Abstract

Objective:

To analyze the profile and temporal trends of female homicides in Maranhão, Brazil, between 2000 and 2019.

Methods:

This was an ecological study using data from the Mortality Information System. The profile of the deaths, mortality rate trends (joinpoint method) and correlation with socioeconomic and health indicators (Pearson correlation) were evaluated.

Results:

1,915 female homicides were reported, with predominance among those between 20-29 years old (29.9%), single (62.0%), with 4-7 years schooling (29.7%), mixed race (71.3%), homicides at home (31.9%) and by firearms (41.1%). The mortality rate showed a rising trend (APC = +8.21; 95%CI 5.18;10.28). There was negative correlation between homicides and per capita income (p-value = 0.031) and positive correlation with the proportion of families headed by women (p-value = 0.001) and with the rate of male mortality due to assault (p-value = 0.001).

Conclusion:

There was an increase in female homicides, related to structural violence in society, poverty and women with greater family authority.

Keywords:
Homicide; Violence Against Women; Mortality; Health Information System; Ecological Studies

Introduction

Feminicide is the most perverse aspect of gender violence. As a phenomenon present in all societies, violence against women is a public health problem.¹1. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence [Internet]. Geneva: World Health Organization; 2013 [cited 2021 July 30]. Available from: https://www.who.int/publications/i/item/9789241564625
https://www.who.int/publications/i/item/... Worldwide, approximately 35% of women suffer or have suffered some type of violence, with assault by intimate partners being the most prevalent and common type.²2. Krug EG, Dahlber LL, Mercy JA, Zwi AB, Lozano R, editors. Informe mundial sobre la violencia y la salud [Internet]. Washington: Organización Panamericana de la Salud; 2003 [cited 2021 July 30]. Available from: https://iris.paho.org/bitstream/handle/10665.2/725/9275315884.pdf
https://iris.paho.org/bitstream/handle/1... When this violence culminates in death, it is estimated that globally 38% of all feminicides are committed by intimate partners.¹1. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence [Internet]. Geneva: World Health Organization; 2013 [cited 2021 July 30]. Available from: https://www.who.int/publications/i/item/9789241564625
https://www.who.int/publications/i/item/... The term "feminicide", created to refer to the deaths of women resulting from gender violence, is motivated solely by the fact that the victim is a woman,³3. Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres. Diretrizes nacionais feminicídio: investigar, processar e julgar com perspectivas de gênero as mortes violentas de mulheres [Internet]. Brasília: Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres, 2016 [citado 2021 Jul 6]. Disponível em: http://www.onumulheres.org.br/wp-content/uploads/2016/04/diretrizes_feminicidio.pdf
http://www.onumulheres.org.br/wp-content... which allows us to recognize these deaths as a social and political phenomenon.⁴4. Gomes R, Murta D, Facchini R, Meneghel SN. Gênero, direitos sexuais e suas implicações na saúde. Cienc Saude Coletiva. 2018;23(6):1997-2006. doi: 10.1590/1413-81232018236.04872018
https://doi.org/10.1590/1413-81232018236...

The profile of women who suffer violence and/or homicide is represented, in the main, by Black, young, socially and economically vulnerable women, with low education, in unskilled occupations and living in urban regions with little or no security.⁵5. Meneghel SN, Hirakata VN. Femicídios: homicídios femininos no Brasil. Rev Saude Publica. 2011;45(3):564-74. doi: 10.1590/S0034-89102011000300015
https://doi.org/10.1590/S0034-8910201100...

6. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000... ^-77. Meneghel SN, Portella AP. Feminicídios: conceitos, tipos e cenários. Cien Saude Colet. 2017;22(9):3077-86. doi: 10.1590/1413-81232017229.11412017
https://doi.org/10.1590/1413-81232017229... The aggressors, generally, are young, less educated than the women, conjugal partners or acquaintances of the victims, with criminal records and a history of violence.⁵5. Meneghel SN, Hirakata VN. Femicídios: homicídios femininos no Brasil. Rev Saude Publica. 2011;45(3):564-74. doi: 10.1590/S0034-89102011000300015
https://doi.org/10.1590/S0034-8910201100... ^,66. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000... Moreover, feminicides are associated with factors such as patriarchal society, economic deprivation, machismo, and/or attempts to assert masculinity over women.⁸8. Stöckl H, Devries K, Rotstein A, Abrahams N, Campbell J, Watts C, et al. The global prevalence of intimate partner homicide: a systematic review. Lancet. 2013;382(9895):859-65. doi: 10.1016/S0140-6736(13)61030-2
https://doi.org/10.1016/S0140-6736(13)61... It is noteworthy that the victims often live in regions of greater social inequality, places where there is organized crime, drug trafficking, and places where a high number of homicides of men are registered.⁹9. Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse. 2007;8(3):246-69. doi: 10.1177/1524838007303505
https://doi.org/10.1177/1524838007303505...

