Mortality due to external causes of undetermined intent in the Brazilian regions, 2012 to 2021

Abstract

This descriptive study aimed to analyze mortality from External Causes of Undetermined Intent (ECUI) in Brazil and the Brazilian regions. It included all deaths from external causes recorded in the Mortality Information System between 2012 and 2021. The proportions and percentage variation of each group of causes were calculated, and the trend of the proportions of ECUI was analyzed using the Prais-Winsten method. In Brazil, between 2012 and 2021, deaths from ECUI accounted for 7.8% of external causes. The highest proportions were found in the Southeast (12.9%) and Northeast (7.2%), with an increase from 2019 onwards in all regions of the country. The most significant variation in the percentage of deaths from ECUI in the period was found in the Midwest (124.4%), followed by the Southeast (69.4%). As in Brazil, these regions showed an increase in the proportions of annual deaths from ECUI, while the trend was stable in the other regions. Considering the relevance of information for undertaking actions to prevent accidents and violence, the results of this study point to the need to improve the Mortality Information System data on deaths from external causes and implement more effective strategies in some Brazilian regions.

Key words:
Mortality Registries; Underlying Cause of Death; Health Information Systems; Descriptive study

Resumo

O objetivo foi analisar a mortalidade por Causas Externas de Intenção Indeterminada (CEI) no Brasil e nas regiões brasileiras. Estudo descritivo que incluiu todos os óbitos por causas externas (CE) registrados no Sistema de Informação sobre Mortalidade (SIM) entre 2012 e 2021. Foram calculadas as proporções e a variação percentual de cada grupo de causa, e analisada a tendência das proporções de CEI pelo método de Prais-Winsten. No Brasil, entre 2012 e 2021, os óbitos por CEI representaram 7,8% das CE. Maiores proporções foram encontradas nas regiões Sudeste (12,9%) e Nordeste (7,2%), com elevação a partir de 2019 em todas as regiões do país. A maior variação do percentual de óbitos por CEI, no período, foi encontrada na região Centro-Oeste (124,4%) seguida pela Sudeste (69,4%). Assim como no Brasil, tais regiões apresentaram tendência crescente das proporções de mortes anuais por CEI enquanto para as demais, a tendência foi estacionária. Considerando a importância da informação para empreender ações de prevenção de acidentes e violências, os resultados deste estudo apontam para a necessidade de aprimorar os dados do SIM referentes às mortes por causas externas e a implementação de estratégias mais eficazes em algumas regiões brasileiras.

Palavras-chave:
Registros de Mortalidade; Causa Básica de Morte; Sistemas de Informação em Saúde; Estudo descritivo

Resumen

El objetivo fue analizar la mortalidad por Causas Externas de Intención Indeterminada (ECI) en Brasil y sus regiones. Este estudio descriptivo incluyó todas las muertes por causas externas (CE) registradas en el Sistema de Información de Mortalidad (SIM) entre 2012 y 2021. Se calcularon las proporciones y la variación porcentual de cada grupo de causas, y se analizó la tendencia en las proporciones de ECI mediante el método de Prais-Winsten. En Brasil, entre 2012 y 2021, las muertes por ECI representaron el 7,8% de las CE. Se observaron mayores proporciones en las regiones Sudeste (12,9%) y Nordeste (7,2%), con un aumento a partir de 2019 en todas las regiones del país. La mayor variación en el porcentaje de muertes por ECI, durante el período, se observó en la región Centro-Oeste (124,4%), seguida del Sudeste (69,4%). Al igual que en Brasil, estas regiones mostraron una tendencia creciente en la proporción de muertes anuales por IEC, mientras que en las demás, la tendencia se mantuvo estable. Considerando la importancia de la información para implementar acciones de prevención de accidentes y violencia, los resultados de este estudio apuntan a la necesidad de mejorar los datos del SIM sobre muertes por causas externas e implementar estrategias más efectivas en algunas regiones brasileñas.

