Jornal de Pediatria - Vol. 78, Nº6, 2002 509
0021-7557/02/78-06/509
Jornal de Pediatria
Copyright © 2002 by Sociedade Brasileira de Pediatria
ORIGINAL ARTICLE
Infant death surveillance as an indicator
of health care system effectiveness a study conducted in northeastern Brazil
Paulo G. Frias,1 Pedro Israel C. de Lira,2 Suely A. Vidal,3 Lygia C. Vanderlei3
Abstract
Objective: to evaluate the access to and quality of health care administered to infants based on
postmortem data.
Methods: a descriptive cross-sectional census-based study was carried out to assess the infant deaths
that occurred in the town of Bom Conselho, state of Pernambuco, between January 1st 1999 and December
31st 1999. Home interviews and inspection of medical records were used for data collection. Deaths were
identified by consulting the Mortality Information System, health centers, public notary services,
cemeteries, health workers, and midwives.
Results: seventy-one of 72 deaths were investigated, with a loss of 1.4%. The majority (69.4%) of
deaths occurred in the postneonatal period and 67.6% of them occurred at home. In 77.5% of the cases
medical help was sought at least once, most frequently at emergency units (65.1%). However, 22.5% of
the patients were not taken to any kind of health care service. Most health care services (90.9%) were less
than one hour away from the patient’s home, 78.5% were located in the town of residence and 97% of the
consultations were carried out by doctors. Of 88 consultations, 39.8% resulted in hospitalization and
27.3% in discharge without arrangement of a follow-up appointment. In 84% of the cases the medication
was provided free of charge.
Conclusions: death surveillance revealed restricted access to medical care and poor quality of health
care administered to infants living in the referred town. The high rate of home deaths is related to access,
whilst the journeys made by some of the mothers to health care units, during the illness that caused the death
of their infants, points to the precarious organization of those services.
J Pediatr (Rio J) 2002;78(6):509-16: evaluation of health services; evaluation of health care quality;
evaluation of processes and results; health care quality indicators; home surveys of infant deaths.
Introduction
According to Murnaghan, infant mortality is the principal
indicator of the state of a population’s health and also of the
effectiveness of a poor country’s health services.1 Difficulty
in accessing health services, the quality of care and precarious
socioeconomic conditions have been identified as
determinant and/or limiting factors to the high levels of
infant mortality.2-4
Since 1976, Rutstein5 has recommended the selection
of certain events (deaths or diseases) which could serve as
indicators of the effectiveness of health services and health
programs. The selection of infant and maternal death as
sentinel,5 also termed unnecessary6 or consented,7 is justified
by its strict relationship with the access to and quality of
medical care afforded to the mother-infant group. Through
1. Master’s Degree in Pediatrics, Universidade Federal de Pernambuco.
2. Ph.D. in Medicine, London University.
3. Master’s Degree, Instituto Materno Infantil de Pernambuco.
Manuscript received Jun 25 2001. Accepted for publication Aug 19 2002.
509
510 Jornal de Pediatria - Vol. 78, Nº6, 2002
epidemiological surveillance of mortality it is possible to
identify failures in health care. This should be an integral
part of the implementation of health programs. Such
observation, as a fundamental component of programs or
services, allows a confrontation between standardized and
actually executed activities, expliciting the weaknesses of
health care, in addition to revealing access problems, which
also contribute to the fragilization of the infant. 9
The epidemiological method is being incorporated into
health assessment for the analysis of health service quality
and is coming to constitute an essential stage in the process
of planning and administrating the health sector, allowing
for a rational decision-making process as far as the problems
faced by health services are concerned.10
Performance indicators are indirect assessments of
quality, and are used as a a way to monitor and identify
processes, services or professionals that could be causing
problems or that require a more direct evaluation. They are
expressed in terms of events, rates or causes. It is equally
possible to measure the medical care patients are provided
with as well as the results of such care.11
Taking into account that death is the ultimate effect of a
non-linear causal network with a variety of determinants,8
the in-depth analysis of these determinants can be best
understood by studying single or multiple cases.12,13
The present study aims at inferring on the access to and
quality of medical care provided by health services by way
of surveillance of infant mortality. This is represented by
the number of deaths at home and by the trajectory followed
by mothers in search of care, during the course of the
ailment.