Homicides of women are showing a rising trend worldwide; and the highest rates are found in the Central American countries.¹⁰10. United Nations Office on Drugs and Crime. Global study on homicide: gender-related killing of women and girls [Internet]. Vienna: United Nations Office on Drugs and Crime; 2019 [cited 2021 Jun 20]. Available from: https://www.unodc.org/documents/data-and-analysis/GSH2018/GSH18_Gender-related_killing_of_women_and_girls.pdf
https://www.unodc.org/documents/data-and... In Brazil, the mortality rate was found to have increased from 5.84 per 100,000 women in 2002 to 6.16 per 100,000 women in 2012, despite the stable trend. Only the Southeast region of the country had a falling rate, of 3.41% per year; while the highest mortality rates were found in states with greater social inequality.¹¹11. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... Even with the increase in reported murders in recent years, it is believed that there is still a significant amount of underreporting, especially of homicides occurring outside the family environment, these being situations in which it is difficult to identify the perpetrator, establish the motivation and even register the death.¹⁰10. United Nations Office on Drugs and Crime. Global study on homicide: gender-related killing of women and girls [Internet]. Vienna: United Nations Office on Drugs and Crime; 2019 [cited 2021 Jun 20]. Available from: https://www.unodc.org/documents/data-and-analysis/GSH2018/GSH18_Gender-related_killing_of_women_and_girls.pdf
https://www.unodc.org/documents/data-and... ^,1212. Kind L, Orsini MLP, Nepomuceno V, Gonçalves L, Souza GA, Ferreira MFF. Subnotificação e (in)visibilidade da violência contra mulheres na atenção primária à saúde. Cad Saude Publica. 2013;29(9):1805-15. doi: 10.1590/0102-311X00096312
https://doi.org/10.1590/0102-311X0009631...

Brazilian data on feminicides are still scarce, despite the relevance of the topic. Female homicides in the state of Maranhão, between 2010 and 2015, showed an increase of 52.8% in cases, with an increase of 124.4% in the rate of female mortality due to assault;¹³13. Cerqueira D, Lima RS, Bueno S, Valencia LI, Hanashiro O, Machado PHG,et al. Atlas da Violência 2017 [Internet]. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2017 [citado 2021 Ago 25]. Disponível em: http://www.ipea.gov.br/atlasviolencia/download/2/2017
http://www.ipea.gov.br/atlasviolencia/do... however, there is no information specifically about the profile of these women or the evolution/trend of such deaths.

The objective of this study was to analyze the profile and temporal trend of female homicides in the state of Maranhão, Brazil, in the period from 2000 to 2019.

Methods

This was an ecological time-series study, having at its unit of analysis the state of Maranhão and its mesoregions. The state has 217 municipalities, distributed over five mesoregions: East, North, Center, West and South. In 2010, 52.2% of the 6,674,789 inhabitants of Maranhão were women, 45.3% of whom had children, 38.5% did not study or work, and 76.4% were of Black race/skin color.¹⁴14. Instituto Brasileiro de Geografia e Estatística. Panorama Maranhão 2019 [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019 [citado 2021 Ago 24]. Disponível em: https://cidades.ibge.gov.br/brasil/ma/panorama
https://cidades.ibge.gov.br/brasil/ma/pa...

We used secondary data from the Mortality Information System (SIM) and the Brazilian Institute of Geography and Statistics (IBGE) (http://www.datasus.gov.br/mortalidade and http://www.ibge.com.br), accessed in September 2021. We analzyed all cases of female deaths due to assault that occurred between 2000 and 2019, including all age groups. We chose to use female mortality due to assault as a proxy for feminicides in Maranhão, as this was considered to be an alternative to compensate for the high rates of underreporting.⁶6. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000... ^,99. Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse. 2007;8(3):246-69. doi: 10.1177/1524838007303505
https://doi.org/10.1177/1524838007303505... ^,1515. Leites GT, Meneghel SN, Hirakata VN. Homicídios femininos no Rio Grande do Sul, Brasil. Rev Bras Epidemiol. 2014;17(3):642-53. doi: 10.1590/1809-4503201400030006
https://doi.org/10.1590/1809-45032014000...

The profile of the deaths and the women were assessed according to age group (in years: 0-9; 10-19; 20-29; 30-39; 40-49; 50-59; 60-69; 70 or more), marital status (single; married; separated; other), education (in years of study: none; 1-3; 4-7; 8-11; 12 or more), race/skin color (White; Black; Asian; mixed race; Indigenous), place of occurrence (home; public thoroughfare; health facility), cause of death (one of the ICD-10 codes in the range X85-Y09), and year of death (in five-year periods: 2000-2004; 2005-2009; 2010-2014; 2015-2019).