Palabras clave:
Registros de mortalidad; Causa subyacente de muerte; Sistemas de información sanitaria; Estudio descriptivo

Introduction

The establishment of public policies, particularly those that seek to reduce morbidity and mortality from accidents and violence, depends on accurate information on the causes of death^1-3.

Deaths from external causes are recorded in the Mortality Information System (SIM) of the Brazilian Ministry of Health. They can be classified as accidents, self-inflicted injuries (suicides), and assaults (homicides)⁴. When the intentionality of the event cannot be identified, the death is classified as an event (fact) whose intent is undetermined, also called External Causes of Undetermined Intent (ECUI), and is considered one of the traditional indicators of information quality^2,5. In the literature, assaults and self-inflicted injuries are also referred to as violent deaths⁶.

High ECUI proportions compromise the quality of cause-specific mortality indicators, leading to inaccuracies in analyses of mortality from accidents and violence and hindering comparisons with previous years and the verification of the situation in each location, such as the Brazilian regions^1,3,6-8. A study that analyzed homicide rates among women concomitantly with undetermined external causes revealed that, in the South, North, and Southeast, mortality from events whose intent is undetermined behaved opposite to that of homicide: when one increased, the other decreased, and vice versa, which was not observed in the other regions⁹. Other studies, in this sense, also highlight the disparity between Brazilian geographic regions in death information recording and quality^10,11.

Some authors argue that, over time, the quality of data on deaths from external causes in Brazil has declined due to growing ECUIs, resulting in unreliable analyses of mortality from external causes in the country and, therefore, significantly limiting inferences made about health indicators^1,2,12. This increase also affects the results of analyses of other variables such as gender, age group, and ethnicity/skin color².

A study by the Institute of Research and Advanced Education² revealed that 126,382 ECUI deaths were recorded in Brazil from 2011 to 2021, representing 10% of the total deaths from external causes, with significant growth in these from 2019 onwards, when they represented 12.4%.

In 2021, 1,832,649³ deaths were recorded in the Brazilian SIM. Of these, 149,322 (8.1%) were from external causes, ranking fourth in the proportion of deaths by cause in the country. Considering the initial information from the coroner, the percentage of deaths from ECUIs in Brazil was 18.1%. However, this figure dropped to 9.3% after extensive work updating SIM records by technical teams from municipal health secretariats³.

The reason the record fails to establish intent is primarily due to the forensic doctor’s failure to provide this information when completing the Death Certificate. Notably, the primary source of information for the investigation of ECUIs is the Forensic Medical Institutes (IML), which are public safety units and are recognized for providing detailed technical data^3,5,13.

One of the guidelines of the National Public Security and Social Defense Policy, created in 2018, establishes the systematization and sharing of public security, prison, and drug information nationwide. Therefore, it is essential for developing the investigative network for intentional violent deaths³. However, we should emphasize the relevance of interaction between the Security and Health departments to ensure that investigations into external causes achieve better results.

In this sense, aspiring to improve the recording of the circumstances of deaths from external causes, the Ministry of Health and the Ministry of Justice and Public Security published, in December 2023, a joint technical note that provides guidelines on technical cooperation for epidemiological surveillance teams to access selected data from the IML³.

When the intention of death is highly uncertain, disregarding the occurrence of ECUIs can have negative consequences for diagnosis and the development of public policies, also hindering intervention in sensitive areas². This fact means that the number of deaths from external causes recorded in the SIM reflects only a partial picture of the reality^2,3.

Considering the relevance of deaths from accidents and violence in Brazil, given their magnitude, this study aimed to analyze mortality from external causes of undetermined intent in Brazilian regions.

Methods

This quantitative, descriptive, and exploratory study analyzed deaths from external causes recorded in the Mortality Information System (SIM) from 2012 to 2021, available on the website of the Department of Information Technology of the Unified Health System (DATASUS).

