ABSTRACT:

Objective:

To analyze the mortality trend of children under five years of age living in Brazil and regions, using the “Brazilian List of Preventable Causes of Death.”

Method:

Ecological time-series study of mortality rate due to preventable and non-preventable causes, with corrections for ill-defined causes and underreporting of deaths from 2000 to 2013.

Results:

In Brazil, preventable death rates (5.1% per year) had a higher decrease compared with non-preventable ones (2.5% per year). Preventable causes associated with proper care during pregnancy had the highest concentration of deaths in 2013 (12,267) and the second lowest average percentage reduction in the year (2.1%) and for the period (24.4%). The South and Southeast regions had the lowest mortality rates in childhood. However, the Northeast region had the highest decrease in reducible child mortality (6.1% per year) and the Midwest, the lowest (3.5% per year).

Conclusion:

The decrease in childhood mortality rates was expected in the last decade, suggesting the progress in the response of health systems, in addition to improvements in health conditions and social determinants. Special attention should be given to pregnancy-related causes, i.e., expand the quality of prenatal care, in particular, due to fetal and newborn deaths resulted from maternal conditions, which increased significantly in the period (8,3% per year).

Keywords:
Mortality, premature; Child mortality; Cause of death; Health services evaluation; Unified Health System; Epidemiology

INTRODUCTION

Different authors have used the concept of preventable death¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... ^,22. Charlton JRH, Velez R. Some international comparisons of mortality amenable to medical intervention. BMJ 1986; 292(6516): 295-301.^,33. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... ^,44. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... , with studies by Rutstein et al.¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... considered as precursors in the 1980s. These authors defined these deaths as those that could have been prevented, entirely or in part, by effective health care services and proposed a list with approximately 90 preventable conditions¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... .

In the following years, several studies sought to implement this concept¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... ^,22. Charlton JRH, Velez R. Some international comparisons of mortality amenable to medical intervention. BMJ 1986; 292(6516): 295-301.^,33. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... , aiming to construct indicators sensitive to the quality and diversity of health care, as they are a measure of result or impact of services useful to their surveillance and monitoring processes⁴4. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... . Charlton and Velez were the first to apply the concept in population studies in England and Wales²2. Charlton JRH, Velez R. Some international comparisons of mortality amenable to medical intervention. BMJ 1986; 292(6516): 295-301.. We highlight the studies performed by Holland³3. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... on this theme in several countries and continents (Europe, Asia, and Oceania) ³3. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... .

In Brazil, the scientific production on preventability also increased, including review articles⁴4. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... ^,55. Lansky S, França E, Leal MC. Mortalidade perinatal e evitabilidade: revisão da literatura. Rev Saúde Pública 2002; 36(6): 759-72. http://dx.doi.org/10.1590/S0034-89102002000700017
http://dx.doi.org/10.1590/S0034-89102002... , service performance evaluations⁶6. Abreu DMX, César CC, França EB. Relação entre as causa de morte evitáveis por atenção à saúde e a implementação do Sistema Único de Saúde. Rev Panam Salud Pública 2007; 21(5): 282-91.^,77. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... , and mortality trend studies in specific groups ⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... ^,88. Malta DC, Moura L, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608. http://dx.doi.org/10.5123/S1679-49742014000400002
http://dx.doi.org/10.5123/S1679-49742014... ^,99. 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): 137-45. http://dx.doi.org/10.1590/S1519-38292014000200003
http://dx.doi.org/10.1590/S1519-38292014... ^,1010. Lisboa L, Abreu DMX, Lana AMQ, França EB. Mortalidade infantil: principais causas evitáveis na região Centro de Minas Gerais, Brasil, 1999-2011. Epidemiol Serv Saúde 2015; 24(4): 711-20. http://dx.doi.org/10.5123/S1679-49742015000400013
http://dx.doi.org/10.5123/S1679-49742015... . It is also worth mentioning the “Brazilian List of Preventable Causes of Death” for the under 5 and 5 to 74 age groups, from the perspective of the Brazilian Unified Health System (SUS) ¹¹11. Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais Neto OL, Moura L, et al. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2007; 16(4): 233-44.. The construction of the list involved specialists from relevant areas and intense debate on the topic¹¹11. Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais Neto OL, Moura L, et al. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2007; 16(4): 233-44.^,1212. Malta DC, Sardinha LMV, Moura L, Lansky S, Leal MC, Szwarcwald CL, et al. Atualização da lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2010; 19(2): 173-6.. The theoretical framework adopted in the development of the Brazilian list in 2007 was based on lists available in Brazil and the world, in particular, the ones by Ortiz¹³13. Ortiz LP. Agrupamento das causas evitáveis de morte dos menores de um ano segundo critério de evitabilidade das doenças. São Paulo: Fundação Seade; 2000., and Tobias and Jackson¹⁴14. Tobias M, Jackson G. Avoidable mortality in New Zealand, 1981-97. Aust N Z J Public Health 2001; 25(1): 12-20..