We calculated the rate of female mortality due to assault in the state, by year, for the entire period from 2000 to 2019, using the classification contained in Chapter XX of the International Statistical Classification of Diseases and Related Health Problems - 10^th Revision (ICD-10), according to codes between X85 and Y09. A correction was made to the deaths by means of proportional redistribution of deaths classified as "events of undetermined intent" (Y10-Y34), as per a method used in another study.¹⁶16. Garcia LP, Freitas LRS, Silva GDM, Höfelmann DA. Estimativas corrigidas de feminicídios no Brasil, 2009 a 2011. Rev Panam Salud Publica [Internet]. 2015 [citado 2021 Set 06];37(4/5):251-7. Disponível em: https://www.scielosp.org/pdf/rpsp/2015.v37n4-5/251-257
https://www.scielosp.org/pdf/rpsp/2015.v... To this end, initially we determined the number of deaths due to external causes: accidental falls (W00-X59), intentional self-harm (X60-X84) and legal interventions (Y35). We than calculated the proportion of deaths due to assault (X85-Y09) in relation to total deaths due to external causes. We then multiplied the result by the number of deaths identified as being of "undetermined intent". The result was used as the numerator to calculate the rates of female mortality due to assault. The denominator was the total female population in the age group considered, by year. The result of the division was multiplied by 100,000 women.

The independent variables were divided into socioeconomic indicators and health indicators. The socioeconomic indicators were:

In turn, the health indicators were:

The rate of female mortality due to assault was calculated by year and by mesoregion of the state. Mortality rate trends were assessed using segmented linear regression (joinpoint), with determination of the annual percent change (APC) and 95% confidence intervals (95%CI). We considered that there was an increase in the coefficients when the trend of female mortality due to assault was rising and the minimum value of the 95%CI was greater than 0; and that there was a reduction in female mortality when there was a falling trend, and the maximum value of the 95%CI was less than 0. Stability was defined when, regardless of the trend, the 95%CI included 0. In order to investigate association between the indicators and the mortality rate, we performed bivariate analysis using Pearson’s correlation test, with calculation of the correlation coefficient (r): very weak correlation (0.01-0.19), weak (0.20-0.39), moderate (0.40-0.69), strong (0.70-0.89) and very strong (0.90-0.99). We performed multiple linear regression, with inclusion of variables in the model when the p-value was < 0.20, using the backward stepwise method. Statistical significance was established when the p-value was < 0.05. The analyses were conducted with the aid of the SPSS program (version 20).

As this research used public domain data and with no possibility of the women’s information being indexed, there was no requirement for analysis by a Research Ethics Committee.

Results

Between 2000 and 2019, 1,915 female deaths due to assault were notified in the state of Maranhão. Table 1 shows that notifications were most frequent among women aged 20 to 29 years (29.9%), single (62.0%), with 4 to 7 years of schooling (29.7%), of mixed race (71.3%). Home was the most frequent place of death (31.9%). The state’s Northern mesoregion had the highest number of notifications in the period covered by the time series (39.9%). The highest proportion of cases (35.0%) was recorded between 2015 and 2019, compared to the other five-year periods. The main means of assault that culminated in the death of women in Maranhão were sharp objects (37.1%) and firearms (X93/X94/X95), the latter accounting for 41.1% of cases.

All the state’s mesoregions showed an increase in female mortality rates due to assault during the period, with the Southern mesoregion accounting for the largest variation, from 0.78/100,000 women in 2000 to 5.32/100,000 women in 2015 (data not shown). Female mortality rates due to assault in Maranhão showed a rising trend in the period 2000-2019 (APC = +8.21; 95%CI 5.18;10.28); effectively, all the state’s mesoregions showed an upward trend in these rates, with the East (APC = +11.93; 95%CI 9.12;14.84) and the South (APC = +13.10; 95%CI 9.66;17.82) standing out (Table 2).

Table 3 shows the socioeconomic and health indicators in 2010, with a description of the mean and minimum and maximum values. In that year, mean per capita income in the state was BRL 225.7 and 38.7% of the families residing in Maranhão were headed by women. Also noteworthy was the male mortality rate due to assault: 27.8/100,000.

