Brazilian National Policy of Comprehensive Women’s Health Care and Mortality in Menopause: Has Anything Changed?

Background: The National Policy for Integral Attention to Women’s Health was implemented more than two decades ago, and the monitoring of potential benets should be explored. One of the life cycles of women contemplated in this health policy is the importance of health care during the climacteric. In fact, prevention and health promotion actions carried out by the Brazil National Health System - Unied Health System (SUS) and enshrined in health Brazilian policies for women. Thus, our purpose is to identify menopausal women’s main causes of death, as well as the mortality trend of such causes, especially after PNAISM implementation. Methods: Ecological study conducted by Disciplina de Ginecologia da Faculdade de Medicina da Universidade de São Paulo from 2018 to 2019. Data were retrieved from Brazilian Health Department by accessing the mortality information system of National Health Information, divided in periods 1996-2004 and 2005-2006 according to implementation of the National Police. The death records of Brazilian women aged 35 to 64 years who had a diagnosis (ICD-10). Trend and differences between periods were evaluated by linear regression. The signicance level was 5%. (Stata 11 ® -StataCorp, LCC). Results: Main causes of women’s death were the circulatory system diseases (29.39%, 736,972 deaths), neoplasms (26.17%, 656,385 deaths), respiratory system diseases (7.29%, 182,812 deaths), endocrine (29.39%), nutritional, and metabolic (6.81%, 170,881 deaths) diseases, and external causes of morbidity and mortality (5.49%, 137,674 deaths). Implementation of PNAISM led to increasing reduction in mortality from circulatory system diseases (β=-0.58; 95% CI, -0.68 to -0.48; r²=0.93; p<0.001), and any signicant changes in neoplasm mortalities (β=0.07; 95% CI, -0.01 to 0.15; r²=0.22; p=0.070). Conclusions: The leading causes of death during climacteric


Background
The National Policy of Comprehensive Women's Health Care, PNAISM (Política Nacional de Atenção Intregral à Saúde da Mulher), launched by the Brazilian Health Department in 2004 and presently being carried out in conjunction with the Unify Health System (UHS) -Sistema Único de Saúde (SUS), aims at reducing women's morbidity and mortality, especially the deaths resulting from preventable causes in all life cycles. [1][2][3] Historically, the assistance and care provided to women by Brazilian health system was restricted to pregnancy and the puerperium, and health actions were speci c (vertical) and oriented to maternal and child health. [1][2][3] In 1984, with the creation of the "Programa de Atenção Integral à Saúde da Mulher" -PAISM (Program for Integral Assistance to Women's Health) and the implementation of SUS, a differentiated attention to women's health was initiated, related to longitudinal assistance, in addition to other aspects relevant to the health of the female population, such as prevalent gynecological diseases; prevention, detection and treatment of neoplasms; menopause; domestic and sexual violence; as well as the incorporation of sexual and reproductive rights, at different levels of complexity. [1][2][3][4] In 2004, PAISM was restructured with new guidelines and goals for assisting women's health, known as the National Policy for Comprehensive Care for Women's Health (PNAISM) and priority was given to the actions taken to guarantee health care for women in Brazil during climacteric period. [1][2][3] Climacteric is the transition period in a woman's life from the reproductive to the nonreproductive cycle. 5 At such a time, clinical changes occur in association with prolonged, permanent, and physiological hypoestrogenism, [5][6][7] and they may be related to the onset or aggravation of chronic noncommunicable diseases. 8,9 In this period, ranging from age 40 to 65 years, a woman can bene t from health prevention and promotion actions taken by SUS and PNAISM.
The epidemiological mortality pro le in Brazil has a marked prevalence of chronic noncommunicable diseases and shows a tendency towards reduction in the deaths -speci cally of menopausal womenbrought on by the circulatory system 8 and ill-de ned causes, as well as a trending increase in neoplasms. [8][9][10] Studies conducted in recent years of the impact of PNAISM on women's health and on the tendency of the causes of disease and death among menopausal women are scarce [8][9][10] and little do they explore the subject. Studies of the mortality of Brazilian women may contribute to changes in health promotion strategies and to the monitoring of the organization and implementation of public health care policies. [11][12] Thus, it is thus our purpose to identify menopausal women's main causes of death, as well as the mortality trend of such causes, especially after PNAISM implementation.

Data source
The DATASUS database covers approximately 96% 13 of the Brazilian population and provides socioeconomic data and information related to health and health care. The data made available by DATASUS are the computerized records of procedures, actions, and services performed by SUS. The data go through an internal validation process before being made available for free public access. However, the individuals treated at SUS are not identi ed by name, rendering the more recent data on the general health of the population vulnerable to subsequent alterations. Hence, they are not utilized for analysis.