Thus, the article applies the list and aims to analyze the trend of preventable and ­non-preventable causes of deaths in children aged 0 to 4 years in Brazil and regions.

METHOD

This is an ecological time-series study on child mortality trend according to preventable criteria in Brazil and regions from 2000 to 2013. The population consisted of children aged 0 to 4 years, who died in this period due to underlying causes according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), whose death was reported to the Brazilian Mortality Information System (Sistema de Informação sobre Mortalidade - SIM) of the Ministry of Health.

The trend analysis of preventable deaths (2000-2013) used the “Brazilian List of Preventable Causes of Deaths”¹¹11. Malta DC, Duarte EC, Almeida MF, Dias MAS, Morais Neto OL, Moura L, et al. Lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2007; 16(4): 233-44.^,1212. Malta DC, Sardinha LMV, Moura L, Lansky S, Leal MC, Szwarcwald CL, et al. Atualização da lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil. Epidemiol Serv Saúde 2010; 19(2): 173-6.. Deaths were classified as:

The original list anticipates the inclusion of ill-defined causes of death; however, the current work excluded this item, because it redistributed these causes.

We used the SIM databases and the Live Birth Information System (Sistema de Informação sobre Nascidos Vivos - SINASC) of the Health Surveillance Secretariat of the Ministry of Health (Secretaria de Vigilância em Saúde/Ministério da Saúde - SVS/MS). The SIM database was corrected using the redistribution of deaths classified as ill-defined causes (IDCDs) and the correction of underreported deaths. IDCDs have decreased significantly in the last decade due to the improvement and qualification of the SIM database, making it necessary to use methodologies to correct it, especially when analyzing time-series ¹⁵15. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33.^,1616. GDB 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014; 385(9963): 117-71. http://dx.doi.org/10.1016/S0140-6736(14)61682-2
http://dx.doi.org/10.1016/S0140-6736(14)... ^,1717. Malta DC, Moura L de, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608. http://dx.doi.org/10.5123/S1679-49742014000400002
http://dx.doi.org/10.5123/S1679-49742014... ^,1818. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... . Therefore, we decided on the proportional redistribution of ill-defined deaths among all known causes, assuming that the distribution of ill-defined causes of death is similar to defined ones¹⁵15. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33.. To that end, we adapted the methodology proposed by Duncan et al.¹⁵15. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33. since we included external causes in the redistribution of IDCDs of the present study. The inclusion of external causes in the redistribution of deaths was based on studies that evidenced findings of violence and accidents among the investigated IDCDs¹⁸18. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... . Thus, we chose to add the total number of ill-defined deaths - including external causes - to the redistribution of deaths.

The correction of the number of reported deaths was estimated by means of SIM coverage in Brazilian cities, using data from the study developed by Szwarcwald et al.¹⁹19. Szwarcwald CL, Morais Neto OL, Frias PG, Souza PRB Jr, Escalante JC, Lima RB, 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. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 79-98. entitled “Active Search for Deaths and Births in the Northeast and in the Legal Amazon: Estimation of SIM and SINASC coverage in Brazilian municipalities.” Deaths were corrected according to year, gender, and federation units for underreporting and redistribution of IDCDs. We used the specific rate for this age group.

