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Assessment of infant mortality surveillance: case study

Abstract

Objectives:

assess the implementation of child mortality surveillance in Recife/PE.

Methods:

an analytical evaluative study was conducted on its implementation. It was a single-case study that correlated degree of implementation with the of the result indicators surveillance. A logic model on this strategy and a matrix of indicators and judgments according to model components were drawn up. The degree of implementation was obtained from structure and process indicators and this was then correlated with result indicators, in a deductive approach based on intervention theory.

Results:

the structure approach presented superior results to the process in all evaluated components. This strategy was considered to have been partially implemented (75. 7%), however, the components of 'identification of deaths' (85.7%), 'epidemiological research' (88.1%) and 'referral of proposals for promotion and health care and correction of official statistics' (95.8%) were classified implemented. Regarding the relation of the degree of implantation of the surveillance and its results with the logical model, only one of the 17 indicators was considered inconsistent.

Conclusions:

this strategy was considered to have been partially implemented. The model of child mortality surveillance and its assessment were shown to be adequate for signaling the consistency of the interrelations between the activities proposed and the effects expected, and would be reproducible within other scenarios.

Key words
Infant mortality; Epidemiological surveillance; Health evaluation

Resumo

Objetivos:

avaliar a implantação da vigilância do óbito infantil no Recife/PE.

Métodos:

realizou-se pesquisa avaliativa do tipo análise de implantação da vigilância do óbito infantil. Estudo de caso único que relacionou o grau de implantação aos indicadores de resultados da estratégia. Foi elaborado um modelo lógico da intervenção e uma matriz de indicadores e julgamento por componente do modelo. O grau de implantação foi obtido a partir de indicadores de estrutura e processo e, posteriormente, relacionado aos de resultado, em uma abordagem dedutiva baseada na teoria da intervenção.

Resultados:

a abordagem estrutura apresentou resultados superiores ao processo em todos os componentes. A vigilância do óbito infantil foi considerada parcialmente implantada (75,7%), entretanto, os componentes 'identificação dos óbitos' (85,7%), 'investigação epidemiológica' (88,1%) e 'encaminhamento das propostas de promoção e atenção à saúde e correção das estatísticas oficiais' (95,8%) foram julgados implantados. Quanto à relação do grau de implantação da intervenção e seus resultados com o modelo lógico, apenas um dos 17 indicadores foi considerado inconsistente.

Conclusões:

a vigilância do óbito infantil foi classificada como parcialmente implantada. O modelo desta estratégia e a sua avaliação mostraram-se adequados ao assinalar a consistência das inter-relações entre as atividades propostas e os efeitos esperados, passíveis de reprodutibilidade em outros cenários.

Palavras-chave
Mortalidade infantil; Vigilância epidemiológica; Avaliação em saúde

Introduction

Infant death is a sentinel event of the quality of healthcare given the early and often preventable nature of these events.11 Victora CG, Aquino EML, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011; 377 (9780): 186376. In view of the magnitude and transcendence of infant mortality, in 2000, the United Nations established the reduction of these deaths by 2/3 by 2015 as one of the Millennium Development Goals.22 AbouZahr C, Savigny D, Mikkelsen L, Setel PW, Lozano R, Nichols E, Notzon F, Lopez A. Civil registration and vital statistics: progress in the data revolution for counting and accountability. Counting births and deaths 1. Series. Lancet. 2015 [acesso em out 2015]. Disponível em: http://dx.doi.org/10.1016/S0140-6736(15)60173-8.
http://dx.doi.org/10.1016/S0140-6736(15)...
Although Brazil achieved this goal in 2012, some countries did not reach the goal despite their efforts, leading to an extension of the deadline to 2030.33 Grove J, Claeson M, Bryce J, Amouzou A, Boerma T, Waiswa P, Victora C on behalf the Kirkland Group. Maternal, newborn, and child health and the Sustainable Development Goals-a call for sustained and improved measurement. Lancet. 2015; 386 (10003): 1511-4.,44 United Nations. 2015-time for global action for people and planet. New York: United Nations. 2015 [acesso em set 2015]. Disponível em: http://www.un.org/sustainabledevelopment.
http://www.un.org/sustainabledevelopment...

