Abstract

Introduction

The health information systems provide data that allows monitoring a population's health situation.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. In Brazil, secondary databases - filled with nationwide data - have been increasingly used in researches. Such interest may be related to the gratuity and speed of access and the quality of such data.²2. Drumond EF, Machado CJ, Vasconcelos MR, França E. Utilização de dados secundários do SIM, Sinasc e SIH na produção científica brasileira de 1990 a 2006. R Bras Est Pop. 2009 jan-jun;26(1):7-19.

Birth is a vital event and its monitoring may contribute to the knowledge of a population's health level, because it allows the construction of indicators that can support the planning, management and evaluation of policies and actions of health care and surveillance in the area of maternal and child health.³3. Mello Jorge MHP, Gotlieb SLD, Soboll MLMS, Almeida MF, Latorre MRDO. Avaliação do Sistema de Informação sobre Nascidos Vivos e o uso de seus dados em epidemiologia e estatísticas de saúde. Rev Saude Publica. 1993; 27(Suppl):1-46.

4. Ministério da saúde (BR). Departamento de Informática do SUS. Eventos vitais ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2008. ENT#091;citado 2012 dez 11ENT#093;. Disponível em: Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0607
http://www2.datasus.gov.br/DATASUS/index... ^-55. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv...

In Brazil, the legal base for birth monitoring dates from the 1970s;⁶6. Brasil. Lei nº 6.015, de 31 de dezembro de 1973. Dispõe sobre os registros públicos, e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília, (DF), 1973 dez 31; Seção 1:13528. however, only in the 1990s the National Information System on Live Births (Sinasc) was created.⁷7. Almeida MF, Alencar GP, Schoeps D. Sistema de Informações sobre Nascidos Vivos - Sinasc: uma avaliação de sua trajetória. In: Ministério da Saúde (BR). A experiência brasileira em sistemas de informação em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz; 2009. ENT#091;citado 2014 mar 20ENT#093; p. 11-37. (Série B. Textos Básicos de Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/experiencia_brasileira_sistemas_saude_volume1.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... In 1998, this system was already working in all country's municipalities.³3. Mello Jorge MHP, Gotlieb SLD, Soboll MLMS, Almeida MF, Latorre MRDO. Avaliação do Sistema de Informação sobre Nascidos Vivos e o uso de seus dados em epidemiologia e estatísticas de saúde. Rev Saude Publica. 1993; 27(Suppl):1-46. The Sinasc - the function of which is to collect and process demographic and epidemiological data on the infant, mother, prenatal care and childbirth - is fed by the Live Birth Statement (DNV).⁸8. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp...

Since its implementation, Sinasc uploading is continuous, keeping the newborn population throughout Brazil under surveillance. The system is universal, therefore, collecting the data is a passive action, in other words, professionals assigned on health services or on registry offices are expected to fill the Live Birth Statements (DNV). However, for some specific situations in which the DNV cannot be issued, it is necessary to perform active search of these records, e.g.: for births that were, for some reason, registered without the issuance of the DNV. The system was reformulated in 1999 and 2009.⁴4. Ministério da saúde (BR). Departamento de Informática do SUS. Eventos vitais ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2008. ENT#091;citado 2012 dez 11ENT#093;. Disponível em: Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=0607
http://www2.datasus.gov.br/DATASUS/index... ^,77. Almeida MF, Alencar GP, Schoeps D. Sistema de Informações sobre Nascidos Vivos - Sinasc: uma avaliação de sua trajetória. In: Ministério da Saúde (BR). A experiência brasileira em sistemas de informação em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz; 2009. ENT#091;citado 2014 mar 20ENT#093; p. 11-37. (Série B. Textos Básicos de Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/experiencia_brasileira_sistemas_saude_volume1.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,88. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp...

The periodic evaluation of a health information system allows verifying if the generated information is useful to direct the public policies, to bring to light the magnitude of events, estimate risks and identify vulnerable groups,¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. as verified on systems' evaluation using data, for example, from the Notification Diseases Information System (Sinan)⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105., Population Based Registry of Cancer¹⁰10. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17. and from Sinasc.¹¹11. Guerra FAR, Llerena Jr. JC, Gama SGN, Cunha CB, Theme Filha MM. Confiabilidade das informações das declarações de nascido vivo com registro de defeitos congênitos no município do Rio de Janeiro, Brasil, 2004. Cad Saude Publica. 2008 fev;24(2):438-46.