Data were collected on deaths from external causes of residents of the five Brazilian regions (North, Northeast, Southeast, South, and Midwest) and nationwide, for each year of the analysis period (2012 to 2021), selected according to the ICD-10, under codes V01 to Y98, disaggregated into: 1) Transport accidents (V01-V99); 2) Other external causes of accidental injury (W00-X59), named Other accidents; 3) Intentional self-harm (X60-X84); 4) Assault (X85-Y09) that were added to the deaths of the legal interventions and war operations subgroup (Y35-Y36), named Interpersonal violence; and 5) Events (facts) with undetermined intent (Y10-Y34), designated External Causes of Undetermined Intent⁴.

The proportions of each group of external causes were calculated for each year (number of deaths for each cause group, divided by the total number of deaths from external causes*100). For the total period (2012 to 2021), the deaths recorded in all years for each cause group were added, divided by the total number of external causes for all years*100. Then, the percentage change in the proportion of each group between 2012 and 2021 was calculated using the formula: [(final value/initial value) - 1] * 100.

The trends in the proportions of deaths due to ECUIs were estimated using the Prais-Winsten linear regression method, which is suitable for data that may be influenced by serial autocorrelation¹⁴ and, therefore, do not meet the independence of residuals requirement, one of the premises of simple linear regression¹⁵. This method allowed us to obtain the value of the regression slope coefficient and then calculate the estimates of the annual percentage change (APC) and their confidence intervals (95%CI), as described below:

$APC\%=\left(-1+{10}^b\right)\times \mathrm{100,}$

Where: b is the regression coefficient.

For the confidence interval:

$I{C}_{minimum}\%=\left(-1+{10}^b{}_{minimum}\right)\times 100$

$I{C}_{maximum}\%=\left(-1+{10}^b{}_{maximum}\right)\times 100$

Where: b_minimum and b_maximum correspond to the confidence interval of b, respectively.

A p-value less than 0.05 (p<0.05) was considered statistically significant. All APC estimates with a p-value<0.05 indicate an increasing trend when the APC is positive and a decreasing trend when the APC is negative. When a p-value>0.05, the series was considered stationary. Data were analyzed using Microsoft Excel 2016 and Stata, version 16.0.

This work uses only secondary data without identifying participants, publicly available and, therefore, did not require submission to the Research Ethics Committee, in compliance with National Health Council Resolution N°466/2012¹⁶.

Results

From 2012 to 2021, 1,495,187 deaths from external causes were recorded in Brazil, with the highest number in 2019 (156,431). Interpersonal violence was the leading cause of deaths from external causes in the country (37.7%), with the highest proportion in the Northeast (49.0%) and the lowest in the South (29.6%). Transport accidents accounted for approximately one-fifth of these deaths, like the North, Northeast, and Southeast. In the South and Midwest, this group showed an even larger share, 30.0% and 30.7%, respectively. Self-inflicted injuries ranged from 5.9% to 8.6% of deaths from EC, except in the South, where they accounted for 13.3% of deaths in the period (Table 1).

Table 1
Proportion of deaths by type of external cause, region, and year. Brazil, 2012 to 2021.