Several nations have acknowledged the need to associate the epidemiological profile of mortality with quality assessments of care provided to women and children during their trajectory, and have perfected strategies to facilitate greater understanding of social and care-related determinants of the deaths, including the mortality surveillance.55 Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth. 2014; 14 (280): 1-12.,66 Bamber JH, Kinsella SM. MBRRACE-UK - the new home for the Confidential Enquiries into Maternal Deaths - reports for the first time. Anaesthesia. 2015; 70 (1): 5-9.

In the inspection and investigation of child deaths, international experiences have produced several configurations based on availability of information and the supply of more or less complex health services.55 Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth. 2014; 14 (280): 1-12.,77 Shrestha S, Sharma A, Upadhyay S, Rijal P. Perinatal mortality audit. Nepal Med Coll J. 2010; 12 (4): 257-9.,88 WHO (World Health Organization). Death reviews: maternal, perinatal and child. WHO. 2013 [acesso em 24 jan 2016]. Disponível em: http://www.who.int/pmnch/knowledge/publications/summaries/ks27/en/.
http://www.who.int/pmnch/knowledge/publi...
The investigation of deaths can explain the circumstances in which they occurred and the results should be notified to managers and any interested people so they may act on various levels of the health system to improve access and quality of care provided during pregnancy, labour, childbirth, and child and mother follow-up.55 Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth. 2014; 14 (280): 1-12.,77 Shrestha S, Sharma A, Upadhyay S, Rijal P. Perinatal mortality audit. Nepal Med Coll J. 2010; 12 (4): 257-9.,88 WHO (World Health Organization). Death reviews: maternal, perinatal and child. WHO. 2013 [acesso em 24 jan 2016]. Disponível em: http://www.who.int/pmnch/knowledge/publications/summaries/ks27/en/.
http://www.who.int/pmnch/knowledge/publi...

In Brazil, a similar strategy was implemented by the Ministry of Health (MH) in 2010, with the publication of a normative base of Infant Death and Foetal Surveillance,99 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Portaria n° 72, de 11 de janeiro de 2010. Dispõe sobre a regulamentação da Vigilância de Óbitos Infantis e Fetais. Diário Oficial da União 2010, n. 7, 11 jan. although municipal and state initiatives with different conformations have existed for some years.1010 Oliveira CM, Bonfim CV, Guimarães MJB, Frias PG, Medeiros ZM. Infant mortality: temporal trend and contribution of death surveillance. Acta Paul Enferm. 2016; 29 (3): 282-90.

11 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.

12 Santana IP, Santos JMD, Costa JRD, Oliveira RRD, Orlandi MHF, Mathias TADF. Aspects of infant mortality, according to an investigation of death. Acta Paul Enferm. 2011; 24 (4): 556-62.

13 Jodas DA, Scochi MJ, Moura MB, Tiwata MZ. Atendimento à criança e às mães: investigação do óbito evitável em menores de cinco anos. Rev Gaúcha Enferm. 2011; 32 (4): 669-75.

14 Santana M, Aquino R, Medina MG. Effect of the Family Health Strategy on surveillance of infant mortality. Rev Saúde Pública. 2012; 46 (1): 59-67.
-1515 Santos HGD, Andrade SMD, Silva AMR, Carvalho WOD, Mesas AE, González AD. Agreement on underlying causes of infant death between original records and after investigation: analysis of two biennia in the years 2000. Rev Bras Epidemiol. 2014; 17 (2): 313-22.

In Recife, since 2003, infant mortality surveillance was implemented to investigate and discuss all infant deaths (except those caused by congenital malformations) of mothers living in Brazil. Cases are discussed with healthcare workers, inspectors, and managers in order to identify preventable deaths caused by medical errors, to use this information for reflection and planning, and to adopt measures to reduce infant mortality.1010 Oliveira CM, Bonfim CV, Guimarães MJB, Frias PG, Medeiros ZM. Infant mortality: temporal trend and contribution of death surveillance. Acta Paul Enferm. 2016; 29 (3): 282-90.