Participants
Participants were selected from databases. Only the records of women who died between 35 and 64 years of age, but not during pregnancy or the postpartum period, who were residents of Brazil, and who had a precise diagnosis were retrieved. The deaths occurring during pregnancy and the postpartum period were excluded because of the age bracket. The women who had signs and symptoms and whose clinical examinations and laboratory tests showed abnormalities were left out owing to a lack of diagnostic precision. All deaths occurring in this population between 1996 and 2016 that were reported to SIM were included in this study.

Variables
Age patterns of mortality Retrievals were carried out according to the tenth edition of the International Classi cation of Diseases (ICD-10) 14 . The women who died between 35 and 64 years of age had their records retrieved and they were strati ed into 4-year age brackets (35-39;40-44; 45-49; 50-54; 55-59; 60-64) and year of death.
The estimates of the resident population were obtained from two projections made by IBGE. 10 The population estimate for the years between 1996 and 2000 based on the intercensal projections covering the years between 1981 and 2012 was organized by age bracket, sex, and housing status, and that between 2001 and 2015 from projections for the 2000 to 2006 period was classi ed by sex and age. The resident population was arranged into 4-year age brackets.
Mortality was calculated as the relationship between the number of deaths and the resident population for every 100,000 people. The resultant rate was standardized by age by the direct method, having the world population as a reference. 15 Periods related to PNAISM Rate behavior was analyzed according to ranges related to the year of PNAISM implementation. The preimplementation period corresponds to the 1996 to 2004 range and the postimplementation period to the subsequent 2005 to 2016 range.

Ethical aspects
This study analyzed secondary data freely accessible to all and thus it respects work ethics and good research practices. Nevertheless, it cannot show any approval number given by the research ethics committee. According to resolution number 510 of the National Health Council published on April 5, 2016, studies conducted with secondary data or with public data that render identi cation of the individual impossible should not be submitted for approval or evaluated by the research ethics regulatory system in Brazil, be it the Research Ethics Committee or the National Council on Research Ethics. 16 Data analysis Frequency distribution of deaths following the ICD-10 14 sections was done with absolute numbers and frequency relative to the number of deaths noti ed during the period. Trend was evaluated by linear regression and the slope (B) and the respective 95% con dence interval, the coe cient of determination (R 2 ), and the probability value (p) were calculated. The signi cance level was set at 5%. Stata 11® (StataCorp, LCC) was used.

Results
Deaths from nonobstetric causes of women aged 35 to 64 years totaled 2,286,723 between 1996 and 2016. The major causes of death were classi ed as circulatory system diseases (29.39%, 736,972 deaths), neoplasms (26.17%, 656,385 deaths), respiratory tract diseases (7.29%, 182,182 deaths), nutritional and metabolic endocrine disorders (6.81%, 170,881 deaths), and external causes of morbidity and mortality (5.49%, 137,674 deaths), adding up to 75.1% of the deaths in that period (Table 1). Trend analysis of the ve major causes of death showed a mortality reduction in the diseases of the circulatory system (β = -2.5; 95% CI, -2.  Table   2).