Location		Transport accidents	Other accidents	Self-inflicted injuries	Interpersonal violence	EC of undetermined Intent
North
	2012	29.6	16.1	5.3	46.8	2.2
	2013	28.4	17.5	5.7	46.0	2.4
	2014	28.3	17.7	5.2	46.1	2.8
	2015	25.8	17.0	6.2	48.8	2.3
	2016	23.8	16.0	5.5	52.6	2.2
	2017	22.1	16.5	5.7	54.1	1.6
	2018	20.5	15.6	6.5	54.9	2.6
	2019	22.0	17.8	7.6	48.8	3.8
	2020	24.7	18.4	8.3	44.7	4.0
	2021	23.8	18.7	8.4	45.8	3.2
	Total	24.8	17.1	6.4	49.0	2.7
Northeast
	2012	29.0	13.5	5.0	45.2	7.4
	2013	27.4	14.1	5.3	46.7	6.6
	2014	27.3	13.9	4.9	47.7	6.2
	2015	25.3	14.1	5.2	47.7	7.7
	2016	23.9	14.4	5.4	49.3	7.0
	2017	21.2	14.5	5.7	53.0	5.6
	2018	21.5	15.4	6.2	49.6	7.3
	2019	23.1	17.6	7.1	42.8	9.5
	2020	21.7	16.7	6.7	46.7	8.2
	2021	22.5	17.3	8.1	44.8	7.4
	Total	24.3	15.1	5.9	47.5	7.2
Southeast
	2012	29.3	22.6	7.2	31.6	9.2
	2013	27.7	23.8	7.2	31.8	9.6
	2014	27.7	24.1	7.5	32.0	8.6
	2015	24.9	27.1	8.1	31.0	8.9
	2016	23.6	26.8	8.0	31.5	10.1
	2017	22.8	26.5	8.6	31.4	10.6
	2018	21.1	27.4	9.1	28.5	14.0
	2019	21.1	26.9	9.7	21.3	21.0
	2020	21.8	28.1	10.1	24.4	15.6
	2021	21.9	29.4	10.8	22.4	15.6
	Total	24.3	26.2	8.6	28.7	12.2
South
	2012	36.0	17.8	11.0	31.1	4.0
	2013	34.1	21.3	11.5	29.5	3.5
	2014	33.5	20.4	11.0	31.4	3.8
	2015	29.9	21.6	12.1	33.2	3.3
	2016	28.4	22.5	12.1	34.0	3.0
	2017	27.7	23.2	13.3	33.1	2.8
	2018	27.5	25.6	14.1	29.2	3.6
	2019	27.8	27.1	15.8	25.2	4.1
	2020	27.3	25.6	15.6	25.5	5.9
	2021	27.7	27.1	16.5	23.5	5.2
	Total	30.0	23.2	13.3	29.6	3.9
Midwest
	2012	34.1	15.8	6.9	40.7	2.5
	2013	33.0	16.8	7.0	40.8	2.6
	2014	33.3	16.4	6.7	41.1	2.4
	2015	30.9	17.4	7.1	42.1	2.5
	2016	29.3	18.0	7.7	42.1	3.0
	2017	27.8	20.6	8.7	40.7	2.2
	2018	28.2	21.1	9.4	38.1	3.2
	2019	28.9	21.9	10.8	34.7	3.7
	2020	29.3	22.3	10.4	32.9	5.1
	2021	31.0	22.9	11.3	29.2	5.6
	Total	30.7	19.2	8.5	38.4	3.2
Brazil
	2012	30.6	17.9	6.9	37.9	6.7
	2013	29.0	19.2	7.0	38.3	6.5
	2014	28.9	19.1	6.9	39.0	6.1
	2015	26.4	20.3	7.4	39.4	6.5
	2016	24.9	20.3	7.4	40.7	6.7
	2017	23.3	20.5	8.0	41.9	6.3
	2018	22.6	21.5	8.6	39.0	8.3
	2019	23.4	22.7	9.6	32.4	11.9
	2020	23.4	22.5	9.6	34.7	9.8
	2021	23.9	23.6	10.6	32.6	9.4
	Total	25.7	20.7	8.2	37.7	7.8

• EC: External Cause.
• Source: Authors.

In Brazil, 7.8% of deaths from external causes were recorded as external causes of undetermined intent (116,029). The highest values were found in 2019 (11.9%), 2020 (9.8%), and 2021 (9.4%). The Southeast had the highest proportion of deaths from ECUIs throughout the period (12.9%), and the highest value in the series (21.0%) was recorded in 2019. The Northeast had the second-highest proportion (7.2%), also with the highest value in 2019 (9.5%). On the other hand, lower proportions were found in the Midwest and North (3.2% and 2.7%, respectively), with the highest values recorded in 2021 for the Midwest (5.6%) and in 2020 for the North (4.0%) (Table 1).