In the surveillance assessments conducted in Brazil, the strategy is considered a management tool capable of providing information to health teams, generating critical awareness on the offered care, and enhancing information systems.1111 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.,1616 Frias PG, Lira PIC, Vidal SA, Vanderlei LCM. Vigilância de óbitos infantis como indicador da efetividade do sistema de saúde - estudo em um município do interior do Nordeste brasileiro. J Pediatr. 2002; 78 (6): 509-16.,1717 Caetano SF, Vanderlei LCM, Frias PG. Avaliação da completitude dos instrumentos de investigação do óbito infantil no município de Arapiraca, Alagoas. Cad Saúde Coletiva. 2013; 21 (3): 309-17. Moreover, it can be used to plan interventions for the main problems and barriers of the care system and to reduce preventable deaths and iniquities.66 Bamber JH, Kinsella SM. MBRRACE-UK - the new home for the Confidential Enquiries into Maternal Deaths - reports for the first time. Anaesthesia. 2015; 70 (1): 5-9. Given its potential, mortality surveillance generates special interest for the monitoring actions required to achieve the Sustainable Development Goals.22 AbouZahr C, Savigny D, Mikkelsen L, Setel PW, Lozano R, Nichols E, Notzon F, Lopez A. Civil registration and vital statistics: progress in the data revolution for counting and accountability. Counting births and deaths 1. Series. Lancet. 2015 [acesso em out 2015]. Disponível em: http://dx.doi.org/10.1016/S0140-6736(15)60173-8.
http://dx.doi.org/10.1016/S0140-6736(15)...
,33 Grove J, Claeson M, Bryce J, Amouzou A, Boerma T, Waiswa P, Victora C on behalf the Kirkland Group. Maternal, newborn, and child health and the Sustainable Development Goals-a call for sustained and improved measurement. Lancet. 2015; 386 (10003): 1511-4.

Despite the relevance and scope of national infant mortality surveillance and the guidelines adopted by Brazilian states and municipalities, no publications assessing the implementation of this strategy in Brazil were identified. A case study, with its high potential for internal validity, provides valuable insight for managers, technicians, and researchers. The aim of this paper is to assess the implementation of infant mortality surveillance in a capital city from northeastern Brazil.

Methods

This is an evaluative analysis of qualitative research of infant mortality surveillance. The methodological strategy is a single case study to relate the degree of implementation to the result indicators of intervention in the city of Recife,1818 Champagne F, Brousselle A, Hartz Z, Contandriopoulos AP, Denis J-L. A análise de implantação. In: Brousselle, A, Champagne F, Contandriopoulos A-P, Hartz Z. Avaliação: conceitos e métodos. Rio de Janeiro: Ed. Fiocruz; 2011. p. 217-38.,1919 Chen HT. Pratical Program Evaluation: assessing and improving, planning, implementations, and effectviness. Thousand Oaks, CA: Sage Publications, 2005. northeastern Brazil, thestate capital of Pernambuco with the fourth largest urban concentration in the country. The city covers an area of 218.5 km2 and its population, according to the Brazilian Institute of Geography and Statistics, is estimated at 1,617,260 inhabitants (2015).2020 IBGE (Instituto Brasileiro de Geografia e Estatística). Portal On-line Cidades. [acesso em 07 out 2017]. Disponível em: http://cidades.ibge.gov.br/xtras/perfil.php?codmun=261160.
http://cidades.ibge.gov.br/xtras/perfil....
The mother and child healthcare network consists of 17 maternity hospitals, 275 family health teams (60% coverage), 21 family health support centres, 22 health centres, and 12 polyclinics.

A logical intervention model was initially prepared to clarify how the components work together using activities and available resources to achieve the expected results. The following documents were used for the model: infant mortality surveillance implementation project;2121 Recife. Secretaria Municipal de Saúde. Projeto de implantação da vigilância do óbito infantil no Recife. Recife, 2002. MS Ordinance No. 116/2009 that regulates data collection, flow and periodicity of data on deaths and live births submitted to the information systems; MS Ordinance No. 72/2010 establishing the obligation of infant and foetal mortality surveillance; and the manual of foetal and infant mortality surveillance and infant and foetal death prevention.2222 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Manual de vigilância do óbito infantil e fetal e do comitê de prevenção do óbito infantil e fetal. 2 ed. Brasília, DF; 2009. The listed intervention components were: 'identification of deaths', 'epidemiological investigation', 'discussion of deaths', and 'submission of health promotion and care proposals and correction of official statistics' (Figure 1).