The trend of child mortality due to preventable causes and its subgroups and non-preventable causes were analyzed using the Simple Linear Regression method. The analysis of residuals evaluated the adequacy of the model, as well as the homoscedasticity of the variables by states and causes. The SPSS Statistics 17.0 software was used. The level of acceptable statistical significance was p <0.05.

This study complied with the recommendations of Resolution 466/12 of the National Health Council (NHC). We used secondary data, available on the official website of the Ministry of Health, which did not include confidential information, such as name and address. Thus, the study did not need the approval of a Research Ethics Committee.

RESULTS

In Brazil, 103,976 children under the age of 5 died -due to all causes - in 2000, this number dropped to 66,160 deaths in 2007, and 51,344 in 2013. In the same period, the number of deaths due to preventable causes decreased from 78,703 in 2000 to 35,318 in 2013, with a percentage reduction in mortality rate of 5.1% per year and 49.3% in the period (Table 1).

Reducible causes by vaccination actions remained stable in Brazil, with 181 deaths in 2000 and 128 in 2013 (p = 0.193), with an increase in deaths by pertussis (p = 0.014) (Table 1).

Reducible causes by adequate pregnancy care had the highest proportion of deaths among all subgroups in 2013 (12,267), approximately one-third of cases. There was a reduction of 24.4% (p <0.001) in the mortality rate for these causes between 2000 and 2013 and 2.1% per year. Among the main specific causes of death in this group, we highlight:

Preventable deaths due to adequate delivery care revealed a decrease in the mortality rate of 45.1% (p <0.001) between 2000 and 2013 and 4.4% per year. The specific causes of death that contributed most to this group were:

The group of reducible causes due to adequate neonatal care decreased from 22,605 deaths in 2000 to 8,278 in 2013, with a reduction in mortality rate of 6.5% per year and 58.7% in the period (p <0.001), holding the second position in magnitude. The main causes of death in this group include:

Adequate diagnosis and treatment actions were responsible for 13,731 deaths in 2000 and 5,112 in 2013, with a reduction of 6.4% per year and 58% in the period (p <0.001). The three main causes of death in this group were:

Reducible causes by adequate health promotion actions decreased from 14,316 deaths in 2000 to 4,888 in 2013, constituting a mean annual reduction of 6.8% and 61.5% (p <0.001) in the period. The largest reductions were:

Other accidental respiratory risks showed stability (p = 0.866) (Table 1).

Non-preventable causes due to health service actions also dropped from 25,273 deaths in 2000 to 16,026 in 2013, with a decrease of 2.5% per year and 28.4% in the period (Table 1).

Figure 1 shows the decline in under-five mortality rate related to preventable and non-preventable causes in Brazil in the period. Preventable causes decreased 5.1% per year and 49.3% in the period (p <0.001), while non-preventable causes halved, 2.5% per year and 28.4% in the period (p <0.001).

Table 2 demonstrates similar results of the mortality rate from preventable and non-preventable causes according to Brazil and regions. The decrease in preventable causes was twice the non-preventable ones in all regions. The Northeast had the highest average annual reduction in the period (6.1% per year), followed by the North (4.7%), South (4.5%), and Southeast (4.4%), and the Midwest had the lowest (3.5%). The percentage of annual reduction in mortality rate from non-preventable causes was lower (2.5%), varying per region, with 1% in the Midwest and 3.9% in the Northeast (the highest) (Table 2).

Figure 2 shows the progress of preventable death according to subgroup and region in the period 2000-2013. The mortality rate in the period studied decreased in all groups, except for reducible causes by vaccination actions, which dropped until 2005-2007 and increased again in all regions until 2012, when it showed a reduction trend in all but the North and Midwest regions, where the rise persisted in 2013 (Figure 2A).

