Mortalidade feminina e anos de vida perdidos por homicídio/agressão em capital brasileira após promulgação da Lei Maria da Penha

Violence against women is a phenomenon that affects all people in all parts of the world. In Brazil, in 2006, was enacted the law 11.340/2006, called Maria da Penha, with basilar function to inhibit the domestic, family and affective violence. The aim of this study was to compare female mortality due to aggression/homicide in Rio Branco, Acre, Brazil, before and after the law came into effect. For that, an ecological study was conducted with victims of aggression and homicide registered in the Mortality Information System from 2002 to 2010. The women, victims of homicide, were aged between 21 and 25 years of age (28.6%), had low level of education (39.3%); and did not have an occupation (64.3%). The incidence of deaths declined followed by an increased in the last two years with repercussions on Potencial Years of Life Lost of those from 16 to 39 years old. Maria da Penha law is a reality in Brazil and has a relevant role in society, thus, should be analyzed in terms of its effectiveness and influence.


INTRODUCTION
Violence has always been part of human history and is a subject seldom addressed in its complexity in an attempt to ignore, in many cases, its consequences. 1It has its own and separable characteristics, such as physical, psychological, socioeconomic, domestic violence or violence against women, among others. 2 regard to violence against women, which is this study's object, it is undeniably a world phenomenon affecting all social classes.Therefore, various countries have applied preventive and control measures to stop these actions.As a result, violence against women is now a problem to be countered with public policies. 2 this sense, violence against women has an endemic nature and can manifest around the world in different ways and in the most varied spaces of society, not restricted to a certain environment, ethnicity, age or social status. 3 Latin America has the highest homicide rates in the world and the probability of a young individual dying as a victim of homicide is 30 times greater than a young individual dying in Europe and 70 times greater than in Greece. 4 In 2003, the rate of mortality due to homicide reached 28.6 deaths per 100,000 inhabitants, followed by a period of decrease between 2003 and 2006.Analyzing the different Brazilian states, the homicide rate in 2003 in Pernambuco was 56/100,000, 48/100,000 in Rio de Janeiro, 18/100,000 in Rio Grande do Sul, and 12/100,000 inhabitants in Santa Catarina. 5 2004, homicides were the leading cause of death among external causes in the North. 7The state of Acre, with a rate of 18.7/100,000 inhabitants in 2004, ranked 12 th in the country. 8In 2006, it ranked 16 th with 22.1/100,000 inhabitants.When the murder weapon was verified, the capital of Acre, Rio Branco, ranked the 25 th in the country in the use of firearms. 9tween 2003 and 2007, approximately 20,000 women died as victims of aggression in Brazil.The states of Espírito Santo, Pernambuco, Mato Grosso, Rio de Janeiro, Rondônia, Alagoas, Mato Grosso do Sul, Roraima and Amapá where those with the highest coeficients. 8proximately 4,000 women were murdered between 2000 and 2005 in Brazil.These data show the need for greater focus on female deaths due to external causes.These are preventable deaths that indicate deficiencies in the security system. 10Most of those who perpetrate such an act are familiar to the victim (husbands, partners, and close relatives). 11[14][15][16] Due to the situation of violence against women, social movements became engaged in demanding a legal review from institutions of the criminal justice system.As a result, Law n. 11,340/2006, called the Maria da Penha Law, was created.It was designed to curb all forms of violence, whether physical, moral, sexual, psychological, injurious or resulting in death, suffered by women, fatal victims, who, most of time, have their partners or former partners as the active subject of aggression. 17is law was a milestone in Brazilian legislation and is marked by an emphasis on the valorization and inclusion of the victim in the context of the criminal process, in addition to heeding the needs of thousands of Brazilian women, as victims of violence, who have been deprived for centuries of participating in the diverse social and legal sectors. 18e Maria da Penha Law has generated positive social effects and its effectiveness has been achieved in society. 19This law came to meet the aspirations of countless victims.Its real effectiveness, however, should be assessed in different Brazilian cities.There is a provision in Article 8 of the law, as one of the integrated measures to prevent violence against women, to promote studies and research, statistics and other relevant information concerning the causes, consequences, and frequency of this problem. 17is study's objective was to compare the rate of female mortality due to aggression/homicide, before and after the implementation of the Maria da Penha Law in Rio Branco, Acre, in addition to describing the profile of the victims, the place where the homicides occurred, type/means of aggression, and the total potential years of life that were lost due to the violence.