Table 4 shows the bivariate correlation between the female mortality rate due to assault and socioeconomic and health indicators. Moderate and positive correlation was found between assault due to mortality and the HDI (r = 0.532; p-value = 0.034), the proportion of families headed by women (r = 0.673; p-value < 0.001), unemployment rate (r = 0.477; p-value = 0.001), cervical cancer mortality rate (r = 0.451; p-value = 0.001), breast cancer mortality rate (r = 0.562; p-value = 0.001), male mortality rate due to assault (r = 0.634; p-value < 0.001), and proportion of male deaths from ill-defined causes (r = 0.546; p-value < 0.001). Furthermore, there was a moderate negative correlation between mortality due to assault and per capita income (r = -0.658; p-value < 0.001).

In the multiple model, after adjustments, three indicators remained associated with female mortality due to assault: the lower the per capita income β = -0.553; p-value = 0.031), the higher the mortality coefficient; moreover, the higher the proportion of families headed by women β = 0.637; p-value = 0.001) and the male mortality rate due to assault β = 0.624; p-value = 0.001), the higher the coefficients for mortality due to assault (Table 5).

Discussion

The data produced by this study show that the trend of female mortality due to assault increased in Maranhão in the period from 2000 to 2019. The predominant profile of the victims was that of young adult women, single, with a low level of education, of mixed race, the majority of whom died at home. Moreover, there was negative correlation with per capita income; and positive correlation with the proportion of families headed by women and with the rate of male mortality due to assault.

Feminicide is not specified on the Brazilian Death Certificate, making it impossible to identify this type of death in secondary data. In view of this, in this study the concept of female mortality due to assault was used as a proxy for femicides in the state of Maranhão, with correction of deaths classified as "undetermined" in order to calculate the mortality rates.¹⁶16. Garcia LP, Freitas LRS, Silva GDM, Höfelmann DA. Estimativas corrigidas de feminicídios no Brasil, 2009 a 2011. Rev Panam Salud Publica [Internet]. 2015 [citado 2021 Set 06];37(4/5):251-7. Disponível em: https://www.scielosp.org/pdf/rpsp/2015.v37n4-5/251-257
https://www.scielosp.org/pdf/rpsp/2015.v... If, on the one hand, there is a possibility that this indicator overestimates the true numbers of feminicides found, on the other hand, this is an alternative described in the literature as a form of compensating for the underreporting of feminicide.⁶6. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000...

The rising trend in mortality due to assault was found both for the entire state of Maranhão and also for its mesoregions. It is possible that this fact has occurred not only due to the greater monitoring and visibility that feminicide has gained in society, but also due to the actual increase in female deaths related to gender issues. The data from this study corroborate the increase in the trend of female mortality due to asssault found in the Northeast, Midwest and Southern macro-regions of Brazil between 2002 and 2012.¹¹11. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... Moreover, even taking into account regional discrepancies, states with lower HDI tertiles and greater inequality, such as Maranhão and Amazonas, had higher and increasing mortality rates.¹¹11. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... In 2014, Maranhão had a higher rate of female mortality due to assault (4.74 per 100,000 women) than both the entire Northeast region (4.05 per 100,000 women) and the entire Southern region (3.82 per 100,000 women) of Brazil.¹⁷17. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229... However, it is necessary to consider that the failure to reduce this type of mortality, even after the implementation of Law No. 13,641, of April 3, 2018, known as Maria da Penha Law, stems from a possible failure in the implementation and enforcement of the law at all stages of the process.¹⁸18. Garcia LP, Freitas LRS, Höfelmann DA. Avaliação do impacto da Lei Maria da Penha sobre a mortalidade de mulheres por agressões no Brasil, 2001-2011. Epidemiol Serv Saude. 2013;22(3):383-94. doi: 10.5123/S1679-49742013000300003
https://doi.org/10.5123/S1679-4974201300...