Figure 1
Logical model of infant mortality surveillance in Recife.

A matrix of indicators and a judgment was built according to the component of the logical model related to the approaches (structure, process, and result). A parameter was established for each indicator based on the legal instruments mentioned above. The non-normalised indicators were defined according to the service routine of the municipality where the established and territorialised structure is provided, and where actions have been developed constantly for over ten years. The scores 1; 0.75; 0.5; 0.25, and 0 were established to judge the values found for each indicator (Table 1).

Table 1
Matrix of indicators and parameters by component and approaches of infant mortality surveillance in Recife.

Data were collected from July to December 2015 by means of observation and questionnaires containing closed-ended and open-ended questions with those responsible for inspecting infant deaths and for the Mortality Information System (MIS) of the Municipal Department of Health and the Hospital Epidemiology Centres (HEC) of the State Department of Health.

Data of 2014 were collected from the MIS, including the online version; Information System on Live Births (Sinasc); municipal system of death certificate (DC) distribution and control; infant mortality surveillance panel; infant death and birth certificate (BC) submission protocol for sanitary districts (SD); form of investigation and summary of infant deaths, death certificate submission sheets at the health units and necropsy services, compulsory notification of death (CND) by disease, and death entry sheets.

One hundred indicators were analysed, of which 83 were used to define the degree of implementation (structure and process) and 17 were used to define the results. The maximum estimated score was 100 points divided into the four components: 'identification of deaths' (10 points), epidemiological investigation' (30 point), 'discussion of deaths' (40 points), and 'submission of health promotion and care proposals and correction of official statistics' (20 points).

A lower score division was assigned to the component 'identification of deaths' because it is part of the MIS, essential for mortality surveillance. For 'submission of health promotion and care proposals and correction of official statistics' a lower score was also attributed because it is a major interface for the discussion on deaths between the workers and managers. The highest scores were assigned to 'epidemiological investigation' and 'discussion of deaths' since they are central aspects of intervention. A weight of 30% was attributed to the approach 'structure' and a weight of 70% was attributed to 'process' because the assessment was performed in a large municipality with a minimally structured services network.

The classification of the degree of implementation of infant mortality surveillance, arbitrated by the authors, was based on the time and duration of intervention, according to the indicators of structure and process, and categorised as: implemented (between 80.0 and 100.0%), partially implemented (60.0 to 79.9%), and not implemented (<60.0%).

Subsequently, the degree of implementation by components and as a whole was confronted with the theory of intervention, expressed in the logical model with empirical results based on deduction, and the intensity of relations was noted as consistent (degree of implementation and result indicators in the same category), partially consistent (degree of implementation and result indicators included in the category immediately above or below), and inconsistent (involves the relationship between the highest and lowest degree of implementation categories and result indicators).1818 Champagne F, Brousselle A, Hartz Z, Contandriopoulos AP, Denis J-L. A análise de implantação. In: Brousselle, A, Champagne F, Contandriopoulos A-P, Hartz Z. Avaliação: conceitos e métodos. Rio de Janeiro: Ed. Fiocruz; 2011. p. 217-38.,2323 Yin RK. Estudo de caso: planejamento e métodos. 3 ed. Porto Alegre: Bookman; 2005. The degree of implementation analysis was confronted with each of the result indicators of respective components.

This study was approved by the research ethics committee of the Centro de Pesquisas Aggeu Magalhães da Fundação Oswaldo Cruz (CAAE: 07336313.6.0000.5190). The interviews were scheduled and recorded after the participants signed an informed consent statement.

Results

In the universe of structure indicators, all the infant mortality surveillance components were above 85%. In the component 'submission of health promotion and care proposals and correction of official statistics', all the indicators obtained a high score, while 'discussion of deaths' reached 85.7% of the expected score (Table 2).

Table 2
Indicators of the infant mortality surveillance structure by component according to recorded values and judgment. Recife, 2014.