MATERIAL AND METHOD
This ecological, descriptive and retrospective study with a quantitative approach was conducted in Rio Branco, capital of Acre, Brazil, located in the western Amazon.The study's population was composed of women, victims of aggression/homicide recorded in the Mortality Information System (MIS) between 2002 and 2010, all of whom were residents of Rio Branco, Acre.Access to the MIS was possible through the epidemiological surveillance of Rio Branco, the agency responsible for providing data obtained from the death certificates to the information system.Inclusion criteria were women 16 to 39 years old, residents of Rio Branco and whose basic cause of death was aggression/homicide that occurred between 2002 and 2010, coded according to the International Classification of Diseases and Related Health Problems, 10 th review (ICD10, codes X85 to Y09). 20e population considered for the calculation of the mortality rate per year was the simple average of the population of years in the middle of the period, according to the Demographic Census of 2000 and 2010, while the number of deaths was obtained according to the basic cause and analyzed using the statistical software SPSS, version 10.0 for Windows.
Deaths due to aggression/homicide were selected and classified by sex, color, and age, using the same criteria and same area for 2002 to 2010.Information concerning the place of occurrence and type/means of aggression/homicides was also obtained.
We considered the age groups to estimate the Potential Years of Life Lost (PYLL), for which the remaining years of life were calculated by subtracting the years of life that would be lived if the woman had not died, based on life expectancy.Then, these values were multiplied by the number of deaths in each age group; the values were then totaled.The PYLL were calculated in its raw form, i.e., according to data contained in the database.
Criteria suggested by the Ministry of Health, which establishes the limit age for the calculation of PYLL (70 years old), was used to base the calculation of the PYLL coefficient.Hence, this study complied with the ethical recommendations established for studies of this nature.

RESULTS
A total of 56 homicides of women 16 to 39 years old were recorded between 2002 and 2010 in Rio Branco.Data were restricted to external causes and related to homicides/aggression against women living in the capital.
A predominance of victims aged between 21 and 25 years old was observed, while in the second decade of life 53.6% of them were Caucasian with a low level of education, no partners and no occupation.Of the victims, 91.1% (51 deaths) lived in an urban area of the capital, as shown in table 1.
Pregnancy was reported in two deaths (3.6%); there was no report of pregnancy in 21 (37.5%)cases; and most reports, 33/58.9%,had no information regarding pregnancy.Among the homicides, there was one case of criminal uterine perforation, a fact that shows the vulnerability of both victims (mother and child).
The primary place where the homicides occurred was the victim's home, followed by the hospital.That hospitals appear in the report may distort the information, because it does not reveal the place where the event that resulted in the victim's death actually occurred.Therefore, the number of deaths that occurred at home, in public areas, or in other places, is higher than what is reported.Nevertheless, this information can be considered relevant concerning the severity of injuries because even after receiving specialized care, the victim still dies.It is worth noting that for basic causes, the option non-specified place of occurrence was chosen in 80.4% (45) of the reports.
Necropsies were not performed for three of the victims (5.4%) and no further information was provided.Violent deaths or those with a suspicion of an external agent should be assessed by a forensic physician.Lack of this investigation raises questions, which were solved here only in two cases that occurred in a rural area, where there was no medical care, and confirmation of death was obtained through investigation by a professional from the epidemiological surveillance system, consulting with the victim's family members and neighbors.Narratives provided in the reports contribute to the clarification of doubts that may emerge in the report's previous items.Narratives were provided in 25 reports (46.4%).The main basic causes of death, according to ICD-10, were aggression with slashing, piercing or cutting objects, characteristic of inner cities or poorly developed cities, followed by the use of firearms and bodily force, as shown in table 2. Aggression with sharp or penetrating objects, non-specified place of occurrence, code X99.9, was reported in 53.6% (30) of the homicides, while aggression with a firearm or non-specific gun, non-specific place of occurrence, code X95.9, was reported in 19.6% (11 deaths) of the cases.Figure 1 shows that only in 2004 was there an inversion in the type/means of aggression with a higher occurrence of firearms at the expense of slashing, cutting and perforating objects.In the remaining years of the study, the second type of weapon had a higher rate.In 2008, there was a decrease in the mortality rate in both types/means of aggression/homicide followed by an increase in the use of firearms in 2010.Table 3 shows the coefficients of mortality by homicide over the historical series in Rio Branco.In the studied period, a higher magnitude of coefficients was observed in 2006, the year when the Maria da Penha Law was enacted in Brazil.The previous year (2005) presented the lowest rate of mortality among the studied years.The impact on productivity, estimated with the number of PYLL, was higher among women between 21 and 25 years old (753; 29.5%).A decrease was observed in the quantity of years lost in the remaining age groups.Homicides among women in the third decade of life resulted in 1,427 PYLL (55.9%).The results in the other age groups were: 520 PYLL (20.4%) among women aged from 16 to 20 years old; 674 PYLL (26.4%) from 26 to 30 years old; 440 PYLL (17.3%) from 31 to 35 years old; and 162 PYLL from 35 to 39 years old (6.4%).
The profile of PYLL differs when the years from 2002 to 2010 were considered.A decreasing trend up to 2005 was observed.There was a peak in 2006 in the values of potential years of life lost, followed by two years of decline, while since 2009, PYLL have been increasing in the age group from 16 to 39 years old due to the occurrence of homicides.Total PYLL was high in the nine years assessed, a fact that results in loss of productivity for the collectivity, as shown in table 3.
In Rio Branco, there was in the years prior to the Maria da Penha Law a sequence of decreasing rates, a trend that continued through 2009, when there was an increase followed by stabilization in the following year.There is, however, a trend of decline over the course of the historical series, with the exception of 2006 and the two last years.