Young and unmarried women were the main victims identified in this research. Other studies confirm that mortality due to assault is responsible for a large portion of deaths of women of reproductive age, with years of potential life lost in the female population, in addition to legal, prison system and public health issues, generating physical and psychological harm for their families.¹³13. Cerqueira D, Lima RS, Bueno S, Valencia LI, Hanashiro O, Machado PHG,et al. Atlas da Violência 2017 [Internet]. Rio de Janeiro: Instituto de Pesquisa Econômica Aplicada; 2017 [citado 2021 Ago 25]. Disponível em: http://www.ipea.gov.br/atlasviolencia/download/2/2017
http://www.ipea.gov.br/atlasviolencia/do... ^,1717. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229... ^,1919. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet. 2017;22(9):2963-70. doi: 10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229... Higher prevalence of femicides among single women has also been found by national studies.⁵5. Meneghel SN, Hirakata VN. Femicídios: homicídios femininos no Brasil. Rev Saude Publica. 2011;45(3):564-74. doi: 10.1590/S0034-89102011000300015
https://doi.org/10.1590/S0034-8910201100... ^,1515. Leites GT, Meneghel SN, Hirakata VN. Homicídios femininos no Rio Grande do Sul, Brasil. Rev Bras Epidemiol. 2014;17(3):642-53. doi: 10.1590/1809-4503201400030006
https://doi.org/10.1590/1809-45032014000... ^,1919. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet. 2017;22(9):2963-70. doi: 10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229... In other countries, rates of female mortality due to assault were about eight times higher than those of women who, despite living with their partners, were not formally married.⁸8. Stöckl H, Devries K, Rotstein A, Abrahams N, Campbell J, Watts C, et al. The global prevalence of intimate partner homicide: a systematic review. Lancet. 2013;382(9895):859-65. doi: 10.1016/S0140-6736(13)61030-2
https://doi.org/10.1016/S0140-6736(13)61... However, it is known that women, when taking the initiative to seek separation from their partners, husbands and even boyfriends, are more likely to be victims.¹1. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence [Internet]. Geneva: World Health Organization; 2013 [cited 2021 July 30]. Available from: https://www.who.int/publications/i/item/9789241564625
https://www.who.int/publications/i/item/... ^,33. Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres. Diretrizes nacionais feminicídio: investigar, processar e julgar com perspectivas de gênero as mortes violentas de mulheres [Internet]. Brasília: Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres, 2016 [citado 2021 Jul 6]. Disponível em: http://www.onumulheres.org.br/wp-content/uploads/2016/04/diretrizes_feminicidio.pdf
http://www.onumulheres.org.br/wp-content... A large part of the population does not consider domestic partnership to be marriage or a legally valid situation and therefore many non-fatal victims of violence have reported that even though they are in domestic partnership relationships, they still consider themselves to be single.²⁰20. Mota JC, Vasconcelos AGG, Assis SG. Análise de correspondência como estratégia para descrição do perfil da mulher vítima do parceiro atendida em serviço especializado. Cien Saude Colet. 2007;12(3):799-809. doi: 10.1590/S1413-81232007000300030
https://doi.org/10.1590/S1413-8123200700...

In this research, the most frequent schooling level of murdered women was 4 to 7 years of study. This fact has already been found in previous studies.⁶6. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000... ^,1919. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet. 2017;22(9):2963-70. doi: 10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229... ^,2121. Caicedo-Roa M, Cordeiro RC, Martins ACA, Faria PH. Femicídios na cidade de Campinas, São Paulo, Brasil. Cad Saude Publica. 2019;35(6):e00110718. doi: 10.1590/0102-311X00110718
https://doi.org/10.1590/0102-311X0011071... There is no consensus on the reasons why women having low levels of education is a risk factor for feminicide, but one of the reasons for this result could be that having less formal education results in less empowerment for women and therefore leads them to seek help less frequently in cases of previous violence.³3. Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres. Diretrizes nacionais feminicídio: investigar, processar e julgar com perspectivas de gênero as mortes violentas de mulheres [Internet]. Brasília: Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres, 2016 [citado 2021 Jul 6]. Disponível em: http://www.onumulheres.org.br/wp-content/uploads/2016/04/diretrizes_feminicidio.pdf
http://www.onumulheres.org.br/wp-content... Another characteristic observed was the predominance of women of mixed race as the main victims of homicides, even though in Maranhão, the greater part of the population is Black.¹⁴14. Instituto Brasileiro de Geografia e Estatística. Panorama Maranhão 2019 [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019 [citado 2021 Ago 24]. Disponível em: https://cidades.ibge.gov.br/brasil/ma/panorama
https://cidades.ibge.gov.br/brasil/ma/pa... Although there is probably an intersection with other vulnerabilities, among which is the low level of education of this population,²²22. Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Cien Saude Colet. 2017;22(9):2929-38. doi: 10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... the fact is that, between 2006 and 2013, there was a 2.1% reduction in the number of homicides among White women and a 35% increase among Black women.²³23. Waiselfisz JJ. Mapa da violência 2015: homicídios de mulheres no Brasil [Internet]. Rio de Janeiro: Cebela-Flacso; 2015 [citado 2021 Nov 05]. Disponível em: Disponível em: https://www.onumulheres.org.br/wp-content/uploads/2016/04/MapaViolencia_2015_mulheres.pdf
https://www.onumulheres.org.br/wp-conten...