When analyzing the percentage variations in the proportions of deaths from each group of external causes, considering 2012 and 2021 (Table 2), we observed that, although there was a reduction in the proportion of deaths from transport accidents and interpersonal violence in Brazil and all regions, the proportions of other accidents, self-inflicted injuries, and, especially, external causes of undetermined intent showed a positive percentage variation. Deaths from ECUI varied by 124.4% in the Midwest, the most significant variation recorded, followed by the Southeast, with a variation of approximately 69.4%, while the variation was 41.1% in Brazil. The Northeast stands out with the smallest percentage variation (0.5%) in the period.

Table 2
Variation (%) in the proportion of deaths by external cause. Brazil and regions, 2012 and 2021.

Location	Transport accidents	Other accident	Self-inflicted injuries	Interpersonal violence	EC of undetermined intent
North	-19.4	16.2	58.2	-2.1	46.2
Northeast	-22.4	28.2	61.8	-0.9	0.5
Southeast	-25.4	29.8	49.7	-29.3	69.4
South	-23.2	51.7	50.7	-24.5	29.8
Midwest	-9.2	44.7	64.2	-28.1	124.4
Brazil	-22.1	31.6	53.8	-14.1	41.1

• EC: External Cause.
• Source: Authors.

The trend analysis of the ECUI proportions shows that, at the national level, Brazil had an annual increasing trend of approximately 5.70% over the study period. Notably, the Midwest and Southeast stood out with an increasing trend, with annual increases of 9.34% and 8.30%, respectively. The other regions had a stationary trend (Table 3).

Table 3
Annual percentage change and trend in mortality rates from external causes of undetermined intent. Brazil and regions, 2012 to 2021.

Region	APC (%)	95%CI		p-value	Trend
		LL (%)	UL (%)
North	5.04	-2.78	13.48	0.218	Stationary
Northeast	2.01	-1.62	5.77	0.211	Stationary
Southeast	8.30	2.77	14.13	0.007	Increase
South	3.49	-3.93	11.40	0.110	Stationary
Midwest	9.34	2.73	16.36	0.016	Increase
Brazil	5.70	0.95	10.67	0.008	Increase

• APC: Annual Percentage Change; 95% CI: 95% Confidence Interval; LL: Lower Limit; UL: Upper Limit.
• Source: Authors.

Discussion

The study revealed significant differences between the Brazilian regions in the magnitude and trends in the proportion of deaths from ECUIs from 2012 to 2021. Notably, the increase in the proportion of deaths from ECUIs occurred with greater intensity from 2019 onwards.

The North and South had relatively low rates of deaths from ECUI, and although the trends were stable, the percentage variations between 2012 and 2021 were high. Although the Midwest had a low rate of deaths from ECUIs, the variation during this period was the highest, with twice as many deaths from ECUIs in 2021 as in 2012. Furthermore, the Southeast had the highest percentage of deaths from ECUIs compared to other regions. It showed significant variation over the period, indicating a deteriorated quality of information on ECUI mortality. These indices are not only of poor quality for both regions and for Brazil as a whole, but the trend revealed was upward, highlighting the need to seek strategies to change this outlook.

A study conducted in the state of São Paulo found that, from 2000 to 2016, deaths from ECUIs decreased by 14.3%. However, in 2020, these causes increased, accounting for 16.8% of deaths from ECUIs¹⁷. Another study⁶ showed that the increase in deaths from ECUIs in the state of Rio de Janeiro from 2018 to 2019 was 232.0%, while it was 35.2% nationwide. The fact that these two Southeastern states are highly populated and, consequently, have a higher absolute number of deaths, may have influenced the results of this study regarding the high percentages of ECUIs in this region.

On the other hand, the results from the Northeast are noteworthy. Although the variation during the period was very low and the trend remained stable, the percentages of ECUIs were high, showing that it is crucial to invest in curbing the percentages of these causes in this region.