Discussion
In this study, the diseases of the circulatory and respiratory systems, as well as endocrine, nutritional, and metabolic diseases, and those of external causes accounted for approximately 50% of the deaths of women in the 35 to 64 age bracket, while neoplasms alone were responsible for 26% of women's deaths in that same population. The discussion about public policies and climacteric women emphasizes the importance of preventing damage and promoting health, considering the life cycle mainly associated with hormonal instability and the reduction of estrogen levels that interfere in mortality due to cardiovascular diseases and neoplasms. Still, the unavailability of health services interferes with the demand of women in the climacteric period to receive guidance and resolution on issues that affect or live in the life stage [18][19][20][21][22] .
In addition, authors recommended the need to put into practice the constitutional right to integrality in health and contemplate health promotion, prevention and recovery present on our health policies. This achievement must preserve the women's rights and expand assistance services, so that they can correspond, quantitatively and qualitatively, to the demands of women's users of the Brazilian health system 23,24 .
The epidemiological pro le of mortality in Brazil currently shows a marked predominance of circulatory system diseases and neoplasms as causes of death since 1985.
In that year such causes overrode infectious and parasitic diseases and became the chief agents of death in the country. 25,26 This tendency, speci cally in women in the climacteric, was demonstrated by Schmitt et al. 8 , who found, in decreasing order, circulatory system diseases, neoplasms, symptoms, signs, and ill-de ned disorders, respiratory system diseases, external causes (external causes of morbidity and mortality), diseases of the digestive system, infectious and parasitic diseases, endocrine, nutritional, and metabolic diseases, genitourinary system diseases, and nervous system diseases.
In our study, 75.1% of the deaths which have occurred in the last 20 years were caused by circulatory system diseases, neoplasms, respiratory system diseases, endocrine, nutritional, and metabolic diseases, and external causes of morbidity and mortality. The death distribution shown by the sections of the tenth international classi cation of diseases is similar to the women's death distribution found in the results of national studies. [8][9][10][11] The higher percentages found for cardiovascular diseases, neoplasms, and metabolic diseases constitute a familiar scenario to women in the age bracket corresponding to menopause, 26,27 and they are attributed to factors related to lifestyle, such as smoking, alcoholism, excess weight, and high blood pressure. 27 These are frequent habits and concomitant diseases reported during menopause and may occur or aggravate as a result of physiological and progressive hypoestrogenism. 26,27 The downward slope of the mortality tendency of cardiovascular and metabolic diseases and the increase in neoplasm mortality were observed in a study by Mondul et al. 6 , who found that mortality from circulatory and ill-de ned diseases was declining and that neoplasms were moving upwards.
One of the guidelines of PNAISM is related to health care in all of women's life phases and mainly to the circumstances which aggravate health, but which can be avoided, prevented, or detected early on, such as breast and cervical cancers. [1][2][3][4] Implementation of PNAISM allowed menopausal women to have access to health care and was an incentive to the family health care strategy teams to act at the level of public policy, orienting the promotion, prevention, and health actions in all of the Brazilian territory. 12,24 It was also a stimulus for family health care strategy policies aimed at controlling chronic noncommunicable diseases. Both may have contributed towards the reduction in mortality from circulatory system diseases. [19][20][21][22][23][24] In the course of the 20 years of this study , the mortality tendency of neoplasms remained constant when compared to the other major causes of death. Furthermore, mortality from neoplasms did not increase among menopausal women in Brazil according to our results. This was a scenario that maintained its stability independent of and subsequent to the implementation of PNAISM (2005-2016).  [28][29][30][31] The mortality rate stability in the post-PNAISM period detected in the present study may be regarded as an expected result, given the cancer progression time from early detection to the time of death with respect to breast 28 and cervical 29 cancers, as well as an improvement in the lling out of forms and in the quality of information of the information systems concerning the causes of death. [28][29][30] Still, the stability of the cancer mortality rates may be viewed as a warning for the type of unorganized screening done in Brazil, with breast and cervical cancers at the forefront in women's health. 31 There was no reduction in deaths from respiratory diseases, a fact also to be found in the Schimitt et al 8 results. The implementation success of other public policies, such as that of smoking, 32 could have changed the outcome. However, it is worth highlighting that, despite the studies 33,34 which demonstrate the harmful effects of environmental pollution, the behavioral changes in our women, who have been smoking less in the past decades, and the smoking cessation campaigns, mortality from respiratory diseases has not decreased.
The reduction in mortality from endocrine, nutritional, and metabolic diseases following PNAISM implementation, as shown in this study, as well as in mortality from circulatory system diseases, may be associated with a reduction in shared risk factors, such as diabetes mellitus and dyslipidemia, 35 and with the health care provided to (Brazilian) diabetic patients, by making available pharmacological treatments (oral hypoglycemic drugs and insulin) to them through SUS. 35 The mortality analysis of neoplasms as a whole and not as separate entities, some of which top the priority list of women's health care in PNAISM, particularly cervical and breast cancers, is a limitation of the present study. However, PNAISM should reduce morbidity and mortality due to neoplasms in general. In addition, the implementation of National Health Policies does not clearly place health indicators or targets related to health parameters. The analysis of its results is very limiting over time, in fact between the temporality of the data analysis process. In relation to this point, considering that the age of women in our case-by-case analyzes was between 35 and 64 years old as being less than the age of mortality among women in our country. Thus, it could be a limitation in our study.
What is novel about this study is that it acknowledges PNAISM as a public health milestone and as a wellspring of thought more than two decades after its implementation. This national policy is one of the pillars in SUS 36,37 of the maintenance and assurance of actions for prevention and promotion that impact women's mortality, speci cally during climacteric period. Thus, analyses of women's health indicators, such as mortality rates and health diagnoses, are necessary and should make it possible to monitor the bene ts of PNAISM, taking into account health care levels and the female life cycle. 38

Conclusions
The primary causes of death among menopausal women are still circulatory system diseases and neoplasms, followed by respiratory system diseases, endocrine, nutritional, and metabolic diseases, as well as external causes. Among climacteric women after PNAISM implementation, there is a downward trend in the rates of mortality from circulatory system diseases and from endocrine, nutritional, and metabolic diseases and there is stability in the rates of neoplasm and respiratory system diseases.
The analysis of women's health indicators, such as mortality rates, are fundamental in order to enable the monitoring of bene ts and results related to PNAISM as well as directing the design and implementation of other new health policies to be developed for the women. ICES have made substantial contributions to the conception, design of the work; interpretation of data and have drafted the work.

List Of Abbreviations
FWFS have made substantial contributions to the design of the work, acquisition, analysis, interpretation of data and have drafted the work.
JLSR have made substantial contributions to the design of the work and have substantively revised it.
LTSZ have made substantial contributions to the design of the work and have substantively revised it.
FA have made substantial contributions to the acquisition, analysis and have substantively revised it.
ECB have made substantial contributions to the conception and have substantively revised it.
JMSJ have made substantial contributions to the conception and have substantively revised it.