Other groups presented more homogeneous declines for other preventable causes (Figures 2B to 2F). Adequate diagnostic and treatment actions also decreased throughout the period, except in the North and Midwest regions, which increased between 2012 and 2013 (Figure 2E).

DISCUSSION

The results of the current study reveal improvements in child mortality rates. Deaths due to causes considered preventable had a more significant reduction, while non-preventable causes showed a smaller decline - half - in the period under study. The greatest reductions - 6.8% per year - resulted from health promotion actions linked to care actions (causes such as intestinal infectious diseases) and adequate newborn care (neonatal respiratory disorders), followed by adequate diagnostic and treatment actions (pneumonia, bacterial infections). Adequate delivery care (causes such as hypoxia, asphyxia) had a reduction of 4.4% per year, and the lowest decrease in rates resulted from vaccine-preventable diseases, which already presented very low rates due to advances in the past decades, with vaccines against poliomyelitis, measles, diphtheria, tetanus, and others. Causes associated with adequate pregnancy care accounted for a quarter of the causes of death and had the second lowest reduction in the period. The South and Southeast regions had the lowest mortality rates in childhood. However, the Northeast region had the highest decrease in reducible child mortality (6.1% per year) and the Midwest, the lowest (3.5% per year).

The literature has been presenting the use of indicators of preventable deaths as a useful tool for monitoring the impact of the Health sector on the risk of death of populations. According to Malta and Duarte⁴4. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... , these methodologies are characterized by objectivity, timeliness, ease, and availability of indicators, enabling analysis of their temporal trends and comparisons between regions and cities. Preventable deaths become indicators sensitive to the quality of care provided by the health system and, therefore, allow the performance evaluation of its services¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... ^,33. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... ^,44. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... ^,1414. Tobias M, Jackson G. Avoidable mortality in New Zealand, 1981-97. Aust N Z J Public Health 2001; 25(1): 12-20..

The present study advances methodological aspects by including the redistribution of deaths not registered in the SIM, according to the methodology proposed by Szwarcwald et al.¹⁹19. Szwarcwald CL, Morais Neto OL, Frias PG, Souza PRB Jr, Escalante JC, Lima RB, 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. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 79-98., in addition to incorporating the redistribution of IDCDs. The redistribution of IDCDs in defined causes represents a methodology to qualify death records. Statistical methods for this correction are used based on the behavior of the defined causes reported¹⁵15. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33.^,1616. GDB 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014; 385(9963): 117-71. http://dx.doi.org/10.1016/S0140-6736(14)61682-2
http://dx.doi.org/10.1016/S0140-6736(14)... ^,1717. Malta DC, Moura L de, Prado RR, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608. http://dx.doi.org/10.5123/S1679-49742014000400002
http://dx.doi.org/10.5123/S1679-49742014... ^,1818. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... . More commonly, proportional redistribution is used according to defined causes, registered by gender and age, excluding external causes¹⁵15. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33.. França et al.¹⁸18. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... highlighted the importance of investigating death to support its redistribution. The authors found 9.3% of deaths by external causes among the ill-defined deaths investigated¹⁸18. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... . These findings indicate the importance of including external causes in the redistribution of deaths. The Global Burden Disease (GBD) study¹⁶16. GDB 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014; 385(9963): 117-71. http://dx.doi.org/10.1016/S0140-6736(14)61682-2
http://dx.doi.org/10.1016/S0140-6736(14)... has new parameters for redistribution of deaths, based on census estimates, death record systems, and other existing studies, and includes garbage codes, or non-specific codes, in the redistribution. The current study redistributed all causes of death, including external causes, according to findings by França et al.¹⁸18. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... ^. These methodological advances aim to establish estimates and incorporate rates closer to reality¹⁸18. França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito Rev Saúde Pública 2014; 48(4): 671-81. http://dx.doi.org/10.1590/S0034-8910.2014048005146
http://dx.doi.org/10.1590/S0034-8910.201... ^,1919. Szwarcwald CL, Morais Neto OL, Frias PG, Souza PRB Jr, Escalante JC, Lima RB, 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. In: Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 79-98..

