio de Janeiro: Editora Garamond; 2006.^,66. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: indicadores de saúde e mercado de trabalho. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.^,77. Alan Guttmacher Institute. Aborto clandestino: uma realidade latino-americana. New York: Alan Guttmacher Institute; 1994.^,88. Corrêa S, Freitas A. Atualizando os dados sobre a interrupção voluntária da gravidez no Brasil. Revista Estudos Feministas 1997; 5:389-95..

Even with many studies in this field, methodological differences, non-standardized data in health information systems, lack of data from the private health system, among other factors, contribute to the continuing existence of a controversy regarding the number of abortions in Brazil.

Abortion is still an important cause of maternal death, though one with a downward trend, with an 83.3% reduction in the risk of death from 1990 to 2012 ⁹9. Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014.^,1010. Laurenti R, Mello Jorge MHP, Gotlieb SLD. A mortalidade materna nas capitais brasileiras: algumas características e estimativa de um fator de ajuste. Rev Bras Epidemiol 2004; 7:449-60.. The causes of maternal mortality are obtained from the Brazilian Mortality Information System (SIM, in Portuguese), in which data from Death Certificates (DC) are processed. The assessment of the magnitude of maternal mortality through data available in SIM faces under-diagnosis problems. A large part of these deaths are not declared as such ¹¹11. Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Guia de vigilância epidemiológica do óbito materno. Brasília: Ministério da Saúde; 2009. (Série A. Normas e Manuais Técnicos)., given the difficulty of their identification. For the classification as a maternal death, the patient must be a woman of reproductive age, that is, women aged between 10 and 49 years, the death must be reported as having taken place in the pregnancy-puerperal cycle in field 37 of the Brazilian DC and, further, the underlying cause must be classified as a maternal cause ¹²12. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: Ministério da Saúde; 2018.. The difficulty in correctly identifying and classifying maternal deaths, with subsequent under-reporting, gave rise to the need for correction factors to better estimate deaths ¹²12. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Saúde Brasil 2017: uma análise da situação de saúde e os desafios para o alcance dos objetivos de desenvolvimento sustentável. Brasília: Ministério da Saúde; 2018.. In 2017, the Ministry of Health presented an updated standardized correction factor for maternal deaths ¹³13. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Saúde Brasil 2015/2016: uma análise da situação de saúde e da epidemia pelo vírus Zika e por outras doenças transmitidas pelo Aedes aegypti. Brasília: Ministério da Saúde; 2017..

Among maternal deaths from abortion, the classification difficulty is even greater. Since SIM was implemented, studies have shown the under-reporting of maternal deaths from abortion ¹⁰10. Laurenti R, Mello Jorge MHP, Gotlieb SLD. A mortalidade materna nas capitais brasileiras: algumas características e estimativa de um fator de ajuste. Rev Bras Epidemiol 2004; 7:449-60.^,1414. Ministério da Saúde. Portaria nº 653, de 28 de maio de 2003. Diário Oficial da União 2003; 30 mai.. In the case of induced abortions, their illegality further contributes to under-reporting ²2. Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Aborto e saúde pública no Brasil: 20 anos. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde).^,1515. Souza KV, Almeida MRCB, Soares VMN. Perfil da mortalidade materna por aborto no Paraná: 2003-2005. Esc Anna Nery 2008; 12:741-9.^,1616. Valongueiro S. Mortalidade (materna) por aborto: fontes, métodos e instrumentos de estimação. In: Anais do 12º Encontro Nacional de Estudos Populacionais. http://www.abep.org.br/~abeporgb/publicacoes/index.php/anais/issue/view/32/showToc (acessado em 26/Set/2018).
http://www.abep.org.br/~abeporgb/publica... . Even with the considerable difficulty in identifying maternal deaths from abortion, no specific standardized correction factors were proposed for this cause of death.