In relation to the process approach shown in Table 3, 'submission of health promotion and care proposals and correction of official statistics' was the best rated (91.7%) and 'discussion of deaths' obtained the lowest score (67.9%). Of these indicators, five were rated zero: percentage of discussions with the participation of representatives of outpatient units and hospitals involved in care, managers/technicians of maternal health and primary care at central level, and sanitary district manager. The structure approach obtained higher results than the-process in all the assessed components.

Table 3
Indicators of infant mortality surveillance by component according to values found and judgment Recife, 2014.

Infant mortality surveillance was classified as partially implemented (75.7%). Three components, however, were classified as implemented, namely 'identification of deaths', 'epidemiological investigation', and 'submission of health promotion and care proposals and correction of official statistics', with 85.7%, 88.1%, and 95.8%, respectively.

Of the 17 result indicators in relationship assessment of the degree of implementation of infant mortality surveillance and its results with the logical model, only one indicator was considered inconsistent, namely 'percentage of infant deaths discussed with discussion reportprepared and submitted' (13.6%). This indicator is linked to the component 'submission of health promotion and care proposals and correction of official statistics' (Figure 2).

Figure 2
Relationship ofthedegree of implementation of infant mortality surveillance components and their results with the logical model Recife, 2014.

NC=central level; MIS=Mortality Information System; Sinasc=Live Births Information System.


Discussion

Infant mortality surveillance was considered partially implemented, although three components ('identification of deaths', 'epidemiological investigation', and 'submission of health promotion and care proposals and correction of official statistics') were classified as implemented. The component 'discussion of deaths', which was attributed the highest weight, was decisive in the definition of the degree of implementation obtained in the intervention. Moreover, the empirical results obtained in mortality surveillance were compatible with its degree of implementation.

The structure approach was not considered a problem for operation and intervention activities, although other studies state the scarcity of resources as an obstacle to more productive action.1111 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.,2424 Pereira CCB, Vidal AS, Carvalho PI, Frias PG. Avaliação da implantação do Sistema de Informações sobre Nascidos Vivos (Sinasc) em Pernambuco. Rev Bras Saúde Matern Infant. 2013; 13 (1): 39-49. Some difficulties were detected in the indicators of 'identification' and 'discussion of deaths', all of which are related to failure to notify deaths in a timely manner and low participation of important actors in the discussion.

The identification of a child's death triggers the case notification process. This notification is submitted after the death certificate issued by the health workers and services is sent to municipal departments of health, within 48 hours from the date of occurrence as recommendation.99 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Portaria n° 72, de 11 de janeiro de 2010. Dispõe sobre a regulamentação da Vigilância de Óbitos Infantis e Fetais. Diário Oficial da União 2010, n. 7, 11 jan. This component depends on the quality of the MIS, which has been perfected over the years, and precedes the investigation of infant deaths.2525 Frias PG, Szwarcwald CL, Lira PIC. Avaliação dos sistemas de informações sobre nascidos vivos e óbitos no Brasil na década de 2000. Cad Saúde Pública. 2014; 30 (10): 206880.

The rapid flow of information and the timely start of investigations are important for the success of mortality surveillance.2222 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Manual de vigilância do óbito infantil e fetal e do comitê de prevenção do óbito infantil e fetal. 2 ed. Brasília, DF; 2009. In Brazil, the deadline to complete an investigation is 120 days from the date of the occurrence,99 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Portaria n° 72, de 11 de janeiro de 2010. Dispõe sobre a regulamentação da Vigilância de Óbitos Infantis e Fetais. Diário Oficial da União 2010, n. 7, 11 jan. while in the United Kingdom the investigation must be concluded within one month of the death notification.2626 GOV.UK. Department for Education. Child death reviews: forms for reporting child deaths. [acesso em 09 fev 2016]. Disponível em: from:http://www.nrhmhp.gov.in/sites/default/files/files/Child%20death%20Review%20guidelines.pdf.
http://www.nrhmhp.gov.in/sites/default/f...
Delays in this process can hinder interventions to improve the quality of vital statistics information systems and prevent new deaths.