12. Costa JMBS, Frias PG. Avaliação da completitude das variáveis da Declaração de Nascido Vivo de residentes em Pernambuco, Brasil, 1996 a 2005. Cad Saude Publica. 2009 mar; 25(3):613-24^-1313. Guimarães EAA, Hartz ZMA, Loyola Filho AI, Meira AJ, Luz ZMP. Avaliação da implantação do Sistema de Informação sobre Nascidos Vivos em municípios de Minas Gerais, Brasil. Cad Saude Publica. 2013 out;29(10):2105-18.

The objective of this study was to analyse attributes and usefulness of the National Information System on Live Births (Sinasc), Brazil, 2006-2010.

Methods

Sinasc's evaluation was conducted using as reference the Updated Guidelines for Evaluating Public Health Surveillance System, published by the Centers for Disease Control (CDC/USA).¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35.

The study was divided into two stages. The first stage consisted of describing Sinasc and, in order to dimension its magnitude, the number of live births was raised and the percentage of births by sex and type of delivery was calculated. Sinasc's objectives were described, as well as the steps to information collection, data source and the system's operation, available on documents related to its creation.³3. Mello Jorge MHP, Gotlieb SLD, Soboll MLMS, Almeida MF, Latorre MRDO. Avaliação do Sistema de Informação sobre Nascidos Vivos e o uso de seus dados em epidemiologia e estatísticas de saúde. Rev Saude Publica. 1993; 27(Suppl):1-46.^,66. Brasil. Lei nº 6.015, de 31 de dezembro de 1973. Dispõe sobre os registros públicos, e dá outras providências. Diário Oficial da República Federativa do Brasil, Brasília, (DF), 1973 dez 31; Seção 1:13528.^,77. Almeida MF, Alencar GP, Schoeps D. Sistema de Informações sobre Nascidos Vivos - Sinasc: uma avaliação de sua trajetória. In: Ministério da Saúde (BR). A experiência brasileira em sistemas de informação em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz; 2009. ENT#091;citado 2014 mar 20ENT#093; p. 11-37. (Série B. Textos Básicos de Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/experiencia_brasileira_sistemas_saude_volume1.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,88. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp... ^,1414. Ministério da Saúde (BR). Fundação Nacional de Saúde. Manual de procedimentos do Sistema de Informações Sobre Nascidos Vivos . Brasília; 2001.

In the second stage Sinasc's attributes were evaluated: simplicity, flexibility, data quality, acceptability, representativeness, opportunity and stability; and their usefulness as an information system. Some evaluation criteria were adopted to each one of these attributes, as it follows.

The simplicity of a system reflects on its structure and operation convenience.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. The component elements of the DNV flow and responsibilities of each level of government were evaluated. From this evaluation, the attribute was defined as simple or complex, comparing to other systems.⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105.^,1010. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17.

The flexibility was analysed by observing the system adaptation to changes resulting from the information needs or to improve its operational conditions.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. The DNV changes that occurred in 2009 were compared to the ones from 1999, such as the content changes in the number of variables (inclusion/exclusion) in the record files, reformulation of the normative material for filling the DNV, as well as the process for implementing these changes. This attribute allowed evaluating if the system was flexible or not to changes, including when comparing to other information systems evaluated in this attribute. ⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105.^,1010. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17.

The data quality reflected the completeness and the validity of records in the system.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35.Sinasc recommends filling all the fields on the DNV, however there is not a blockade of data entry if any of the fields is blank. In this study, the following variables were considered for quality analysis:

Since there are no evaluation parameters of data completeness for Sinasc, this study estimated as a standard reference of this quality, the (i) median of completeness of all variables at 90% - if the data filled were equal or above that proportion, it was considered adequate completeness⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105. and, consequently, inadequate if completeness was bellow it - and an (ii) exclusion percentage of up to 5%.

The acceptability was defined as the measure of people's and institutions' interest in conducting the system and participating of it, having the completeness of registered information¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. as one of the parameters from the percentage calculation, adapted from Souza et al.⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105., that represents the relation between the sum of the percentage of completeness (excluding ignored and blank fields) and the number of variables. Data from the hospital childbirths were considered for this calculation. The variables included were those collected during the childbirth and initial assistance to the newborn: type of pregnancy, type of childbirth, gestational age, sex, ethnicity/skin color (newborn), Apgar score 1 minute and 5 minutes after birth, birth weight and congenital anomaly detection. This attribute, evaluated for Brazil and its geographic macroregions, was considered acceptable if the indicator presented completeness above 90%.