The regional inequalities observed in this study corroborate results described in the literature^9,10. When analyzing mortality from external causes among the Brazilian regions, Amador¹⁰ found different percentages of undetermined causes, showing that the North, South, and Midwest reached the lowest percentages in 2000 and 2010, from 2.5 to 7.0%. One possible explanation for this finding is that in some regions, such as the Southeast, the absolute number of deaths, which is higher than in other locations, requires greater investigative potential, including resources and professional qualifications. These challenges may be influencing the quality of information, resulting in higher ECUI rates. However, in regions with lower percentages (North and Midwest), there may be general underreporting of deaths, which allows for the identification of the specific causes of most deaths, resulting in lower ECUI rates, although this does not imply an improvement in the quality of information.

A study using SIM data found that, in 2017, deaths from ECUIs in Brazil accounted for 21.7% of all deaths from ECs. The authors found that hospital deaths certified by forensic institutes were associated with ECUI deaths.⁸ Other studies have also pointed to this association^18,19. Some authors state that it is not uncommon for coroners to register deaths with an unspecific code to avoid potential inaccuracies in their work, leading them to disregard information from hospital records when police reports do not confirm it^5,19-21.

The increase in violent deaths from undetermined causes hinders a better understanding of the evolution of lethal violence in Brazil^2,3,6,22. These studies state that the extent of this increase influenced the analysis of the declining Brazilian homicide rate in 2019, also observed in this study. However, the authors state that it is unknown to what extent this reduction was attributed to deaths from ECUIs. The literature also highlights that the analysis of other variables, such as gender, age group, and ethnicity/skin color, may be affected by the failure to account for these homicides^2,6.

Otherwise, we should recall that some factors contributed to the decrease in homicides in the country: the change in the demographic profile with an aging population and a consequent decrease in the number of young people; the implementation of qualified public safety actions and programs in some municipalities and states; and the Disarmament Statute^6,23.

In this study, we observed that the percentage increase in deaths from ECUIs occurred concomitantly with declining deaths from intentional violence and traffic accidents. In a study conducted with SIM data in Bahia, the authors found that municipalities and regions with low homicide rates simultaneously had high proportions of ECUIs. At the same time, there was a low proportion of ECUIs in places with high rates.¹ Other studies also report similar results^2,6,9,10.

The National Policy for Reducing Morbimortality from Accidents and Violence²⁴, established in Brazil in 2001, mentions in its text the improvement of information as a priority to which special attention should be given, highlighting the adoption of different strategies for the qualification of EC records²⁴. In this regard, the active search for data with the Forensic Medical Institute (IML), in press publications, through home visits, and database linkage is relevant³. Recently, the Ministry of Health published several technical notes to regulate these activities³.

Investing in medical training and ongoing education for forensic doctors, who are responsible for completing death certificates due to external causes, is a fundamental step toward improving the quality of this information. Training technicians, coders, and external cause investigation teams also contributes to reducing the number of ECUIs and, consequently, producing more reliable information. From this perspective, it is crucial to strengthen intersectoral coordination, as outlined in the National Policy for Reducing Morbimortality from Accidents and Violence, between the Health Department and institutions affiliated with the Ministry of Justice and Public Security, aiming to share information and integrate data.

The use of database linkage methodologies has also been used to improve the quality of information on causes of death^3,21. A study conducted based on deaths recorded in several public databases in the state of Rio de Janeiro in 2014 revealed that the percentage of ECUIs in the total number of ECs decreased from 41.9% to 6.9% after applying the methodology. Consequently, there was an increase in other EC: transport accidents increased from 11.1% to 21.0%; violence from 22.9% to 40.0%; other accidents from 22.3% to 28.3%; and self-harm from 1.8% to 3.7%²¹. The authors also highlighted that 11.2% of EC records were only found in the SIM and were not recorded in other databases (Legal Medical Institute, Civil Police, Mobile Emergency Care Service, and the press).