In order to identify maternal deaths not declared in the DC, the Ordinance n. 653, issued on 28 May 2003 ¹⁴14. Ministério da Saúde. Portaria nº 653, de 28 de maio de 2003. Diário Oficial da União 2003; 30 mai., established the mandatory investigation of all deaths of women of reproductive age. The investigation further makes it possible to qualify information on causes of maternal deaths that are incorporated into SIM, in addition to revealing intervention opportunities for improving health care. The information originating from these investigations is recorded in a specific SIM module. However, this does not remove the need for corrections of the System’s database, as defined by the Guia de Vigilância Epidemiológica do Óbito Materno¹¹11. Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Guia de vigilância epidemiológica do óbito materno. Brasília: Ministério da Saúde; 2009. (Série A. Normas e Manuais Técnicos)..

Another source of data on the occurrence of abortions in Brazil are hospitalization records available on the Brazilian Hospital Information System (SIH, in Portuguese). The system records hospitalizations in the public system, collecting them for the administrative purpose of counting procedures carried out during hospitalizations and to control the costs for transferals to health units by municipal health secretariats (Departamento de Informática do SUS. Sistema de Informações Hospitalares do SUS. http://datasus.saude.gov.br/sistemas-e-aplicativos/hospitalares/sihsus, accessed on 12/Dec/2018). SIH also contains data that allow for tabulation of hospitalizations for procedures or diagnoses connected to abortion. On the other hand, abortion care not requiring hospitalization, consistent data on abortion care at an outpatient level and data on procedures performed in the private health sector are not available for analysis (Procedimentos hospitalares do SUS. http://tabnet.datasus.gov.br/cgi/sih/Proced_hosp_loc_int_1992_2007.pdf, accessed on 01/Feb/2018).

This article seeks to describe the situation of abortion in Brazil and regions, in the periods from 2006 to 2015, based on official data from the health information systems.

Methods

This is a descriptive, time-series, population-based study that sought to describe the scenario of abortion in Brazil using public data available for download in the country’s different Health Information Systems. For death information, we used SIM data from 2006 to 2015. For births, we used data from the Brazilian Information System on Live Birth (SINASC, in Portuguese), also from 2006 to 2015. We obtained the SIM and SINASC databases by downloading them from the SUS Brazilian Health Informatics Department (DATASUS) website, available at http://datasus.saude.gov.br/informacoes-de-saude/servicos2/transferencia-de-arquivos.

We also obtained hospitalization data from SIH using the Tabnet tool, also from the DATASUS website, available at http://www2.datasus.gov.br/DATASUS/index.php?area=0202&id=11633 and http://www2.datasus.gov.br/DATASUS/index.php?area=0203&id=6926. We included data from 2008 to 2015, since tabulation by hospitalization year is only available through Tabnet from 2008 onward. For previous years, tabulation is only available for processing year, which may introduce distortions due to the possibility of processing hospitalizations from previous years.

In order to identify and analyze deaths from abortion, we considered the Underlying Cause of Death, as established in the International Classification of Diseases (ICD - 10th review) ¹⁷17. Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde. 10ª revisão. São Paulo: Edusp; 2012.. We used the classification suggested by Guia de Vigilância Epidemiológica do Óbito Materno¹¹11. Departamento de Análise de Situação em Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Guia de vigilância epidemiológica do óbito materno. Brasília: Ministério da Saúde; 2009. (Série A. Normas e Manuais Técnicos). to calculate the abortion-specific Maternal Mortality Ratio (MMR), using the following ICD-10 categories: O03 (miscarriage), O04 (abortion due to medical and legal reasons), O05 (other types of abortion), O06 (non-specified abortion) and O07 (failed abortion attempt). The calculation of the abortion-specific MRR was based on the woman’s place of residence. We did not use correction factors because there is no specific standardized factor proposed for deaths from abortion. The ratio denominator was the number of live births obtained from SINASC.