The representativeness of a system refers to its ability to accurately describe the occurrence of a health event over time and its distribution by place and person.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. A comparison between data on live births by sex, region and federative unit of residence of the mother, collected by 2010 Sinasc and the Demographic Census was performed. The year of 2010 was chosen for being a year with information available on the entire population derived from the Census and, therefore, could be compared to the population registered on Sinasc, a continuous collection system. In this comparison, deaths of children under 1 year of age were excluded, according to the Mortality Information System (SIM), because the Census considers all living people on the reference date of the demographic survey.¹⁵15. Instituto Brasileiro de Geografia e Estatística. Sinopse do censo demográfico 2010 ENT#091;InternetENT#093;. Rio de Janeiro: IBGE; 2011. ENT#091;citado 2013 jan 30ENT#093;. Disponível em: Disponível em: http://biblioteca.ibge.gov.br/visualizacao/livros/liv49230.pdf .
http://biblioteca.ibge.gov.br/visualizac... Using the Pearson Chi-square test (χ²), the Sinasc's representativeness was considered acceptable when the region or Federative Unit presented statistical differences with 5% significance level.

The opportunity reflects the speed among all the steps of attainment of a surveillance system in public health.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. This attribute was evaluated from the information volume received from municipalities and federative units, considering the month of birth and of the first data entry in the national system. The parameter of this evaluation was defined by the value of 80% of the expected (agreed) volume data to be received up to 60 days after the end of the month of birth occurrence, as provided in the Ordinance of the Ministry of Health, MS/SVS No. 116 dated February 11, 2009;¹⁶16. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Portaria nº 116, de 11 de fevereiro de 2009. Regulamenta a coleta de dados, fluxo e periodicidade de envio das informações sobre óbitos e nascidos vivos para os sistemas de informações em saúde sob gestão da secretaria de vigilância em saúde. Diário Oficial da República Federativa do Brasil, Brasília, (DF), 2009 fev 12; Seção 1:37. thereby, this attribute was analysed only for the year of 2010 in this study.

Stability refers to the system's ability to collect, manage and provide data properly and operates them as needed.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. Current documents, technical standards, legislation and official publications of the Ministry of Health and the Presidency of the Republic were evaluated during the study. The system was considered stable when the documents necessary for its continued operation were presented. To the recognition of Sinasc's stability, it was also considered their capacity to enlist events - or coverage - estimated by the ratio between live births reported in the system and estimated by demographic projections of IBGE, as the suggested indicator by the Inter-Network Information on Health (Ripsa):⁵5. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv... when the ratio was close to 100, it would indicate a coincidence between the frequencies obtained from both sources; above, it would indicate underestimation of demographic projections; and below this parameter, underreporting of the system.⁵5. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv...

To evaluate the Sinasc's usefulness, the fulfilment of the proposed objective was assessed, namely, providing information on the live births characteristics and its ability to contribute to the definition of specific health indicators.¹1. Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR Recomm Rep. 2001 jul;50(RR-13):1-35. A search for documents, technical standards, legislation and official publications of the Ministry of Health was performed for the purpose of checking Sinasc's usage as a data source for these indicators' construction⁵5. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv... ^,1717. Rede Interagencial de Informações para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Pan-Americana da Saúde; 2008. ENT#091;citado 2014 abr 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv...

18. Ministério da Saúde (BR). Secretaria Executiva. Departamento de Apoio à Descentralização. Regulamento dos pactos pela vida e de Gestão. Brasília: Ministério da Saúde; 2006. v.2.^-1919. Ministério da Saúde (BR). Programação das Ações de Vigilância em Saúde. Brasília: Ministério da Saúde; 2010. and to verify the potential of the system data usage on technical publications from the Ministry of Health.²⁰20. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2006: uma análise da desigualdade em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2006. ENT#091;citado 2014 abr 15ENT#093;. (Série G. Estatística e Informação em Saúde). Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/2044.pdf
https://www.nescon.medicina.ufmg.br/bibl...

21. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2007: uma análise da situação de saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2008. ENT#091;citado 2014 maio 05ENT#093;. (Série G. Estatística e Informação em Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2007.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe...

22. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde (SUS) no Brasil ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2009. ENT#091;citado 2014 mar 30ENT#093;. (Série G. Estatística e Informação em Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2008.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe...

23. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2009: uma análise da situação de saúde e da agenda nacional e internacional de prioridades em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2010. ENT#091;citado 2014 maio 20ENT#093;. (Série G. Estatística e Informação em Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2009.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... ^-2424. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde ENT#091;InternetENT#093;. Brasília: Ministério da Saúde; 2011. ENT#091;citado 2014 maio 20ENT#093;. (Série G. Estatística e Informação em Saúde). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/saude_brasil_2010.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe...

The study used the Sinasc database (available on SUS IT Department [Datasus] website, of the Ministry of Health)²⁵25. Ministério da saúde (BR). Departamento de Informática do SUS. Informações de saúde (TABNET). Brasília: Ministério da Saúde; 2008. ENT#091;citado 2014 maio 20ENT#093;. Disponível em: Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02
http://www2.datasus.gov.br/DATASUS/index... and, for population data, census information from 2010 and the estimation of live birth provided by the Brazilian Institute of Geography and Statistics (IBGE).¹⁰10. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17. Tabwin and Microsoft Office(r) Excel 2007 software were used in the data analysis and processing.

The analysis of Sinasc data included information publicly available in aggregated form, accessible through the electronic site of the Datasus/Ministry of Health without identification of live births or implication on any harm to the them as the resolution of the National Health Council (CNS) No. 466, dated December 12, 2012.

Results

From 2006 to 2010, there were 14,514,533 live births registries in Brazil: being 7,437,664 (51.0%) males, 14,172,782 (98.0%) of hospitals childbirths and 49.2% of those, from caesarean sections.

The Live Birth Statement (DNV) has been developed with the collaboration of a specific Technical Committee and adopted by the Ministry of Health as a single instrument as a source of Sinasc data. The DNV follows instructions appropriated to the place of birth conditions, and can be filled by (i) reporting units - hospitals where the childbirth took place or where the first care after it was offered, (ii) individual notifiers - health professional or traditional midwife who attended homebirths or, by (iii) registry offices, subject to authorization granted by the State Justice of Internal Affairs. When the childbirth occurs without a healthcare professional assistance, in locations where families are enrolled in the Family Health Strategy (ESF) or in the Program of Community Health Agents (PACS), the DNV must be issued by a professional belonging to the staff or unit where the mother is registered.

DNV's flow happens as follows: the first copy of the document is sent to the local Municipal Health Department data processing organ, to be typed and filed; the duplicate is taken by the family or by a registrar at the registry's office for the issuance of the birth certificate; and the third copy (i) is filed at the health care unit where the childbirth happened, or (ii) is taken by the family to the health care unit responsible for the first care when the childbirth did not happen within hospital care, to medical records on file (Figure 1).

There is a strict control of data flow in the system at all levels of management. Since the files distribution process, there are some singularities concerning the notification. Regardless of the place of birth, expertise in maternal and child healthcare is necessary for filling the DNV clinical variables (Figure 1), which is why Sinasc was evaluated as a complex system.

With regard to the system's flexibility, the DNV used during the study period (2006-2010) was established in 1999 and altered in 2009, both in its contents and in its presentation. When comparing both models, it was observed that 14 fields were included, three were excluded and five were altered. For example, in 2009, 'father's age' variable was included in the new DNV which is now composed of eight blocks, 52 fields and 63 variables. In 2010, its distribution to the federative units began, accompanied by adjustments in the interface of data entry program and by review of instructional material - dictionary of variables, reasons why the system was considered flexible to change when necessary.

23 DNV variables were evaluated. In the assessment of filling completeness - a median of 99.6% - 13 (52.0%) variables were above this value, being considered adequate. Only the variables 'stillbirth' (85.8%) and 'occupation' (82.5%) presented completeness below 90.0%. Concerning data amount with ignored information, with the exception of 'marital status' (1.5%) and 'congenital anomaly detection' (2.5%), all the other variables held a percentage of ignored information below 1%. The median of ignored data was below 0.1%, and 8 (35.0%) variables were above this parameter, considering the filling as adequate (Table 1). The data was considered of good quality.