Methods
The data used in this study are part of the evaluative
research on the Analysis of Implementation of the Infant
Mortality Reduction Project in two Municipalities With
Similar Living Conditions in the State of Pernambuco. The
study was approved by the Ethical Research Committee of
the School of Medicine of Universidade Federal de
Pernambuco, in 1999.9
This is a descriptive, cross-sectional, census-based study
of a series of deaths of infants younger than one year in the
municipality of Bom Conselho, between January 1st 1999
and December 31st 1999. This type of study was chosen
because it allows the internal observation of the cases,
offering a deeper analysis of a situation or phenomenon,
with a high level of internal validity.12-14
Bom Conselho is 204 Km away from the state capital
and has 41,067 inhabitants, of whom 50.6% live in urban
areas. It ranks in 84th and 56th places according to the
Municipal Index of Human Development (IDH-M) and to
the Living Conditions Index (ICV), respectively, out of the
184 municipalities within the state of Pernambuco. The
town has a medium-sized hospital, a family health unit and
Infant death surveillance as an indicator... - Frias PG et alii
eight basic health units. The Community Health Agents
Program (PACS), in effect since 1992, covers an estimated
70% of the population.
The deaths were surveyed through the Mortality
Information System (SIM) processing units and
complemented by active searches in health units, registry
offices, cemeteries - both official and not, and in the
community by community health agents and traditional
midwives. The reliability of the data, particularly those
obtained from alternative sources, was cross-checked with
age, types of death declared, death certificates and domestic
and hospital investigations into the cases involved.
The investigation consisted of a questionnaire applied
in Rio de Janeiro by Duchiade2 and of another questionnaire
used by Escola Nacional de Saúde Pública (ENSP/FIOCRUZ
-National School of Public Health) and by the State
Department of Health of Pernambuco,15,16 which were
adapted to the objectives of the current study. The first
questionnaire had been validated by Hartz et al. 7 and the
second one by Leal et al.15,16 The questionnaires contained
closed and semi-open questions regarding socioeconomic
background, obstetric history, and history of morbid events,
with a special focus on the last episode. With regard to
morbid events, questions related to the search for health
care were asked, in order to elicit the date and time of
consultation, type of service that was sought, location,
distance from home address, health professional involved,
conduct adopted, interval between consultations and
purchase of medication.
The data were collected from January and May 2000 by
technicians from the epidemiological section of the
Municipal Department of Health, previously trained to
carry out home interviews with mothers, guardians or
relatives. The information was obtained after verbal
authorization and after the research objectives had been
explained. Each questionnaire was checked by the
coordinator, together with the interviewer. Unanswered
questions and inconsistent or doubtful answers were resolved
with further domestic visits or through reference to official
documents (statements of live births and death certificates)
In cases where there was medical care at health units,
identified during the home interview, the patients’ medical
records and forms were accessed in order to exclusively
retrieve important information about the morbid process
that resulted in death. In order to reconstruct clinical histories,
the home interview, case reports obtained from health
services, death certificates and birth certificates were used.
The use of various documents was an attempt to obtain the
greatest possible amount of evidence which could, to some
extent, accurately elucidate relevant facts about the sickness
and death of the child and which would contribute to
increasing the explanatory power of the study. These
documents were analyzed by three independent sanitarists,
masters in mother-infant health, who used implicit technical
and scientific quality criteria to reconstruct the clinical
histories.
Infant death surveillance as an indicator... - Frias PG et alii
Results
Between January and May 2000, in the town of Bom
Conselho, 72 deaths of infants younger than one year, which
had occurred in 1999, were identified. Of these deaths, 71
were investigated, which represents a loss of only 1.4%.
Certain biological characteristics of these children were
analyzed and it was observed that 69.4% were found mainly
in the 28 day to 11 month age group (postnatal period),
predominated in males (62.5%), in full term newborns
(81.7%) and in those with normal birthweight (60.6%)
(Table 1).
With respect to maternal characteristics, the majority of
the mothers were in the 20 to 35 year-old age group (64.8%)
and 60% of them had attended school for three years or less
(Table 2).
Although two thirds (67.6%) of the deaths occurred at
home (Table 1), 77.5% of the children had been taken to
health services at least once, and of these 8.4% had been
taken four times, which means that 55 children were taken
a total of 88 times to health services before death.
Notwithstanding, 22.5% of the children had not been taken
to any health service during the course of the disease that
resulted in their death. Among the types of service sought,
the majority were emergency services of public hospitals
(65.1%), preferably located within the city of residence
(78.5%), whereas the regional referral hospital, located in
the neighboring town, was used in almost 16% of the 88
Table 1 -
Jornal de Pediatria - Vol. 78, Nº6, 2002 511
incidents. With regard to the time taken to access the
service, the majority (90.9%) were less than an hour’s
journey from the place of residence. (Table 3).