We analyzed the SIH data on hospitalizations from abortion according to admission diagnosis and according to the procedure carried out. The analysis according to diagnosis included the groups “miscarriage”, “abortion due to medical reasons” and “other pregnancies that resulted in abortion”. The following procedures from the SUS Table of Procedures, Medications and OPM were included in the analysis: “post-abortion/puerperal curettage” (0411020013) and “post-abortion uterine evacuation via manual vacuum aspiration (MVA)” (0409060070). For the comparative analysis of the number of hospitalizations due to abortion among the different states, we used the relationship between the number of hospitalizations from abortion in SIH and the number of hospitalizations for deliveries in SIH, with the goal of reducing the influence of fertility variations in the population and the use of supplementary health services. For the analysis of hospitalizations for procedures related to delivery, we considered all procedures classified in Subgroup 10 (delivery and birth) from Group 3 (clinical procedures), except “newborn care at the time of birth” (031001002-0). We further considered the procedures classified in Subgroup 11 (obstetric surgery) from Group 4 (surgical procedures), organization Form 01 (delivery).

We assessed data on mortality from abortion and on hospitalizations for diagnoses or procedures related to abortion according to the following variables (when available): woman’s place of residence, sociodemographic characteristics (age, educational level, marital status, race/color), abortion classification (legal/miscarriage/other types/non-specified), year of occurrence and costs of hospitalizations from abortion. We analyzed the variable marital status for the period from 2011 to 2015 because of changes in the DC and Live Birth Certificate forms, with the inclusion of the field stable union.

This study was not submitted to an Ethics Review Board because it used public Ministry of Health data. Results are shown in aggregate, with no possibility of identification, in accordance with Resolution 466/2012 of the Brazilian National Health Council.

Results

The SIM analysis showed that, between 2006 and 2015, 770 deaths with abortion as the underlying cause were recorded in Brazil. Despite the variation over the years due to the low magnitude of the absolute numbers, we observed a trend of reduction among the deaths from abortion in Brazil, with regional differences. The regions North, Southeast and Central had, at different times, the highest abortion-specific MMR over the period and the South Region had the lowest abortion-specific MMR in the whole period. The Central Region is the only Brazilian region that shows a clear rising trend in mortality from abortion based on data recorded in SIM. Abortion-specific MMRs for Brazil and each macro-region are presented in Figure 1.

There was a reduction in the proportion of deaths from abortion among maternal deaths recorded in SIM from 2006 to 2015. Deaths from abortion were 5.7% of maternal deaths in Brazil in 2006 and 4.1% in 2015, and were only 3.2% in 2014. The Southeast region had the highest reduction in the proportion and the Central Region saw an important increase, going from 3.9% in 2006 to 6.1% in 2015.

Non-specified abortion (category O06 of ICD-10) was the most frequent underlying cause among deaths from abortion in the period we analyzed, with an average of 56.5% of cases. Among the 770 deaths whose declared underlying cause was abortion, only 7 (0.9%) were from abortions performed for medical and legal reasons (O04), 115 (14.9%) were declared as miscarriages (O03), 117 (15.2%) as other types of abortion (O05) and 96 (12.5%) as failed abortion attempts (O07).

Between 2006 and 2015, deaths from abortion were most frequent in the 20-29 years aged group. Only in the year 2007 did the age group 30-39 years register a higher number of deaths. All regions also had a greater volume of deaths in the 20-29 year group in the set of analyzed data. The abortion-specific MMR was higher among women over 40 years of age and, in 2010 and 2014, among adolescents aged 10-14 years. In the Northeast and Southeast regions, which concentrate the highest number of deaths from abortion in SIM, we observed the highest abortion-specific MMR at both extremes of the age groups. In the other regions, despite the small proportion of deaths with no information (0.004% of births and no deaths), the small number of deaths from abortion leads to great variation to the indicator, which makes the analysis difficult.

The distribution of the total number of deaths from abortion between 2006 and 2015 according to skin color maintained a relatively stable distribution, with approximately half of deaths among brown women. The abortion-specific MMR according to skin color shows that, in Brazil, according to data recorded in SIM and SINASC, black women had the highest values from 2006 to 2012. In 2013 and 2014, indigenous women had the highest MMR. In 2015, with only one death from abortion and with 0.36% of the country’s births, Asian women had the highest MMR in Brazil. In the 10-year average, black women maintained the highest MMR, however, there was an important reduction in this group’s MMR in the past five years (Figure 2). Only in the Southeast region do black women still have the highest MMR. This variable also has a low proportion of missing data (around 5%) regarding deaths from abortion and births in the period.