DISCUSSION
Deaths due to external causes reflect violence in different regions. 21Information on mortality is obtained from the Mortality Information System, the database of which is fed with data contained in the death certificates that are completed by physicians or forensic physicians (non-natural deaths). 22ence, all the death certificates entered should have been completed by a forensic-physician.] In the health field, the magnitude of violence is analyzed through mortality data, classified according to Chapter XX of the International Classification of Diseases -10 th review (ICD 10), codes X85 to Y09, which include homicides, suicides and accidents. 20,25Data presented are restricted to deaths due to homicide and do not represent the dimension the full spectrum of events of this classification.
The use of homicides in studies assessing the different variables contributes to understanding factors associated with violence. 5:5-6 Female mortality and years of life lost due to homicide… In 2005, a WHO report estimated that 14% of the deaths among males and 7% of the deaths among females are attributed to violence. 28Research on the rate of mortality between men and women show a significant difference for males. 29he high rates among men has compromised analysis of specific factors for females because data are underestimated. 8n Brazil, deaths due to external causes stand out among women of childbearing age and are the leading cause of death among women 15 to 35 years old. 10Homicides account for up to 50% of deaths in women of childbearing age among external causes. 30Identifying the reality of different Brazilian cities in regard to female mortality due to homicide contributes to the design of strategies to prevent violence against women.
It is important to keep in mind that up to the 1970s, the discussions presented here were meaningless in the face of a sexist society, summarized in the saying: "nobody should meddle in a fight between husband and wife."Female oppression was present in all spheres, including the law.Feminist struggles have achieved numerous accomplishments over the past years.
One of these accomplishments was Law n. 11,340/06, known as the Maria da Penha Law, which treats violent offenses against women within the domestic and family spheres more rigorously.Nonetheless, not all women seek out the institutions responsible for ensuring their safety due to a fear of social judgment, which results from a historical memory of patriarchal and sexist foundations. 31Not seeking to assert their rights may result in the perpetuation of violent acts, which in some cases culminate in the death of women, helpless victims of force and ignorance.
The most frequent ages in this study were from 21 to 30 years old, coinciding with those found in São Paulo and Recife. 29,32A greater proportion of cases occurred among non-Caucasian women, while in São Paulo, 56% of deaths due to external causes resulting from aggression occurred with Afro-Brazilian women 33 though it is not a constant in the country. 31iolence against women that does not result in death is concentrated among women 20 to 39 years old with a low level of education. 34Additionally, lack of an occupation reveals a common characteristic among assaulted women, that of economic dependence, which is associated with a history of repression and neglect and jointly provides the basis for the perpetuation of violence.
Women excluded from the basic rights of citizens seldom free themselves from the oppressive and violent environment in which they live, becoming subjugated by the imposed reality.
Lack of a partner is not reported in studies addressing female homicides because these are the offenders in 50% of cases. 14The studies with nonfatal victims, however, show that most have stable relationships.Additionally, it is worth noting that most people report being single when asked about their marital status due to a view that their union does not characterize a common law marriage. 35omicides in Brazil have grown sharply, especially in urban areas, mainly due to the rapid and uncontrolled urbanization process, largely occurring in neighborhoods with low-quality infrastructure. 36eing pregnant results in higher rates of homicides and can be considered a risk factor. 37onsidering this possibility and the cruelty of interrupting the lives of helpless people displays the need for differentiated interventions when the subject is violence.For this reason, The Maria da Penha Law, treats unequal people unequaly. 38n studies addressing female mortality due to external causes, hospitals are the most commonly reported place for occurrences, followed by the victim's homes.The same is the case of female mortality due to homicide. 39This information on deaths due to aggression is not meaningful, since the relevant event did not occur in the hospital but at home, in a public area, or other places, as reported in one study comparing information provided in death certificates and accident reports. 40nformation indicating the hospital as the place of occurrence falsifies the records and prevents a correct analysis of findings.This is a fact that is corroborated by the use of ICD codes referring to a non-specified place, hindering studies addressing deaths due to accidents and violence. 41ggression is common in households.At home, which should represent safety, there is fear and oppression. 42Statistical reports, however, are underestimated because there is a portion of victims who do not seek help, and many do not acknowledge the violence they face. 43It seems that home is not as 'sweet' as it would first appear.Transformations in interpersonal relationships have not changed relationships of hierarchy and domination between men and women. 44The case of Maria da Penha exemplifies this reality, when at the 38 years of age, she suffered the second attempt of murder against her, which left her a paraplegic.
Amaral NA, Amaral CA, Amaral TLM Nineteen years later, nothing had been done to punish the offender, her own husband. 45his reality, imposed by gender inequality, is common in the violence perpetrated against women. 13,33When considering representations of family, a man at home represents strength and the woman represents docility and caring; this difference culminates in an association of homicides at home where the male figure is the offender.Being a man seems to be associated with virility and power among individuals with aggressive and dominating behavior. 6hat a third of deaths occur at home reinforces the idea that deaths were caused by an intimate partner, a relative or someone familiar to the victims. 8he homicides that occurred from 1999 to 2001 in the North represent the main cause of death among women aged 20 to 24 years. 46In Rio Branco, 2006 was the year with the highest rate of mortality, 32.6/100,000 inhabitants.
The year when the Maria da Penha Law was enacted did not see the elimination of homicides in the capital.There is, however, a trend of decline in the rate mortality in the following years.The Maria da Penha Law enabled mechanisms to limit these types of violence to prevent future aggressions. 47n this study, information concerning the type/means of offense that resulted in death and the high percentage of slashing, perforating and cutting objects differs from the reality experienced in other cities that indicates, in those contexts, that firearms are the main mechanism used in homicides. 5,10,46Even though Rio Branco presents a high mortality rate, the use of weapons other than firearms as the means of aggression, differentiates Rio Branco from urbanized cities.
PYLL gives an estimation of the years the person would have lived and is used to measure the occurrence of deaths and to establish health actions. 30A total of 27,205 PYLL were estimated in the city of Duque de Caxias, with approximately 42 potential years of life lost as a consequence of violence for every 1,000 inhabitants. 48n the city of Belo Horizonte, homicide accounted for 61.5% of deaths by external causes. 49he ages from 21 to 25 and from 26 to 30 years old presented the highest PYLL due to homicides among women in Rio Branco.The highest estimates in Recife were among women aged from 10 to 29 years old and the PYLL coefficients due to homicides were 8.82. 30he total PYLL from 2002 to 2010 show the severity of the situation in Rio Branco, because they show the social impact of preventable deaths in the female population of childbearing age.