With respect to the professional who provided medical
care, 97% of the children were seen by doctors. Of the 88
consultations, 39.8% resulted in hospitalization, 8% in
transfers to other units, and 27.3% were seen and discharged
without follow up appointments being made.
Notwithstanding, approximately 84% had access to all
medications, either because they had been admitted to
hospital (39.8%) or because they received the medications
free of charge (44.3%). There was no reference to financial
restraints that prevented purchase of medication (Table 4).
Discussion
Studies focused on infant death, through the use of home
interviews, have been used as an appropriate tool for the
diagnosis of mortality profiles and for studies about access
to health services.3,8-10,20
The investigation into the deaths of infants younger than
one year in Bom Conselho provides food for thought about
the profile of infant mortality and the quality of healthcare
provided in small-sized towns in the northeastern hinterland
of Brazil. The amount of information loss in home interviews
was much less than expected, only 1.4%, which is a very low
figure considering the time between the deaths and the
Distribution of death frequency in patients younger than one year according to age,
sex, birthweight, gestational age and place of death
Death characteristics
n
%
Age
< 24 hours
24 hours to 6 days
7 to 27 days
28 days to 11 months
5
5
12
50
6.9
6.9
16.8
69.4
Sex
Male
Female
45
27
62.5
37.5
Birthweight*
< 1,500 g
1,500 to 2,499 g
> 2,500 g
3
25
43
4.2
35.2
60.6
Gestational age*
< 37 weeks
> 37 weeks
13
58
18.3
81.7
Place of death*
Hospital
Home
23
48
32.4
67.7
Source: Research.
* Total = 71 (one patient was not investigated)
Infant death surveillance as an indicator... - Frias PG et alii
512 Jornal de Pediatria - Vol. 78, Nº6, 2002
Table 2 -
Distribution of death frequency in patients younger than one year according to age and
educational level of the mothers
Maternal characteristics
n
%
Age
< 19 years
20 to 34 years
> 35 years
11
46
14
15.5
64.8
19.7
Educational level (years)
None
1 to 3 years
4 to 7 years
8 to 11 years
> 12 years
Unknown
25
18
16
2
1
9
35.2
25.4
22.5
2.8
1.4
12.7
Source: Research.
interviews, also contrasting with other studies, such as the
ones conducted by Duchiade et al.2 in which the loss was
29% for neonatal deaths and 40% for postneonatal deaths,
Macedo et al.,3 with a loss of 56.2%, Formigle et al.21 with
Table 3 -
a 76.6% loss, and Barreto et al.22 in which a 9% loss was
observed.
Problems with this study included memory and selection
biases. The former is concerned with the time elapsed
Distribution of death frequency of patients younger than one year according to the
number, type and location of health services
n
%
Number of services visited
1
2
3 to 4
None
Total
30
19
6
16
71
42.3
26.8
8.4
22.5
100.0
Type of service
Health center
Outpatient clinic of public hospital
Emergency room
Hospital/Maternity ward
Other
Total*
16
5
58
7
2
88
18.2
5.7
65.1
8.0
2.3
100.0
Location
Town of residence
Regional referral
State referral
Other
Total*
69
14
1
4
88
78.5
15.9
1.1
4.5
100.0
Distance from place of residence
< 1 hour
1 - 3 hours
> 3 hours
Total§
50
4
1
55
90.9
7.3
1.8
100.0
Source: Research.
* Some patients went to the same service more than once. This explains why the total number is 88 instead of 71.
§ 16 children were not taken to any health service.
Infant death surveillance as an indicator... - Frias PG et alii
Table 4 -
Jornal de Pediatria - Vol. 78, Nº6, 2002 513
Distribution of death frequency of patients younger than one year according to the kind of
professional in charge of medical care, the conduct used and purchase of medication
n
%
Professional
Physician
Nurse
Midwife
Unknown
85
1
1
1
97.0
1.1
1.1
1.1
Conduct
Medical care without follow-up
Medical care with follow-up
Medical care and referral
Hospitalization
No medical care
Other (observation)
24
19
7
35
1
2
27.3
21.6
7.9
39.8
1.1
2.3
Purchase of medication
Bought the medication
Got free samples
Bought/got some free of charge
Could not buy
No medical care
Hospital
Other
Total
2
39
6
0
1
35
5
88
2.3
44.3
6.8
1.1
39.8
5.7
100.0
Source: Research.
between the event and the interview, which varied between
one and twelve months, and the latter involves geographic,
socioeconomic and cultural characteristics, which, despite
the extensive, active search of death records, results in the
underreport of socioeconomically underprivileged
families.23 The present study is believed to have identified
practically all deaths of infants aged less than one year,
since the Mortality Information System had registered 39
deaths, whilst the active search through alternative sources
of information identified another 33 cases. A considerable
number of these deaths occurred at home and in many cases
health services were not looked for. Errors and omissions
regarding the filling-in of medical charts should be taken
into account, as in certain cases, they do not allow establishing
an association between the reason for consultation and
death, despite the mother’s account.