The proportions of deaths from abortion according to marital status remained stable from 2011 to 2015. The analysis of the average of the years, considering the categories “living in a union” (married and stable union) and “not living in a union” (single, separated, widow) shows that proportions, excluding records with no information (average of 8.2%), have remained at approximately 30% and 70%, respectively. The higher proportion of deaths from abortion among women not in a conjugal relationship is present in all Brazilian regions, varying in magnitude. This proportion is of 60.6% in the North, 63.5% in the Northeast, 73.8% in the Southeast, 90.5% in the South and 66.8% in the Central.

With regard to educational levels, we found a relative improvement in the quality of the data on deaths from abortion, with a 49% reduction, approximately, in the percentage of missing data, however, 16.7% were still missing this information in 2015. The lower educational categories (“no schooling” and “1 to 3 years of schooling”) had a percentage and absolute increase in the number of of abortions. The remaining categories had a reduction in the number of deaths. The comparative analysis of abortion-specific MMR according to educational groups is hindered by the small number of deaths in each category and the percentage of missing information for this variable.

The analysis of the percentage of deaths of woman of reproductive age that were investigated reveals differences between the Brazilian regions. In 2015, this percentage varied between 92.5% in the Central and 86.7% in the North. Despite the large number of investigated deaths, the percentage of deaths of woman of reproductive age, excluding maternal deaths, with no information on the moment of death with regard to the pregnancy-puerperal cycle, varied from 15.4% in the South to around 36% in the North in 2015. In Brazil, this percentage varied from 54% to 29.2% between 2006 and 2015.

The cause of death considered in mortality analyses is the underlying cause of death. There are, however, other diagnoses listed in death certificates, not selected as underlying causes, but that are associated with the cause of death. The multiple causes analysis shows that, between 2006 and 2015, in addition to the already-mentioned 770 deaths, there were 220 deaths that mentioned abortion, however, with a different underlying cause. Of these, 58.2% had an underlying cause classified in Chapter XV of ICD-10, that is, they were maternal deaths declared for other causes, but with mentions of abortion. The most frequent underlying causes from Chapter XV among the 220 deaths with mention of abortion are those classified in category O99 of ICD-10 (Other maternal diseases, classified in another part, but that complicate pregnancy, delivery and puerperium), followed by O85 (Puerperal infection), O23 (Genitourinary tract infection in pregnancy) and O96 (“death, by any obstetric cause, occurring more than 42 days, but less than one year, after delivery”).

Further, among the 220 deaths that mention abortion, there are deaths whose underlying cause was classified in 13 other chapters of ICD-10. On average, in the years we have analyzed, in addition to those classified with an underlying cause from the abortion-specific ICD-10 categories, there were a further 28.8% of deaths with mentions of abortion. The proportion of the mention of abortion was different in each region, with considerable variation over the years. The average annual percentage was of 41.5% in the North, 34% in the Northeast, 26.9% in the Southeast, 51.6% in the South and 25.7% in the Central. Figure 3 shows the total of deaths with abortion as the underlying cause and the total of deaths from other underlying causes with mentions of abortion.

SIH recorded an average of approximately 200,000 hospitalizations/year for procedures related to abortion from 2008 to 2015. These hospitalizations represented a total value of BRL 40,000,000.00 per year, divided between professional services (35% on average) and hospital services (65% on average). These percentages varied little over time. The procedure informed for approximately 95% of cases was “Post-abortion/puerperal curettage”. “Post-abortion uterine evacuation via manual vacuum aspiration (MVA)” corresponded to only 5% of procedures, on average, in the period we analyzed. There was a progressive reduction in the number of hospitalizations in the period, which was present in all regions, albeit unequally. The highest percentage reduction occurred in the Northeast (12.1%), followed by the Central (11.4%), Southeast (10.7%), North (4.5%) and South (0.9%). At the national scale, this reduction was of 9.5%.