Progress in reducing child mortality worldwide has been described as one of the greatest global success stories in international health. Rates have halved in the last two decades, compared with the 1990 baseline of the Millennium Development Goals (MDGs). Between 1990 and 2013, under-five mortality rates dropped from 90 deaths per 1,000 live births (LB) to 46 deaths per 1,000 LB²⁰20. World Health Organization. World Health Statistics 2015. Genebra: World Health Organization; 2015.. In absolute numbers, under-five deaths decreased from 9.9 million in 2000 to 6.3 million in 2013²⁰20. World Health Organization. World Health Statistics 2015. Genebra: World Health Organization; 2015.. However, this indicator is still very relevant in the world and was included in the Sustainable Development Goals (SDGs) which indicate challenges to be faced²¹21. Organização das Nações Unidas no Brasil. Objetivos de Desenvolvimento Sustentável (ODS): Brasil [Internet]. 2015 [citado em 5 jan. 2016]. Disponível em: https://nacoesunidas.org/pos2015/ods3/
https://nacoesunidas.org/pos2015/ods3/... .

The MDGs report revealed that complications in preterm birth are currently the leading global cause of under-five deaths, accounting for 17% of them, which go beyond the neonatal period (0-29 days) ²²22. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio. Relatório Nacional de Acompanhamento. Brasília: Ipea; 2014. p. 65-75.. This finding demonstrates the transition in child health care, overcoming the predominant causes of the past, such as diarrhea, pneumonia, and infectious diseases²⁰20. World Health Organization. World Health Statistics 2015. Genebra: World Health Organization; 2015.^,2222. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio. Relatório Nacional de Acompanhamento. Brasília: Ipea; 2014. p. 65-75..

Brazil was ahead of many countries, as it achieved the goal of reducing child mortality by 2/3, defined by the fourth MDG²²22. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio. Relatório Nacional de Acompanhamento. Brasília: Ipea; 2014. p. 65-75.. The country also decreased child mortality in both the post-neonatal (29 days to 1 year) and neonatal periods, the latter, however, was less expressive⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... ^,99. 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): 137-45. http://dx.doi.org/10.1590/S1519-38292014000200003
http://dx.doi.org/10.1590/S1519-38292014... ^,1010. Lisboa L, Abreu DMX, Lana AMQ, França EB. Mortalidade infantil: principais causas evitáveis na região Centro de Minas Gerais, Brasil, 1999-2011. Epidemiol Serv Saúde 2015; 24(4): 711-20. http://dx.doi.org/10.5123/S1679-49742015000400013
http://dx.doi.org/10.5123/S1679-49742015... ^,2222. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio. Relatório Nacional de Acompanhamento. Brasília: Ipea; 2014. p. 65-75.^,2323. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p.. Post-neonatal mortality includes causes of death such as diarrhea, malnutrition, pneumonia, HIV/AIDS, and vaccine-preventable diseases - measles, tuberculosis, among others -, and its reduction reveals an improvement in sanitary conditions and progress in the supply of primary health care in the country²⁰20. World Health Organization. World Health Statistics 2015. Genebra: World Health Organization; 2015.^,2222. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio. Relatório Nacional de Acompanhamento. Brasília: Ipea; 2014. p. 65-75.^,2323. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p..