The place where assault occurs is a characteristic indicator of feminicides. In this study, the home was found to be the main place of death, followed by healthcare facilities. The high rates of these homicides at home reinforce the indication that these are cases related to violence perpetrated by intimate partners, family members or acquaintances of the victims. Notwithstanding, it can be assumed that these deaths are related to gender issues, characterizing them as feminicides.³3. Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres. Diretrizes nacionais feminicídio: investigar, processar e julgar com perspectivas de gênero as mortes violentas de mulheres [Internet]. Brasília: Entidade das Nações Unidas para a Igualdade de Gênero e o Empoderamento das Mulheres, 2016 [citado 2021 Jul 6]. Disponível em: http://www.onumulheres.org.br/wp-content/uploads/2016/04/diretrizes_feminicidio.pdf
http://www.onumulheres.org.br/wp-content... ^,1010. United Nations Office on Drugs and Crime. Global study on homicide: gender-related killing of women and girls [Internet]. Vienna: United Nations Office on Drugs and Crime; 2019 [cited 2021 Jun 20]. Available from: https://www.unodc.org/documents/data-and-analysis/GSH2018/GSH18_Gender-related_killing_of_women_and_girls.pdf
https://www.unodc.org/documents/data-and... Between 1980 and 2014, there was an equivalent distribution of these deaths between home, hospital and public thoroughfares, in Brazil as a whole and in the Northeast region of the country in particular, with public thoroughfares being the main place where they occurred.¹⁷17. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229... Other studies also point to public thoroughfares as the main place where female homicides occur, followed by homicides in women’s homes, indicating high rates of domestic violence.²²22. Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Cien Saude Colet. 2017;22(9):2929-38. doi: 10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... ^,2323. Waiselfisz JJ. Mapa da violência 2015: homicídios de mulheres no Brasil [Internet]. Rio de Janeiro: Cebela-Flacso; 2015 [citado 2021 Nov 05]. Disponível em: Disponível em: https://www.onumulheres.org.br/wp-content/uploads/2016/04/MapaViolencia_2015_mulheres.pdf
https://www.onumulheres.org.br/wp-conten... One possibility for the increase in deaths in public thoroughfares would be the fact that many aggressors are ex-husbands and/or ex-partners of the victims and, therefore, know all their routines and assault them on their way from home to work or vice versa.¹⁷17. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229...

As found in Maranhão, several studies have shown the predominance of the use of firearms as a means of assaulting women and killing them.¹⁷17. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229... ^,1818. Garcia LP, Freitas LRS, Höfelmann DA. Avaliação do impacto da Lei Maria da Penha sobre a mortalidade de mulheres por agressões no Brasil, 2001-2011. Epidemiol Serv Saude. 2013;22(3):383-94. doi: 10.5123/S1679-49742013000300003
https://doi.org/10.5123/S1679-4974201300... ^,2222. Barufaldi LA, Souto RMCV, Correia RSB, Montenegro MMS, Pinto IV, Silva MMA, et al. Violência de gênero: comparação da mortalidade por agressão em mulheres com e sem notificação prévia de violência. Cien Saude Colet. 2017;22(9):2929-38. doi: 10.1590/1413-81232017229.12712017
https://doi.org/10.1590/1413-81232017229... In 2015, almost half (48.8%) the homicides of women in Brazil were caused by firearms, despite the increase in homicides by strangulation and/or suffocation, followed by the use of sharp objects.²³23. Waiselfisz JJ. Mapa da violência 2015: homicídios de mulheres no Brasil [Internet]. Rio de Janeiro: Cebela-Flacso; 2015 [citado 2021 Nov 05]. Disponível em: Disponível em: https://www.onumulheres.org.br/wp-content/uploads/2016/04/MapaViolencia_2015_mulheres.pdf
https://www.onumulheres.org.br/wp-conten... It is known that the legal possession of a firearm by the perpetrator is one of the risk factors for feminicide,⁹9. Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse. 2007;8(3):246-69. doi: 10.1177/1524838007303505
https://doi.org/10.1177/1524838007303505... causing concern about the recent relaxation, promoted by the Brazilian government, of the possession and carrying of firearms. In different places, however, the means employed by the aggressor varies, with a higher prevalence of the use of sharp objects, as observed in Manaus, capital of the state of Amazonas, and in the municipality of Campinas, state of São Paulo.²¹21. Caicedo-Roa M, Cordeiro RC, Martins ACA, Faria PH. Femicídios na cidade de Campinas, São Paulo, Brasil. Cad Saude Publica. 2019;35(6):e00110718. doi: 10.1590/0102-311X00110718
https://doi.org/10.1590/0102-311X0011071... ^,2424. Orellana JDY, Cunha GM, Marrero L, Horta BL, Leite IC. Violência urbana e fatores de risco relacionados ao feminicídio em contexto amazônico brasileiro. Cad Saude Publica. 2019;35(8):e00230418. doi: 10.1590/0102-311X00230418
https://doi.org/10.1590/0102-311X0023041... In this type of homicide, besides the victim being killed, they are also often disfigured, with a high number of wounds on the face, indicating hate crimes or crimes motivated by banal and futile reasons.¹⁰10. United Nations Office on Drugs and Crime. Global study on homicide: gender-related killing of women and girls [Internet]. Vienna: United Nations Office on Drugs and Crime; 2019 [cited 2021 Jun 20]. Available from: https://www.unodc.org/documents/data-and-analysis/GSH2018/GSH18_Gender-related_killing_of_women_and_girls.pdf
https://www.unodc.org/documents/data-and... ^,2323. Waiselfisz JJ. Mapa da violência 2015: homicídios de mulheres no Brasil [Internet]. Rio de Janeiro: Cebela-Flacso; 2015 [citado 2021 Nov 05]. Disponível em: Disponível em: https://www.onumulheres.org.br/wp-content/uploads/2016/04/MapaViolencia_2015_mulheres.pdf
https://www.onumulheres.org.br/wp-conten...