The data completeness rate on hospital childbirths in Brazil was 97.9%. Only the Northeast region was below this index (96.7%). The other regions remained at the same level or above it (Table 2). Therefore, the system was considered acceptable.

No statistical differences were found between live births proportions of both sexes in any of the five Brazilian macroregions (p> 0.05) and of the 27 federative unites (> 0.05) when comparing the Sinasc data with the 2010 Census information. Sinasc was considered a representative system (data not presented).

In view of the expected 80% - agreed -, the amount of data received on Sinasc was 82.2% in 2010. These are the system opportunity percentage variations presented monthly: 77.4% (January), 80.1% (February), 83.5% (March), 84.6% (April), 82.7% (May), 83.7% (June), 78.4% (July), 78.4 % (August), 81.8% (September), 81.8% (October), 86.6 (November) and 90.1% (December). However, considering 2010 as a whole (the year analysed), Sinasc proved to be opportune in receiving data.

In addition to the current Ordinances, others related to Sinasc were published during the study period, indicating their sustainability and stability in fulfilling the functions intended for the period (Figure 2). The system coverage ratio in relation to the data by collected IBGE Census was 89.4% (2006), 90.3% (2007), 94.5% (2008), 95.4% (2009) and 97.4% (2010). The system was concluded to be stable.

To analyse the births evolution during the study period, the Inter-Agency Health Information Network - Ripsa - used the Sinasc in the construction of 19 indicators, in its two editions, divided into four categories:

The Pact for Life and Management used the Sinasc system for elaborating two indicators: proportion of live births to mothers with four or more prenatal care visits; and tetravalent vaccine coverage in children under 1 year of age. The Programme of Surveillance Actions in Health (PAVS) used the Sinasc in one indicator: collection of Live Birth Statements.

The Sinasc proved itself useful for monitoring general conditions that subsidize the planning of maternal and child care - for example, in the description of the childbirth profile. The book Saúde Brasil (Health Brazil), in its 2006-2010 editions (except for 2008), presented specific chapters on live birth-related subjects. Here too, the system served its purpose and is considered useful on what it is proposed.

Discussion

In the period studied, the Sinasc system was considered complex in its operation, yet flexible to change when necessary. Besides being rated as of adequate quality, the system proved to be acceptable considering the completeness of the variables of births in hospitals, and also representative when its data were compared with the 2010 Census records. Similarly, the data reception has proved itself opportune, stable and able to meet the goal set for it: support the planning of maternal and child care.

Sinasc was considered complex in its operation when compared to other systems.⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105.^,1010. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17. The apparently excessive strictness in the fulfilment of the record distribution flow, due to the legal implications involved, did not represent a downside and may also have contributed positively to the evaluation of the studied attributes. Furthermore, the heterogeneity of professionals responsible for the fulfilment of the Live Birth Statement - DNV -⁸8. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp... and specificity of the data included in the document led the Ministry of Health to recommend its filling to be conducted by previously trained staff.⁸8. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp... ^,1414. Ministério da Saúde (BR). Fundação Nacional de Saúde. Manual de procedimentos do Sistema de Informações Sobre Nascidos Vivos . Brasília; 2001. In a maternity hospital in Rio de Janeiro-RJ, in 2004, there was 50% agreement between DNV data and respective data records in the newborn and postpartum medical records, suggesting a need for continuous training of the professionals involved.¹¹11. Guerra FAR, Llerena Jr. JC, Gama SGN, Cunha CB, Theme Filha MM. Confiabilidade das informações das declarações de nascido vivo com registro de defeitos congênitos no município do Rio de Janeiro, Brasil, 2004. Cad Saude Publica. 2008 fev;24(2):438-46.

Despite the operational complexity, the system was evaluated as flexible to the changes observed in the period. This complexity was also observed in a study that evaluated Brazil's national surveillance system on leptospirosis in 2007.⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105. The continuity in evaluating Sinasc is considered highly important, in order to observe the data quality after changes, especially those started in 2010. In 2011, with the gradual replacement of the DNV, 58% of births have been informed by the new instrument.²⁵25. Ministério da saúde (BR). Departamento de Informática do SUS. Informações de saúde (TABNET). Brasília: Ministério da Saúde; 2008. ENT#091;citado 2014 maio 20ENT#093;. Disponível em: Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02
http://www2.datasus.gov.br/DATASUS/index...