The WHO report highlights the importance of perinatal causes and, in order to reduce them, it is necessary to focus on prenatal, delivery, and newborn care. Mortality rates due to adequate pregnancy care had the highest concentration of deaths in 2013 (23.8%) and the lowest reduction in the period (24.4%). Data from SINASC showed a rise in access to prenatal care in the country in recent years²³23. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p.. Also, data from the National Health Survey revealed that 97.4% of women reported having received prenatal care, with 83.6% starting within 13 weeks of pregnancy and 78.3% attending 6 or more appointments²⁴24. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde (PNS): ciclos de vida. Brasil [Internet]. Instituto Brasileiro de Geografia e Estatística; 2015 [citado em 5 jan. 2016]. v. 3. Disponível em: http://www.sidra.ibge.gov.br/bda/pesquisas/pns/default.asp
http://www.sidra.ibge.gov.br/bda/pesquis... . In other words, prenatal care increased in the country, which is consistent with the expansion of primary health care and the Family Health Program²⁵25. Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR, et al. Saúde da Família: limites e possibilidades para uma abordagem integral de Atenção Primária à Saúde no Brasil. Ciênc Saúde Colet 2009; 14(3): 783-94. http://dx.doi.org/10.1590/S1413-81232009000300014
http://dx.doi.org/10.1590/S1413-81232009... .

Studies report that inadequate prenatal care results from situations such as social inequality, access to health services, and acceptance of pregnancy²⁶26. Almeida MF, Alencar GP, Novaes MHD, França Júnior I, Siqueira AA, Schoeps D, et al. Partos domiciliares acidentais na região Sul do Município de São Paulo. Rev Saúde Pública 2005; 39(3): 366-75. http://dx.doi.org/10.1590/S0034-89102005000300006
http://dx.doi.org/10.1590/S0034-89102005... ^,2727. Victora CG. Intervenções para reduzir a mortalidade infantil pré-escolar e materna no Brasil. Rev Bras Epidemiol 2001; 4(1): 3-69. http://dx.doi.org/10.1590/S1415-790X2001000100002
http://dx.doi.org/10.1590/S1415-790X2001... ^. Studies also claim that inadequate prenatal care is one of the most important risk factors in neonatal mortality²⁶26. Almeida MF, Alencar GP, Novaes MHD, França Júnior I, Siqueira AA, Schoeps D, et al. Partos domiciliares acidentais na região Sul do Município de São Paulo. Rev Saúde Pública 2005; 39(3): 366-75. http://dx.doi.org/10.1590/S0034-89102005000300006
http://dx.doi.org/10.1590/S0034-89102005... ^,2727. Victora CG. Intervenções para reduzir a mortalidade infantil pré-escolar e materna no Brasil. Rev Bras Epidemiol 2001; 4(1): 3-69. http://dx.doi.org/10.1590/S1415-790X2001000100002
http://dx.doi.org/10.1590/S1415-790X2001... ^,2828. Barros FC, Victora CG, Barros AJD, Santos IS, Albernaz E, Matijasevich A, et al. The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004. Lancet 2005; 365(9462): 847-54. https://doi.org/10.1016/S0140-6736(05)71042-4
https://doi.org/10.1016/S0140-6736(05)71... . Therefore, in addition to increasing access, it is necessary to invest in improving the quality of prenatal care through adequate management of pregnant women with risk factors and complications, such as hypertension, diabetes, genitourinary tract infections, among others.

Regarding prenatal-sensitive causes, deaths due to Neonatal Respiratory Distress Syndrome (NRDS) decreased, with emphasis on initiatives such as the use of pulmonary surfactants, included in the special procedures table of SUS under Directive No. 139 of November 10, 1997, allowing the improvement of the respiratory clinical status as well as the application of protocols that introduced drugs to induce lung maturity²⁹29. Miyoshi MH. Terapêutica de reposição de surfactante. J Pediatr (Rio J) 2001; 77(Supl. 1): S3-16. https://doi.org/0021-7557/01/77-Supl.1/S3
https://doi.org/0021-7557/01/77-Supl.1/S... . However, maternal conditions affecting the fetus and the newborn, e.g., diabetes, kidney diseases, increased in the period, which may reflect both a better diagnosis of these conditions during pregnancy and the growth in their prevalence⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... . Deaths from disorders related to short-term pregnancy and low birth weight were stable in the study period. Some studies have shown an increasing trend in preterm births in Brazilian cities³⁰30. Victora CG, Aquino EML, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780): 1863-76. https://doi.org/10.1016/S0140-6736(11)60138-4
https://doi.org/10.1016/S0140-6736(11)60... . SINASC also reported a rise in the registry of underweight newborns from 7.7% in 1997 to 12.5% in 2012²³23. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p..