Per capita income showed negative correlation with the coefficient for female mortality due to assault. Maranhão is the Brazilian state with the highest rates of social inequality, with an annual per capita household income of BRL 636.00, a 0.639 HDI, the lowest urbanization rate in the country (58.3%), and the highest infant mortality rate (24.7 deaths/1,000 live births).²⁵25. Instituto Brasileiro de Geografia e Estatística.Censo demográfico 2010: Características da população e dos domicílios [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013 [citado 2021 Nov 28]. Disponível em: http://www.sidra.ibge.gov.br/cd/cd2010universo.asp
http://www.sidra.ibge.gov.br/cd/cd2010un... It is known that societies with higher levels of inequality have higher rates of female mortality due to aggression,¹¹11. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... whereby the poorest women are the most affected.⁹9. Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse. 2007;8(3):246-69. doi: 10.1177/1524838007303505
https://doi.org/10.1177/1524838007303505... There is evidence that places with lower HDIs and greater social inequality have higher rates of female mortality due to assault.¹¹11. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... Factors such as unemployment, drug trafficking, family breakdown, and social inequality, especially among youth, exacerbate structural violence and increase women’s vulnerability, with greater impact on gender-based violence.²⁴24. Orellana JDY, Cunha GM, Marrero L, Horta BL, Leite IC. Violência urbana e fatores de risco relacionados ao feminicídio em contexto amazônico brasileiro. Cad Saude Publica. 2019;35(8):e00230418. doi: 10.1590/0102-311X00230418
https://doi.org/10.1590/0102-311X0023041... ^,2626. Melo ACM, Silva GDM, Garcia LP. Mortalidade de homens jovens por agressões no Brasil, 2010-2014: estudo ecológico. Cad Saude Publica. 2017;33(11):e00168316. doi: 10.1590/0102-311X00168316
https://doi.org/10.1590/0102-311X0016831...

Another indicator associated with female mortality due to assault, according to the findings of this study, was the proportion of families headed by women. By subverting traditional gender norms, women challenge the values of a patriarchal society and increase the chance of domestic violence.⁴4. Gomes R, Murta D, Facchini R, Meneghel SN. Gênero, direitos sexuais e suas implicações na saúde. Cienc Saude Coletiva. 2018;23(6):1997-2006. doi: 10.1590/1413-81232018236.04872018
https://doi.org/10.1590/1413-81232018236... On the one hand, the entry of women into the labor market and the changes in social roles have promoted and facilitated female independence. On the other hand, this fact can generate more conflicts with men, since the role of family provider is no longer exclusively male, causing aggressive behavior due to the non-acceptance of this new role for women.⁹ To impose their authority over their female companions, these men often use brute force out of a feeling of inferiority, increasing the risk of feminicide.²⁷27. Sá YRC, Moi PCP, Galvão ND, Silva AMCD, Moi GP. The geography of femicide in Sergipe, Brazil: matriarchy, human development, and income distribution. Rev Bras Epidemiol. 2021;24(Suppl 1):e210016. doi: 10.1590/1980-549720210016.supl.1
https://doi.org/10.1590/1980-54972021001... ^,2828. Dantas-Berger SM, Giffin K. A violência nas relações de conjugalidade: invisibilidade e banalização da violência sexual?. Cad Saude Publica. 2005;21(2):417-25. doi: 10.1590/S0102-311X2005000200008
https://doi.org/10.1590/S0102-311X200500...