FINAL CONSIDERATIONS
In summary, women, victims of homicides in Rio Branco, were from 21 to 25 years old, Caucasian, with a low level of education, no occupation, living in an urban area who were murdered mainly with slashing, perforating or cutting objects.
In this study, we verify that the incident of deaths of victims of aggression/homicides between 2002 and 2010 presented a sequence of results that were initially decreasing, while in the year the Maria da Penha Law was enacted, 2006, there was an increase in homicides followed by another decrease in the next two years, though indicating an increase from 2009 on.Such a fact should be analyzed by society and competent agencies in order to avoid the trivialization of law and also to seek preventive actions and promote a more humane and less sexist society.
PYLL revealed a high loss in the years of life of women 16 to 39 years old due to homicides, which results in a loss of productivity.Information collected in a database on mortality expresses the reality concerning the completion of death certificates in the city.These certifications should be fully completed to ground future studies and to devise strategies in the health field without compromising the variables.
The Maria da Penha Law is a reality in Brazil, a feminist accomplishment with the objective to equalize justice between genders.It plays an important role in society and should be analyzed in studies addressing its effectiveness and influence.Admittedly, the Maria da Penha Law alone is not able to reduce violence against women, because in addition to coercive measures, the promotion of educational actions and valorization of women in society is needed.

Figure 1 -
Figure 1 -Rate of mortality per year (100 inhabitants) according to the type/means of aggression/homicide in Rio Branco, AC, Brazil between 2002 and 2010

Table 1 -Distribution of female deaths due to aggression/homicides according to age, race, schooling, marital status, occupation and place of residence in Rio Branco, Acre, between 2002 and 2010
* The values are smaller due to MIF's lack of information.

Table 3 -Number of female deaths due to aggression/homicide per year, Mortality rate by 100,000 inhabitants and Potential Years of Life Lost in Rio Branco, Acre, between 2002 and 2010
* Potential years of life lost.