In the period we analyzed, SIH also recorded a reduction of hospitalizations for procedures related to deliveries. This reduction, which was of 5.9% for Brazil as a whole, is also present in all regions, but unequally. The Northeastern region also had the greatest reduction (12.2%), followed by the North (7.6%), Central (4.9%), Southeast (0.8%) and South (0,2%). The ratio of the number hospitalizations from abortion and the number of hospitalizations for deliveries experienced a discreet reduction in the country (3.8%), going from 105 hospitalizations for abortions for each 1,000 hospitalizations for delivery in 2008 to 102 hospitalizations for abortion for every 1,000 hospitalizations for delivery in 2015. The Northeast, despite having the greatest reduction in hospitalizations from abortion, both in absolute number and in terms of percentages, still had the highest ratio of hospitalizations from abortion and delivery (104.4/1,000). In 2015, this ratio was of 104.2/1,000 in the Southeast, 103.1/1,000 in the North, 96.6/1,000 in the South and 93.5/1,000 in the Central (Table 1).

The analysis according to hospitalization diagnosis, including the groups “miscarriage”, “abortion due to medical reasons” and “other pregnancies that end in abortion”, from 2008 to 2015, shows that an average of approximately 212,000 hospitalizations/year were recorded in SIH. The total average value was of around BRL 47,000,000.00 per year, divided between professional services (34% on average) and hospital services (66% on average), with no important variations in the period.

As in the analysis of hospitalizations according to procedure, there was also an 8% reduction in the number of hospitalizations between 2008 and 2015, however, with no equivalent reduction in the total value informed. There was a reduction in the number of hospitalizations in all Brazilian regions except the South, where there was a very discreet increase.

The age group 20 to 29 years was the most frequent among women hospitalized with an abortion diagnosis in Brazil for the entire period of analysis, however, it had a reduction form 49.8% in 2008 to 44.5% in 2015. There was an increase in the proportion of the 30 to 39 year group, going from 25.9% in 2008 to 31.8% in 2015. This pattern in common to all regions. There are no hospitalizations recorded with no age information.

The high percentage of records with missing information (average of 38.2%) makes it impossible to analyze hospitalizations with an abortion diagnosis according to the race/color variable. The data on hospitalization according to SIH diagnosis available in the Tabnet tool do not include the variables educational level and marital status.

It is impossible to identify, based on the procedure, if the abortion was induced or if it was a miscarriage and there is no specific ICD-10 category for induced or illegal abortion. These should be classified in the category O05 (other types of abortion) or O07 (failed abortion attempt). Abortion due to medical and legal reasons, in turn, have a specific ICD-10 code. The analysis of SUS hospitalizations with diagnoses in the group “abortion due to medical reasons” is one of the possible ways of assessing access to legal abortion in Brazil. The total of these hospitalizations in the country had an initial reduction between 2008 and 2009 and was stable from 2009 to 2015. The average number of hospitalizations in this period was of approximately 1,600/year. The same stability in the total hospitalizations was verified in the Southeast. In the Northeast, there was an important increase and, in the remaining regions, there was a reduction in the number of hospitalizations in the period, especially in the South. The average number of hospitalizations according to diagnosis in the other groups was of 109,000 hospitalizations/year in the group “miscarriage” and of 100,000 hospitalizations/year in the group “other pregnancies that end in abortion”. There was an inversion in the proportion of hospitalizations between the groups “Miscarriages” and “other pregnancies ending in abortion”. “Miscarriages” stopped being the most frequent category, corresponding to 47% of hospitalizations in 2015.

The SIH records of hospitalizations related to abortion was considerably inconsistent. In 2008, 2009 and 2010, in the State of Pernambuco, in 2014 and 2015 in the State of Goiás and in 2014 in the Federal District, the number of recorded deaths is flagrantly differ from the other states, from other years for the same states, and further from the number of reported hospitalizations. Data relating to these locations in these periods were not considered. From 2008 to 2015, SIH recorded an average of 45 deaths per year resulting from hospitalizations with abortion diagnoses. The data are relatively stable over the period and it is not possible to state if there is a trend of increase or reduction in the regions. Since the SIM analysis shows that there was a decrease in the number of deaths in the period, the ratio of the number of deaths from abortion recorded in SIH and the number of deaths from abortion in SIM increased from 47.4% in 2008 to 72.2% in 2015 (Figure 4).