It is well known that deaths due to assault predominate in males, representing about 90% of deaths resulting from violence, with rates 11.5 times higher than those for females.²⁹19. Bando DH, Lester D. An ecological study on suicide and homicide in Brazil. Cien Saude Colet. 2014;19(4):1179-89.doi: 10.1590/1413-81232014194.00472013
https://doi.org/10.1590/1413-81232014194... In addition to magnitude, female homicides are commonly motivated by gender-based issues centered on beliefs of male superiority and exemption from punishment. Despite these differences, places with high rates of male deaths due to assault also have high prevalence of violence against women, which can result in female homicides,²⁹19. Bando DH, Lester D. An ecological study on suicide and homicide in Brazil. Cien Saude Colet. 2014;19(4):1179-89.doi: 10.1590/1413-81232014194.00472013
https://doi.org/10.1590/1413-81232014194... as found in our study. Younger men, those who live in areas of social vulnerability, who abuse alcohol and illicit drugs, as well as being perpetrators of gender-based violence, are more likely to die due to assault.¹⁷17. Souza ER, Meira KC, Ribeiro AP, Santos J, Guimarães RM, Borges LF, et al. Homicídios de mulheres nas distintas regiões brasileiras nos ultimos 35 anos: análise do efeito idade-período e coorte de nascimento. Cien Saude Colet. 2017;22(9):2949-68. doi: 10.1590/1413-81232017229.12392017
https://doi.org/10.1590/1413-81232017229... In Brazil, between 2010 and 2014, the rate of male mortality due to assault was 133.3/100,000 inhabitants and in Maranhão, during the same period, the rate was higher than the national rate (158.2/100,000 inhabitants). The large number of unemployed young people, who did not attend or do not attend school and who come from broken homes, are factors that contribute to the increase in violence³⁰30. Duarte EC, Schneider M, Paes-Sousa R, Silva JB, Castillo-Delgado C. Expectativa de vida ao nascer e mortalidade no Brasil em 1999: análise exploratória dos diferenciais regionais. Rev Panam Salud Publica [Internet]. 2002 [citado 2021 Out 20];12(6):436-44. Disponível em: https://www.scielosp.org/pdf/rpsp/2002.v12n6/436-444/pt
https://www.scielosp.org/pdf/rpsp/2002.v... and gender crimes.⁵5. Meneghel SN, Hirakata VN. Femicídios: homicídios femininos no Brasil. Rev Saude Publica. 2011;45(3):564-74. doi: 10.1590/S0034-89102011000300015
https://doi.org/10.1590/S0034-8910201100... ^,66. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre: Quantos são? Quem são?. Rev Bras Epidemiol. 2017;20(2):225-36. doi: 10.1590/1980-5497201700020004
https://doi.org/10.1590/1980-54972017000... ^,1111. Leite FMC, Mascarello KC, Almeida APSC, Fávero JL, Santos AS, Silva ICM, et al. Análise da tendência da mortalidade feminina por agressão no Brasil, estados e regiões. Cien Saude Colet. 2017;22(9):2971-8. doi: 10.1590/1413-81232017229.25702016
https://doi.org/10.1590/1413-81232017229... ^,1515. Leites GT, Meneghel SN, Hirakata VN. Homicídios femininos no Rio Grande do Sul, Brasil. Rev Bras Epidemiol. 2014;17(3):642-53. doi: 10.1590/1809-4503201400030006
https://doi.org/10.1590/1809-45032014000... ^,1919. Meneghel SN, Rosa BAR, Ceccon RF, Hirakata VN, Danilevicz IM. Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional. Cien Saude Colet. 2017;22(9):2963-70. doi: 10.1590/1413-81232017229.22732015
https://doi.org/10.1590/1413-81232017229...

This study has limitations that should be highlighted. Firstly, given that it is a study based on secondary data, only the variables available on the death certificate were used, hindering a more comprehensive understanding of this multidimensional phenomenon. Moreover, the incompleteness of some variables favors data invisibility and hinders the analysis of the real pattern of homicides. Secondly, it was not possible to know what motivated the female homicides, since no data regarding the aggressor is held on the Mortality Information System, or whether what led to the deaths of these women were gender issues. When correcting for deaths with undetermined causes, there is a chance of overestimating feminicides. Nevertheless, this is an alternative used to compensate for the frequent underreporting of female mortality due to assault. Thirdly, the possibility of ecological fallacy, typical of the design of this study, must be considered. Thus, it may be inappropriate to generalize the results obtained from the population of the state as a whole to the individuals within it.

Even with these limitations, this study is pioneer in using information on the death of women due to assault in Maranhão. The data obtained may allow the development of public policies for the protection of women and the improvement of strategies to refine the quality of the records. As a serious and shameful phenomenon for any society, a more reliable view of feminicides is a necessary strategy for their eradication. Despite progress with legislation to protect women, an increase in cases of female homicides can be seen. When one takes into account the invisibility and underreporting typical of this phenomenon, the data from this study gains even more relevance. These results reinforce both the magnitude and the omissions that mark the trajectory of the murders of women, indicating the need for new epidemiological studies for a better understanding and continuous surveillance of feminicides.

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