Aside from the biases, the validity of the selected
performance indicator (the mothers’ search across medical
services) is also a limitation. Travassos11 describes two
types of validity: causal and apparent. The causal type is
related to the strong association, based on scientific
knowledge, established between the health care process and
the measurement of results employed11 whereas the apparent
type relates to a logical model used in this study.11 Despite
these limitations, we know that the major role of this type of
information is to provide a basis for the development of
policies and activities, with the aim of improving the quality
of health care.
By analyzing the results, we note that a significant
number of these events occurred at home (67.6%), without
any medical assistance. This situation is a reality in small
cities in northeastern Brazil, as described by Hartz et al.,
who carried out studies in the municipalities of Assu (59.5%)
and Caicó (42.6%) in the state of Rio Grande do Norte.24
Barreto et al. studied infant mortality in three towns of the
state of Ceará, which were well covered by the Community
Health Agents Program (PACS) and by health services
whose main focus was on primary health care, and found
that 46% of deaths had occurred at home.22 In medium and
large-sized towns, however, deaths predominantly occur in
hospitals, due to the prompt availability of medical care. In
the metropolitan region of Salvador,21 in Pelotas,20 and in
Rio de Janeiro,2 these rates were significantly lower: 21.3%,
18.9% and 13%, respectively. It should be stressed that, in
514 Jornal de Pediatria - Vol. 78, Nº6, 2002
Rio de Janeiro, the official statistics for deaths occurring at
home was 7%, but the investigation of the medical records
revealed that 6% had been dead on arrival, totaling 13% of
non-hospital deaths.
The search of mothers for health services indicates a
quest for remedial care, expressed by the number of times
the emergency services were sought (65.1%). A survey of
homes carried out in São Paulo by Cesar and Tanaka10
showed that the emergency room was the most frequently
looked for health service in the last 15 days when morbidity
was present (40.3%). Prompt health care, irrespective of
whether appointment cards have been obtained as well as
the possibility of having complementary exams, appears to
be a decisive factor behind choosing an emergency room
instead of health centers (18.2%), outpatient clinics (5.7%)
or private clinics (2.3%). The less frequent preference for
health centers may be related to the difficulty in arranging
a medical appointment and/or the low success rate of the
basic health system, or even, lack of orientation or the
presence of other social factors. The participation of private
services is nearly nonexistent due to the population’s low
purchasing power, aside from the paucity of such services
in poverty-stricken regions of northeastern Brazil. Only one
case sought private health care twice (2.3%). This contrasts
with the study conducted by César and Tanaka in São Paulo,
in which the preference for private clinics and practices and
for franchised services amounted to 20.1%. Nonetheless,
these authors recognize the importance of public services as
health care providers for the majority of the population.10
On the other hand, emergency care, with 24-hour on-call
professionals who are more concerned with the treatment
and solution of serious cases and immediate complaints, by
virtue of their high qualification, could jeopardize the status
of emergency rooms, since these professionals do not see
the child as a whole, do not follow the progress of the
disease and, more often than not, do not tell the mothers
under which circumstances they should return. It is also
possible that the severity of the disease is not always
identified correctly since numerous children who
subsequently died had been discharged after consultation.
It should be underscored that in the municipality in question
the on-call professionals at emergency rooms are clinicians
and that there is only one pediatrician in the city assigned to
an outpatient clinic.
As far as the discrepancy in the levels of complexity
between the health units in Bom Conselho and Rio de
Janeiro are concerned, the incapacity to detect the severity
of the cases and the lack of an adequate transportation
system were a common denominator in both studies in that
74% of non-hospital deaths in Rio de Janeiro corresponded
to discharges by the health services, as occurred in Bom
Conselho.