Discussion

In 2015, Brazil investigated 91.5% of deaths of woman of reproductive age. Despite the high percentage of investigations, there are clear problems. The investigation proportion is different when calculated based on the SIM investigation module or using the specific variable in the database, which suggests that the investigation information may not be fully incorporated into the database. The percentage of missing information regarding the moment of death, in terms of the pregnancy-puerperal cycle (29.2% for Brazil in 2015) reinforces this idea. It is possible that the lack of correction, by the investigation, of the underlying cause compromises the identification of maternal deaths, contributing to under-reporting. The same determinants that condition the under-reporting of maternal deaths in general apply to deaths from abortion recorded in SIM, especially those related to induced abortion. Other factors may play a role, such as legal, religious, ethical and family factors, among others. These factors may interfere with the determination and identification of the cause of death from abortion.

We identified 770 maternal deaths with abortion as the underlying cause in SIM from 2006 to 2015 which, if added to the 220 deaths that have abortion listed as a cause, would represented an increase of approximately 29% in the total of deaths associated with abortion in the period. Among the 220 deaths with causes associated with abortion, there are some with underlying causes that are frequently associated with abortion, such as puerperal infection. In some of these cases, the incorporation of the investigation results could identify abortion as the cause. There are others in which the ICD-10 rules determine that they should receive a specific code, such as late maternal deaths (more than 42 days of puerperium), which must always appear as the underlying cause in the category O96 of ICD-10 (“death, by any obstetric cause, occurring more than 42 days, but less than one year, after delivery”), even if abortion is the underlying cause. Among deaths with mentions of abortion with underlying causes out of ICD-10 Chapter XV, some have well-specified underlying causes, such as neoplasms and external causes, in which abortion may have been a consequence of other conditions. There are, however, deaths with mention of abortion and unspecified causes, such as sepsis and peritonitis, which may be consequences of abortion. A study carried out in Minas Gerais, from 2000 to 2011, on abortion-related maternal mortality in light of multiple causes concluded that abortion was identified as the underlying cause in around 11% of deaths and a further 4% had causes associated with abortion. In the deaths whose associated cause was related to abortion, underlying causes were classified as maternal in 56% of deaths, while 44% were classified as non-maternal causes ¹⁸18. Martins EF, Almeida PFB, Paixão CO, Bicalho PG, Errico LSP. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115.. This study found similar results.

SIH recorded approximately 200,000 hospitalizations/year for procedures related to abortion from 2008 to 2015. “Post-abortion/puerperal curettage” was the procedure described in 95% of cases, while “Post-abortion uterine evacuation via manual vacuum aspiration (MVA)” corresponded to only 5%. SIH records procedures that require hospitalization. Procedures carried out without hospitalization are not recorded. The difference in the need for hospitalization for both procedures may account for part of the difference in the proportion of hospitalization for both procedures.

The number of hospitalizations from abortion identified in this study is considerably inferior to the estimates of the number of abortions in Brazil. A study carried out in Brazil, Chile, Mexico, Peru, Colombia and the Dominican Republic based on records of curettages performed in public services and on interviews with health professionals estimated, in 1991, the occurrence of 1,443,350 abortions in Brazil ⁷. More recent estimates pointed to the occurrence of between 687,347 and 865,160 induced abortions in Brazil in 2013 ¹⁹19. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido, por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8.. The number of hospitalizations from abortion that can be identified is influenced by the segmentation of the information for the public sector and by the already-mentioned quality of the information regarding the abortion diagnosis. It further refers to the proportion of terminations, whether miscarriages or induced abortions, which require hospital admission. The number of hospitalizations from abortion is only one source of data for estimating the total number of abortions that take place in Brazil.