This study identified that almost all (95.1%) infant deaths, except those caused by congenital malformation, were investigated. This percentage is similar to the results found in the city of Londrina - Paraná (97% to 100% of deaths)1515 Santos HGD, Andrade SMD, Silva AMR, Carvalho WOD, Mesas AE, González AD. Agreement on underlying causes of infant death between original records and after investigation: analysis of two biennia in the years 2000. Rev Bras Epidemiol. 2014; 17 (2): 313-22. and different from the results of Arapiraca - Alagoas (54.3%).1717 Caetano SF, Vanderlei LCM, Frias PG. Avaliação da completitude dos instrumentos de investigação do óbito infantil no município de Arapiraca, Alagoas. Cad Saúde Coletiva. 2013; 21 (3): 309-17. The overall proportion of deaths investigated in Brazilian states is lower (in Bahia 21.3% and in São Paulo 57% of health management units investigated all infant deaths).1111 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.,1414 Santana M, Aquino R, Medina MG. Effect of the Family Health Strategy on surveillance of infant mortality. Rev Saúde Pública. 2012; 46 (1): 59-67. Moreover, the manner in which the forms are completed must be improved, especially in terms of investigating the home, the prenatal care and child care units, and the necropsy services. It is critical to improving the quality of investigations in order to build a chain of events that supports death notifications and provides a better understanding of the socioeconomic, cultural, and care determinants.55 Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, Spector J. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth. 2014; 14 (280): 1-12.,1111 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.,1717 Caetano SF, Vanderlei LCM, Frias PG. Avaliação da completitude dos instrumentos de investigação do óbito infantil no município de Arapiraca, Alagoas. Cad Saúde Coletiva. 2013; 21 (3): 309-17.

National and international discussions of deaths occur in committees by a group of experts from universities, health departments, councils, and nongovernmental organizations.1111 Venâncio S, Paiva R. O processo de implantação dos Comitês de Investigação do Óbito Infantil no Estado de São Paulo. Rer Bras Saúde Matern Infant. 2010; 10 (3): 369-75.,2727 Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Population Health Metrics. 2011; 9 (45): 1-13.,2828 Stratulat P, Curteanu A, Caraus T, Petrov V, Gardosib J. The experience of the implementation of perinatal audit in Moldova. BJOG. 2014; 121 (Suppl 4): 167-71. The studied municipalitydiffers when it that adds social services, inspection, and management workers into the discussion. Nonetheless, this was the component with the lowest degree of implementation.

The absence of relevant actors from the health system in discussions of deaths has a negative effect on one of the most important activities of this strategy. Discussions enable a change of attitude and social practices, improve the education of healthcare workers and managers, and increase the effectiveness of the recommendations. The participation in discussions and horizontal listening sessions of workers and managers with multiple roles and levels of involvement in the deaths can help establish ways to overcome barriers and provide care that better suits the needs of women and children. A study conducted in a capital city of northeastern Brazil on preventable infant deaths and barriers in primary care revealed conflicting understandings of the event depending on the position of the care networkor whether the person was the child's mother.2929 Vanderlei LCM, Navarrete MLV. Mortalidade infantil evitável e barreiras de acesso à atenção básica no Recife, Brasil. Rev Saúde Pública. 2013; 47 (2): 379-89.

In spite of the strategy's potential, international research on the social autopsy of mother and child deaths conducted in several countries found resistance among health workers to report or discuss these deaths due to fear of being held accountable or penalised.2727 Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Population Health Metrics. 2011; 9 (45): 1-13.

Analyses and studies of each death have also helped improve the healthcare information systems since, after the investigations, the team that discussed the case usually attributes new root causes to the infant's death, and completes and/or validates the variables of the live birth and death certificates,99 Brasil. Ministério da Saúde. Secretaria de Vigilância à Saúde. Portaria n° 72, de 11 de janeiro de 2010. Dispõe sobre a regulamentação da Vigilância de Óbitos Infantis e Fetais. Diário Oficial da União 2010, n. 7, 11 jan.,1212 Santana IP, Santos JMD, Costa JRD, Oliveira RRD, Orlandi MHF, Mathias TADF. Aspects of infant mortality, according to an investigation of death. Acta Paul Enferm. 2011; 24 (4): 556-62.,1313 Jodas DA, Scochi MJ, Moura MB, Tiwata MZ. Atendimento à criança e às mães: investigação do óbito evitável em menores de cinco anos. Rev Gaúcha Enferm. 2011; 32 (4): 669-75.,1616 Frias PG, Lira PIC, Vidal SA, Vanderlei LCM. Vigilância de óbitos infantis como indicador da efetividade do sistema de saúde - estudo em um município do interior do Nordeste brasileiro. J Pediatr. 2002; 78 (6): 509-16.,1717 Caetano SF, Vanderlei LCM, Frias PG. Avaliação da completitude dos instrumentos de investigação do óbito infantil no município de Arapiraca, Alagoas. Cad Saúde Coletiva. 2013; 21 (3): 309-17. as observed in this assessment. Furthermore, improving vital information systems promotes changes and adjustments to the child mortality profile and enables appropriate planning of actions for its challenging.