A considerable percentage of the mothers in the current
study (22.5%) did not seek any health service for the
treatment of their children. This could be related to the
nonexistence of professionals at the health units in the
Infant death surveillance as an indicator... - Frias PG et alii
vicinity where the patients lived, problems with transport
and access, lack of reliability in the services, failure of the
mother to recognize the severity of the disease, or also
cultural patterns of regions where infant natality and mortality
are still high. Hartz24 attributes the high number of deaths
at home to the lack of reliability in the services.
Conversely, some mothers took their children to health
services three or more times (8.4%), twice (26.8%) or at
least once (42.3%) before they died. Duchiade et al. found
that, in Rio de Janeiro, 38% of the neonatal cases had been
cared for at health services once, twice or more times before
death, as against 63% of postneonatal cases, of which 25%
were hospitalized in the week that preceded their death.2
Macedo et al., in Salvador, verified that there had been three
consultations for every two children, out of the 165 families
interviewed.3 In Ceará22 79% of the cases had sought health
care, a rate that was similar to that obtained in Bom
Conselho (77.5%). The high frequency at which health
units were sought may suggest inability of the professionals
to detect and treat serious cases, or even inefficiently
structured services. This assumption is corroborated by the
high percentage of consultations made prior to out-ofhospital deaths(48). Approximately 31 children (64.6%)
were taken to health services up to four times, a fact that is
extremely serious considering that 97% of these children
were treated by doctors. This result indicates that there must
be continued educational programs for professionals who
work in these units, so that the quality of health care can be
improved. On top of that, more technicians have to be hired
and adequate equipment supplied, in order to improve
working conditions as well.
It should be noted that death is unlikely to have occured
because of geographically difficult access areas, since the
great majority (91.1%) of services were less than an hour’s
journey from the patient’s place of residence. Only four
health services (7.4%) were one to three hours away from
the place of residence, regardless of the means of
transportation used. The distance between the urban
perimeter of Bom Conselho and Garanhuns (a regional
referral municipality, whose demand reached 15.9%) is
covered in less than an hour and only residents of the rural
area took longer than this. César and Tanaka10 found, in São
Paulo, variations in the percentage of attendance within the
patient’s own municipality of residence (54.7% to 95.3%),
while Bom Conselho occupies an intermediate position
(78.5%). The authors attribute these figures to the low
capacity of the local public sector to attend to the population
and the great need to improve mother-infant services, and
they point out the difficulties in implementing local health
programs, due to the low level of coverage and the mass
exodus in search of health services in other municipalities. 10
Of 88 consultations, 39.8% resulted in hospitalization
and 2.3% in observation within the unit and subsequent
discharge. Almost 30% were seen and had follow-up
appointments made or were transferred, indicating
recognition of the need for observation or for relevant
Infant death surveillance as an indicator... - Frias PG et alii
therapy offered by other services. Nevertheless, 27.3% of
the children were seen without any follow-up appointment
being made, probably due to the failure to perceive the
degree of severity or perhaps to a lack of clinical definition
of the case for seeking the health service too early. This fact
could be associated with a lack of organization and
integration of services with the Family Health Program or
with the Community Health Agents who could monitor
these children potentially at risk, breaking the chain of
vulnerability through an educational approach and
surveillance, and therefore prevent many of these deaths. In
the study by Barreto et al.,22 in Ceará, the agents were
mentioned by less than 30% of the families investigated,
although they notified most of the deaths. This indicates that
health agents are not recognized by the services and families;
these professionals possibly function as reporters of these
events.
Another point which was analyzed was the purchase of
medication prescribed by the services. It was confirmed that
the administrators had fulfilled their tasks with respect to
the supply of medication, since in only 6.8% of the
consultations was there any need to purchase one of the
medicines prescribed, and nobody refrained from using the
prescribed medications because they could not afford them.
Based on the results found it is possible to say that the
large number of deaths at home, many of which are “invisible”
to official statistics and are identified only by active search,
points to difficult access to health services. In addition, the
search of mothers for health services also raises questions
about the quality of health care in the municipality concerned,
since many of the deaths occurred after the child had been
seen and even hospitalized. The results also suggest problems
with the organization of the health system, such as a lack or
hierarchies, indefinite referrals and nonexistent
counterreferrals, and also the need for municipal
administrators to evaluate the functionality of the health
care model and the investments destined for the hiring and
qualification of health professionals and doctors who take
care of children, taking into account the absolute paucity of
pediatricians in the local health system.
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Corresponding author:
Dr. Paulo G. Frias
Rua Jornalista Edmundo Bittencourt, 75 – ap. 402
CEP 50070-590 – Recife, PE, Brazil
Tel.: +55 81 3421.4227