The findings of this assessment indicate: the Sinasc data showed high completeness and low percentage of ignored information during the study period, being the system considered of good quality. Its information has improved over time, as pointed in an evaluative study of the DNV variables completeness for residents in the state of Pernambuco, over the period 1996-2005.¹²12. Costa JMBS, Frias PG. Avaliação da completitude das variáveis da Declaração de Nascido Vivo de residentes em Pernambuco, Brasil, 1996 a 2005. Cad Saude Publica. 2009 mar; 25(3):613-24 However, another study evaluating the completeness of Sinasc variables, held between 2000 and 2009, focusing on the states of the Brazilian Northeast region, found differences in completeness between the states: for the ethnicity/skin color variable, for example, the system showed a higher percentage of incompleteness (20.5%) in 2009 in the state of Sergipe. Nevertheless, its authors considered the completeness of DNV throughout the Northeast region as good to excellent.²⁶26. Silva RS, Oliveira CM, Ferreira DKS, Bonfim CV. Avaliação da completitude das variáveis do Sistema de Informações sobre Nascidos Vivos - Sinasc - nos Estados da região Nordeste do Brasil, 2000 e 2009. Epidemiol Serv Saude. 2013 jun;22(2): 347-52.

An evaluation on the completeness of Sinasc data conducted in Campinas-SP, in 2009, pointed out that the completeness percentage of variables ranged from 99.8 to 100%.²⁷27. Gabriel GP, Chiquetto L, Morcillo AM, Ferreira MC, Bazan IGM, Daolio LD, et al. Avaliação das informações das declarações de nascidos vivos do Sistema de Informação sobre Nascidos Vivos (Sinasc) em Campinas, São Paulo, 2009. Rev Paul Pediatr. 2014 set; 32(3):183-8. This data corroborate with those found for Brazil, highlighting the importance of studies in specific geographical areas since there can be regional differences in the quality of the data.

For Costa and Frias,¹²12. Costa JMBS, Frias PG. Avaliação da completitude das variáveis da Declaração de Nascido Vivo de residentes em Pernambuco, Brasil, 1996 a 2005. Cad Saude Publica. 2009 mar; 25(3):613-24 problems such as ignored variables in monitoring systems are the result of a number of deficiencies, from the lack of information on medical records to the lack of certain information by the women's companions; not to mention the blank variables, possible reflection of the lack of care and importance given to complete the DNV by the responsible staff.

Positive findings for the 'data quality' attribute reflected in the results of the 'acceptability' attribute. The completeness percentage reached 97.9% for the country. However, the selection of variables used among those that could have had data observed and measured at the childbirth moment would justify a completeness percentage closer to 100%. Therefore, these results should be seen with caution, because there is a possibility of discrepancies between hospital records and Sinasc data, as noted on a reliability study conducted in hospitals of Rio de Janeiro-RJ, in 2004.¹¹11. Guerra FAR, Llerena Jr. JC, Gama SGN, Cunha CB, Theme Filha MM. Confiabilidade das informações das declarações de nascido vivo com registro de defeitos congênitos no município do Rio de Janeiro, Brasil, 2004. Cad Saude Publica. 2008 fev;24(2):438-46.

The system's implementation may interfere with the results of the studied attributes, including the acceptability. Sinasc's implementation in 132 municipalities of Minas Gerais State, in 2010, did not occur properly in most of these locations. This conclusion is based on the lack of a qualified professional, unsatisfactory collection and completion of DNV, data sub-utilization and poor dissemination of information.¹³13. Guimarães EAA, Hartz ZMA, Loyola Filho AI, Meira AJ, Luz ZMP. Avaliação da implantação do Sistema de Informação sobre Nascidos Vivos em municípios de Minas Gerais, Brasil. Cad Saude Publica. 2013 out;29(10):2105-18.

The system was considered representative, when compared to the proportions of live births - by sex, federative unit and macroregions - with the 2010 Demographic Census data. Since 1998, there was an improvement in Sinasc's coverage reaching at least 90% of registered children on registry offices. It is noteworthy that during this period, Sinasc already had more than a decade of implementation in all Brazilian municipalities.³3. Mello Jorge MHP, Gotlieb SLD, Soboll MLMS, Almeida MF, Latorre MRDO. Avaliação do Sistema de Informação sobre Nascidos Vivos e o uso de seus dados em epidemiologia e estatísticas de saúde. Rev Saude Publica. 1993; 27(Suppl):1-46.