The trend of reduction in the number of hospitalizations from abortions, of 9.5% in the analysis according to procedures, is also identified by other studies. A study that used SIH data from 1995 to 2013 estimated the number of induced abortions in the country and concluded that there was a 27% decrease in the hospitalizations of woman of reproductive age due to complications from abortion and the estimate of the annual number of induced abortions was reduced by 26% ¹⁹19. Monteiro MFG, Adesse L, Drezett J. Atualização das estimativas da magnitude do aborto induzido, taxas por mil mulheres e razões por 100 nascimentos vivos do aborto induzido, por faixa etária e grandes regiões. Brasil, 1995 a 2013. Reprod Clim 2015; 30:11-8..

The increase in the proportion of deaths recorded in SIH in relation to deaths from abortion in SIM, from 47.4% in 2008 to 72.2% in 2015, could have two explanations. The first is the increase in the proportion of deaths within hospitalizations in the public system, which are recorded in SIH, in comparison with the private sector. The second is the better recording of deaths in hospitalizations in SIH, despite the already-discussed fragility of the data, which mean this analysis must be considered with caution.

The profile of women who died from abortion that we identified coincides with findings from other studies. One study carried out in Minas Gerais ¹⁸18. Martins EF, Almeida PFB, Paixão CO, Bicalho PG, Errico LSP. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115. presented the characteristics of women who died in relation to abortion as: women aged 20 to 34 years, single (68%) and black (70.5%), most with less than 7 years of schooling. The authors further noted that around 40% of data referring to the variables educational level and the moment of death in terms of pregnancy or puerperium were blank. Death from abortion characterizes a situation of health inequity due to the higher number of deaths among more vulnerable groups (low educational level and black race/color) ¹⁸18. Martins EF, Almeida PFB, Paixão CO, Bicalho PG, Errico LSP. Causas múltiplas de mortalidade materna relacionada ao aborto no Estado de Minas Gerais, Brasil, 2000-2011. Cad Saúde Pública 2017; 33:e00133115..

One limitation of this study was that we were unable to include data on the occurrence of abortions that did not require hospitalization and those that resulted in hospitalizations in the private sector. On the other hand, it has shown that more vulnerable women are more likely to die after an abortion, even observing only those who turn to the public system, who are known to be more susceptible to an unsafe abortion ¹1. Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu A, Temmerman M. From concept to measurement: operationalizing WHO's definition of unsafe abortion. Bull World Health Organ 2014; 92:155..

Conclusion

There are no data on unsafe abortion in the Brazilian information health systems.

The official databases do not enable estimates of the number of abortions that occur in Brazil. The available data are restricted to deaths from abortion and hospitalizations due to complications from abortion in the public health system.

The attention to adequately entering information into DC is a crucial factor for gaining greater precision in the mortality information. The quality of the information regarding the cause of death, the under-reporting of maternal deaths and those related to abortion, in addition to the completeness and correction of other variables in SIM could be improved with the systematic incorporation of information from investigations of deaths into the SIM database.

These could have an indirect repercussion on the better identification of deaths from abortion. The identification of deaths with mention of abortion in the DC but with underlying causes classified in other ICD-10 categories suggests the need to include a multiple causes analysis to better determine the scale of mortality involving abortion. The improvement of SIH data quality, especially with regard to the regularity of records, diagnoses and deaths, in addition to systematic, regular access to information from the private health system are actions that would contribute to a better understanding of abortion in Brazil.

Despite the under-reporting of deaths, official data on births and deaths enable us to establish the profile of the women who are at highest risk of dying from abortion in Brazil by calculating specific MMRs. These are black and indigenous women, with low educational levels, over the age of 40 or under the age of 14, in the regions North, Northeast and Central, and not in a conjugal relationship. This profile can be used as a risk marker in post-abortion hospitalizations, so as to increase clinical surveillance of these cases, resulting in a more favorable evolution. These groups mainly need access and qualification of reproductive planning and prenatal care actions so as to reduce the risk of abortion, whether induced or miscarriages.

Acknowledgments

Global Health Strategies provided funding for this study, however, with no influence over research methods and results.

References

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