One of the techniques that aims to correct the distortions caused by ill-defined deaths presupposes the proportional redistribution of ill-defined causes of death, considering the same distribution as known natural causes^25-27. Two redistribution methods are usually adopted: a) Total redistribution - based on the proportional distribution of all reported defined causes; b) Non-external redistribution - similar to the previous one, excluding external causes²⁸. In Brazil, this procedure is used primarily to correct distortions related to mortality from chronic non-communicable diseases^25,28-32.

Some authors^27,33,34 argue that this technique does not allow for the identification of the actual cause of death and may inflate mortality rates, especially where there are more undefined deaths. However, other authors^26,28 argue that redistributing the remaining ill-defined causes, based on investigations conducted by health services, allows for more accurate estimates of the risk of mortality from specific causes and enhances the efforts of health services in investigating deaths without a defined underlying cause.

There has indeed been an improvement in the quality of statistics on external causes, particularly as a result of actions by health secretariat teams that instituted policies for investigating and reclassifying the original causes of death issued by forensic doctors, based on the active search for records in forensic medical institutes^3,21. On the other hand, we should underscore the expenditures incurred by health secretariats to operationalize the investigation of deaths by ECUIs^6,21.

Although the better classification of deaths from external causes is recognized after reclassification of death certificates, the percentage of poorly completed causes remains high, as verified in this study, especially in the Southeast and Northeast, and corroborated by other authors^1,2,5,21.

While this study is relevant in highlighting the importance of deaths from ECUIs in the total number of deaths from ECs, it would be necessary to investigate the magnitude of mortality rates by specific types of external causes and to determine how much deaths from ECUIs influence the risk of mortality from accidents and violence, and from each specific external cause. Furthermore, analyses disaggregated by federal units and municipalities could highlight significant inequalities, identifying areas that need to improve the quality of information on deaths from external causes and more effectively target strategies to reduce deaths from ECUIs.

We can conclude, therefore, that the quality of information on deaths from accidents and violence in the country remains poor, as evidenced by the high rates of external causes of undetermined intent revealed in this study. Moreover, this quality varies across Brazilian regions. Therefore, it is essential to use diverse strategies to obtain indicators that reflect the different settings. Just as this study revealed distinct results across Brazilian regions, it also highlighted differences in the quality of information on external causes in the municipalities that comprise each region, a fact that deserves further investigation.

Information on mortality from accidents and violence should be complete, accurate, and timely to provide an epidemiological overview that approximates reality and can, therefore, contribute to developing public policies aimed at preventing accidents and violence in Brazil.

References

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• ² Cerqueira D, Bueno S, coordenadores. Atlas da violência. Brasília: Ipea. IV Fórum Brasileiro de Segurança Pública; 2023.
• ³ Brasil. Ministério da Saúde (MS). Ministério da Justiça e Segurança Pública. Mortes por causes externas: Qualificação dos registros inespecíficos [Internet]. Brasília: MS; 2024 [acessado 2024 jan 10]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/vigilancia/mortes-por-causas-externas-qualificacao-dos-registros-inespecificos.
• ⁴ Wells RHC, Bay-Nielsen H, Braun R, Israel RA, Laurenti R, Maguin P, Taylor E. CID-10: classificação estatística internacional de doenças e problemas relacionados à saúde. São Paulo: EDUSP; 2011.
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• ⁶ Cerqueira D, Ferreira H, Bueno S, Coordenadores. Atlas da violência. São Paulo: Ipea, Fórum Brasileiro de Segurança Pública; 2021.
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• Data availability statement
  The data sources used in the research are indicated in the body of the article.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources used in the research are indicated in the body of the article.

Publication Dates

• Publication in this collection
  10 Nov 2025
• Date of issue
  Oct 2025

History

• Received
  13 Mar 2024
• Accepted
  03 July 2025
• Published
  05 July 2025