The causes of death related to adequate delivery care presented a reduction in the period; causes such as intrauterine hypoxia, perinatal asphyxia, and neonatal aspiration syndrome decreased significantly, showing advances in delivery care. Perinatal asphyxia and intrauterine hypoxia are syndromic manifestations, and their reduction could also be due to a more correct indication of other causes of death⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... . Deaths from placenta previa, placental abruption, and hemorrhage also decreased in the period.

Child mortality rate due to reducible causes regarding adequate newborn care presented the second highest reduction (58.7%), suggesting an improvement in the access to delivery and newborn care²⁰20. World Health Organization. World Health Statistics 2015. Genebra: World Health Organization; 2015.^,2323. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p.. Deaths resulting from neonatal-specific respiratory disorders and neonatal-specific infections decreased, except congenital rubella and viral hepatitis. The set of preventable causes related to health promotion and care actions showed the most significant decline (61.5% per year) in the study period. In this group, we highlight the significant reduction in deaths by intestinal infectious diseases (80.5%), confirming results from previous global and national studies²³23. Brasil. Ministério da Saúde. Saúde Brasil 2013: uma análise da situação de saúde e das doenças transmissíveis relacionadas à pobreza. Brasília: Ministério da Saúde; 2014. 384 p.. The expansion of basic sanitation, the growth of intersectoral actions, the improvement of oral rehydration therapy⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... , and the impact of rotavirus vaccination³¹31. Ambrosini VA, Carraro E. Impacto da vacinação contra rotavírus no Brasil. Medicina (Ribeirão Preto. Online) 2012; 45(4): 411-8. https://doi.org/10.11606/issn.2176-7262.v45i4p411-418
https://doi.org/10.11606/issn.2176-7262.... were initiatives that promoted the reduction in child mortality in the country. In addition, deaths resulting from traffic accidents decreased, which has been attributed to legal measures, such as the mandatory use of car seats and safety devices³²32. Garcia LP, Freitas LRS, Duarte EC. Avaliação preliminar do impacto da Lei da Cadeirinha sobre os óbitos por acidentes de automóveis em menores de dez anos de idade, no Brasil: estudo de séries temporais no período de 2005 a 2011. Epidemiol Serv Saúde 2012; 21(3): 367-74. http://dx.doi.org/10.5123/S1679-49742012000300002
http://dx.doi.org/10.5123/S1679-49742012... .

The group of reducible causes by adequate diagnostic and treatment actions, including pneumonia and other bacterial diseases, had the third largest reduction in this period (58%). In Brazil, this result can be accredited to the expansion of the primary health care system and the family health program strategy⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... ^,2525. Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR, et al. Saúde da Família: limites e possibilidades para uma abordagem integral de Atenção Primária à Saúde no Brasil. Ciênc Saúde Colet 2009; 14(3): 783-94. http://dx.doi.org/10.1590/S1413-81232009000300014
http://dx.doi.org/10.1590/S1413-81232009... ^,3333. Macinko J, Guanais FC, Fátima M, Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60(1): 13-9. https://doi.org/10.1136/jech.2005.038323
https://doi.org/10.1136/jech.2005.038323... .

Vaccine-preventable diseases represent the group with the lowest number and rate of deaths - demonstrating the advances observed in the past - due to the incorporation of numerous vaccines in the schedule of the National Immunization Program (NIP) ⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... . However, more recently, rates have been stable, with an increase in deaths due to causes such as pertussis, reinforcing the need to maintain surveillance, immunization, and health care actions, as these deaths are entirely preventable with the access to vaccines.