A low proportion of infant deaths involved the preparation and submission of reports with propositions of the healthcare sector to the sectors responsible for taking the necessary precautions. These reports provide an overview of the quality of mother and child care in order to encourage healthcare authorities to act.2727 Kalter HD, Salgado R, Babille M, Koffi AK, Black RE. Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method. Population Health Metrics. 2011; 9 (45): 1-13. However, the discussion of death with the workers involved in care allows a change of attitude based on their own participation because of the educational, reflective, and purposeful nature of these meetings, which was also observed in perinatal audits in other regions of the world.2828 Stratulat P, Curteanu A, Caraus T, Petrov V, Gardosib J. The experience of the implementation of perinatal audit in Moldova. BJOG. 2014; 121 (Suppl 4): 167-71. The experience of Moldova shows that if all stages of this strategy are correctly executed, the quality of mother and child care will also improve and possibly reduce the occurrence of preventable infant deaths.2828 Stratulat P, Curteanu A, Caraus T, Petrov V, Gardosib J. The experience of the implementation of perinatal audit in Moldova. BJOG. 2014; 121 (Suppl 4): 167-71.

The consistency between the result indicators and the degree of implementation of infant mortality surveillance suggests the model is suitable to understand the degree of implementation and situation of all activities in the studied case. One of the advantages of making the logical model of an intervention explicit is the possibility of extrapolation to other scenarios. In addition, the model improves the studied strategy by precisely outlining the objective, enhancing individual and collective actions, and identifying planned activities to achieve the expected results in an educational training perspective, thus strengthening the acts and decisions of all stakeholders involved.1919 Chen HT. Pratical Program Evaluation: assessing and improving, planning, implementations, and effectviness. Thousand Oaks, CA: Sage Publications, 2005.

The strengths of the studied strategy are related to the quality and complexity of the logic on which the research is based, and in the plausibility of interrelationships between the activities and the results, which guarantees greater internal validity.1919 Chen HT. Pratical Program Evaluation: assessing and improving, planning, implementations, and effectviness. Thousand Oaks, CA: Sage Publications, 2005. However, in terms of external validity, a limit would be the extrapolation of results. The logical model can be extrapolated, not the results.2323 Yin RK. Estudo de caso: planejamento e métodos. 3 ed. Porto Alegre: Bookman; 2005.

In conclusion, infant mortality surveillance does not fully adhere to the norms and guidelines established in regulatory documents. Some factors regarding this point were identified as being more fragile and should be considered in interventions to improve the strategy. In order to overcome the obstacles preventing appropriate mortality surveillance, scientific, organisational, and experience-based knowledge must be correctly combined and applied. Discussing a child's death is a problem situation of circumstance that requires reflection, followed by decoding, acknowledgment, and denaturalisation, especially in situations of restricted budget and rights.3030 Vanderlei LCM, Frias PG. Uncertainties in the Brazilian scenario and its implications in mother and child health. Rev Bras Saúde Matern Infant. 2016; 16 (4): 375-6.

The logical model of infant mortality surveillance and its assessment were considered appropriate because they were capable of detecting the consistency of interrelationships between the proposed activities, and can, therefore,be reproduced in other scenarios. This type of assessment is critical to identify the weaknesses and potentialities of the strategy and enable managers and technicians to act according to requirements.

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Publication Dates

  • Publication in this collection
    Oct-Dec 2017

History

  • Received
    09 May 2017
  • Reviewed
    07 Oct 2017
  • Accepted
    10 Oct 2017
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