The system proved to be opportune concerning data reception. The monitoring of this system attribute must be maintained, since this evaluation was performed on data from 2010, the first year after the publication of Ordinance No. 116/2009.¹⁶16. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Portaria nº 116, de 11 de fevereiro de 2009. Regulamenta a coleta de dados, fluxo e periodicidade de envio das informações sobre óbitos e nascidos vivos para os sistemas de informações em saúde sob gestão da secretaria de vigilância em saúde. Diário Oficial da República Federativa do Brasil, Brasília, (DF), 2009 fev 12; Seção 1:37.Sinasc was also considered stable, thanks to the legislation that gives it sustainability. The very obligation of the issuance of Live Birth Statements to the Civilian Birth Record⁸8. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Manual de instruções para o preenchimento da declaração de nascido vivo ENT#091;InternetENT#093;.; Brasília: Ministério da Saúde 2011. ENT#091;citado 2014 mar 30ENT#093; (Série A. Normas e Manuais Técnicos). Disponível em: Disponível em: http://www.uff.br/epidemiologia2/blog/wp-content/uploads/2012/10/Manual-de-DNV-4ed-2011.pdf
http://www.uff.br/epidemiologia2/blog/wp... may have interfered positively in the results found for the attributes of acceptability, representativeness, opportunity and stability. Furthermore, the results of this evaluation showed the potential of Sinasc information and its usefulness in Public Health context as a source of data for the development of health indicators.²2. Drumond EF, Machado CJ, Vasconcelos MR, França E. Utilização de dados secundários do SIM, Sinasc e SIH na produção científica brasileira de 1990 a 2006. R Bras Est Pop. 2009 jan-jun;26(1):7-19.^,55. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv... ^,1717. Rede Interagencial de Informações para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Pan-Americana da Saúde; 2008. ENT#091;citado 2014 abr 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv...

18. Ministério da Saúde (BR). Secretaria Executiva. Departamento de Apoio à Descentralização. Regulamento dos pactos pela vida e de Gestão. Brasília: Ministério da Saúde; 2006. v.2.^-1919. Ministério da Saúde (BR). Programação das Ações de Vigilância em Saúde. Brasília: Ministério da Saúde; 2010.^,2828. Pedraza DF. Qualidade do Sistema de Informações sobre Nascidos Vivos (Sinasc): análise crítica da literatura. Cienc Saude Colet. 2012 out; 17(10):2729-37.

As limitations of this research, there is the lack of comparative parameters for some of the attributes evaluated. This happened because the parameters considered for this study were used for evaluating information systems⁹9. Souza VMM, Brant JL, Arsky MLS, Araújo WN. Avaliação do sistema nacional de vigilância da leptospirose: Brasil, 2007. Cad Saude Colet. 2010;18(1):95-105.^,1010. Moura L, Curado MP, Simões EJ, Cezário AC, Urdaneta M. Avaliação do registro de câncer de base populacional do município de Goiânia, estado de Goiás, Brasil. Epidemiol Serv Saude. 2006 dez;15(4):7-17. with distinct characteristics, restricting comparisons with this study.

Periodic evaluations of the information systems must be integrate into the routine of the health surveillance systems. Quality information is essential for the health situation analysis and taking evidence-based decisions.⁵5. Rede Interagencial de Informação para a Saúde. Indicadores básicos para a saúde no Brasil: conceitos e aplicações ENT#091;InternetENT#093;. 2 ed. Brasília: Organização Panamericana de Saúde; 2008. ENT#091;citado 2014 mar 15ENT#093;. Disponível em: Disponível em: http://tabnet.datasus.gov.br/tabdata/livroidb/2ed/indicadores.pdf
http://tabnet.datasus.gov.br/tabdata/liv... In this study, the evaluated attributes and the National Information System on Live Births - Sinasc - ratify the quality and the importance generated by it to subsidy public policies for maternal and child health.

Acknowledgements

To the Training Program in Epidemiology Applied to the National Health System Services, Department of Communicable Disease Surveillance (Episus).

To the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) of the Brazilian Ministry of Science, Technology and Innovation (Ministério da Ciência, Tecnologia e Inovação - MICT) for the financial support.

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