Upon analyzing the trend of reducible child mortality rates, the Northeast region had the highest decline and the Midwest, the lowest. This information shows that although regional inequalities have decreased, differences remain, with the lowest child mortality rates being reported in the South and Southeast regions.

Limitations of the study include the use of lists of preventable causes of death, which may vary according to advances in knowledge and use of new technologies, as well as the need to answer if effective health care can impact the proposed causes. In addition, external determinants of health care can affect the analyzed events and also alter the incidence and lethality of these causes of death regardless of the Health sector; for example, changing risk factors, as well as the identification of ecological associations of preventable deaths with the improvement of quality and coverage of health care must be interpreted with caution⁷7. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... . Lastly, another limitation is the use of SIM data, which, even if corrected, can be subjected to sub-enumeration, making the decline rates uncertain, despite the corrections.

International¹1. Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB, Zuidema GD. Measuring the quality of medical care: second revision of tables of indexes. New Eng J Med 1980; 302(20): 1146. http://doi.org/10.1056/NEJM198005153022012
http://doi.org/10.1056/NEJM1980051530220... ^,22. Charlton JRH, Velez R. Some international comparisons of mortality amenable to medical intervention. BMJ 1986; 292(6516): 295-301.^,33. Holland WW, Fitzgerald AP, Hildrey SJ, Phillips SJ. Heaven can wait. J Public Health Med 1994; 16(3): 321-30. https://doi.org/10.1093/oxfordjournals.pubmed.a042992
https://doi.org/10.1093/oxfordjournals.p... and national⁴4. Malta DC, Duarte EC. Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura. Ciênc Saúde Coletiva 2007; 12(3): 765-76. http://dx.doi.org/10.1590/S1413-81232007000300027
http://dx.doi.org/10.1590/S1413-81232007... ^,77. Malta DC, Duarte EC, Escalante JJC, Almeida MF, Sardinha LMV, Macário EM, et al. Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde. Cad Saúde Pública 2010; 26(3): 481-91. http://dx.doi.org/10.1590/S0102-311X2010000300006
http://dx.doi.org/10.1590/S0102-311X2010... ^,99. 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): 137-45. http://dx.doi.org/10.1590/S1519-38292014000200003
http://dx.doi.org/10.1590/S1519-38292014... ^,1010. Lisboa L, Abreu DMX, Lana AMQ, França EB. Mortalidade infantil: principais causas evitáveis na região Centro de Minas Gerais, Brasil, 1999-2011. Epidemiol Serv Saúde 2015; 24(4): 711-20. http://dx.doi.org/10.5123/S1679-49742015000400013
http://dx.doi.org/10.5123/S1679-49742015... ^,1515. Duncan BB, Stevens A, Iser BPM, Malta DC, Silva GA, Schmidt MI. Mortalidade por doenças crônicas no Brasil: situação em 2009 e tendências de 1991 a 2009. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2011. p. 119-33. studies show the benefits of care factors in reducing preventable deaths. As a result, non-preventable causes due to external non-modifiable factors decrease more slowly than preventable ones, as they receive less intervention.

CONCLUSION

The current study introduced methodological changes in the application of the “List of Preventable Causes of Death” as it incorporated correction factors for underreporting and proposed the distribution of IDCDs.

Child mortality rates dropped globally, revealing advances in the delivery of health care. However, it still presents a challenge. In order for Brazil to meet the SDGs, the gaps from previous years must be identified and overcome.

Although the under-five mortality coefficients showed a declining behavior, they remain high when compared to other countries such as Sweden, Japan, Germany, Cuba, and the United States of America. It is important to pay special attention to pregnancy-related causes of death, that is, we need to improve the quality of prenatal care and the management of pregnant women, especially concerning fetal and newborn deaths resulting from maternal conditions, which increased significantly in the period of the study.

The list considers the advances in the field of public health care in Brazil and the potential for SUS intervention, according to its principles and technological incorporation. The use of the preventable death indicator is useful for monitoring trends, allowing the identification of gaps as well as supporting the proposition of suitable solutions.

References

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