Wigglesworth Classification Research Articles

Brasilian List of Avidable Causes of Death that can be avoided by National Health System interventions, and its applicability for analysis of perinatal deaths in municipalities in the states of Rio de Janeiro and São Paulo, Brazil, 2011.

Objective to assess the applicability of the Brazilian List of Avoidable Causes of Death (BAL) to perinatal mortality in public maternity hospitals in the states of Rio de Janeiro (RJ) and São Paulo (SP) in 2011. Methods this was a descriptive case series study of perinatal deaths using primary data from the Mortality Information System; the BAL was applied, with adaptations (codes P20.9 and P70-74) and, in addition in Rio de Janeiro the Extended Wigglesworth (EW) Classification was also used. Results according to the BAL, 61.2% of the 98 perinatal deaths were avoidable, mainly by providing adequate attention to women in pregnancy; 'Ill-defined causes of death' accounted for 26.6% of cases, mainly fetal deaths; use of EW in RJ indicated that the 'Antepartum Fetal Death' category was predominant and was related to inadequate prenatal care; this was in line with the BAL. Conclusions after reallocating some codes, the BAL can improve fetal death evaluation, whereby studies with a larger number of participants are needed.

Perinatal mortality: epidemiological profile, causes and avoidable factors at a reference public maternity hospital in the State of Santa Catarina, Brazil, 2011-2015.

Background This study aimed to identify the perinatal mortality coefficient, the epidemiological profile, causes and avoidable factors at a reference public maternity hospital in southern Brazil. Methods In this cross-sectional study, 334 medical records of postpartum women and newborns were evaluated between January 1st, 2011 and December 31st, 2015. The Expanded Wigglesworth Classification was used to assess the causes of perinatal mortality and the International Statistical Classification of Diseases and Related Health Problems (ICD-10/SEADE Foundation) was used for the preventable perinatal mortality analysis. Absolute numbers and percentages were used for data analysis. The perinatal mortality formula was used to calculate the perinatal mortality rate. Results The perinatal mortality rate was 13.2/1000 total births, with a predominance of white race/color; mothers were 21-30 years of age, had experienced their first pregnancy and had completed their high school education. Conclusion The main factors associated with perinatal death were antepartum fetal death in 182 (54.49%) cases, and avoidable death through appropriate prenatal care in 234 (70.05%) cases.

Incidence and Causes of Perinatal Mortality in Georgia

Georgia has one of the highest perinatal mortality rates (i.e., stillbirths and early neonatal deaths combined) in Europe. The Georgian Birth Registry was started in 2016 to provide data for preventive measures of maternal and child health. In this study, we aim to determine the incidence of perinatal mortality, assess the distribution of stillbirths and early neonatal deaths, and to determine the major causes of perinatal mortality in Georgia. Data sources were the Georgian Birth Registry and the vital registration system for the year 2017. Causes of early neonatal deaths were assigned into five categories, using the Wigglesworth classification with the Neonatal and Intrauterine deaths Classification according to Etiology modification. The study used descriptive statistics only, specifically counts, means, proportions, and rates, using the statistical software STATA version 15.0 (StataCorp, College Station, TX, USA). In 2017, 489 stillbirths and 238 early neonatal deaths were recorded, resulting in a perinatal mortality rate of 13.6 per 1000 births. About 80% of stillbirths had an unknown cause of death. The majority of stillbirths occurred before the start of labor (85%), and almost one-third were delivered by caesarean section (28%). Prematurity (58%) and congenital malformations (23%) were the main causes of early neonatal deaths, and 70% of early neonatal deaths occurred after the first day of life. The perinatal mortality rate in Georgia remained high in 2017. The major causes of early neonatal deaths were comparable to those of many high-income countries. Contrary to global data, most early neonatal deaths occurred after the first day of life.

Risk factors and classification of stillbirth in a Middle Eastern population: a retrospective study.

To estimate the incidence of stillbirth, explore the associated maternal and fetal factors and to evaluate the most appropriate classification of stillbirth for a multiethnic population. This is a retrospective population-based study of stillbirth in a large tertiary unit. Data of each stillbirth with a gestational age >/=24 weeks in the year 2015 were collected from electronic medical records and analyzed. The stillbirth rate for our multiethnic population is 7.81 per 1000 births. Maternal medical factors comprised 52.4% in which the rates of hypertensive disorders, diabetes and other medical disorders were 22.5%, 20.8% and 8.3%, respectively. The most common fetal factor was intrauterine growth restriction (IUGR) (22.5%) followed by congenital anomalies (21.6%). All cases were categorized using the Wigglesworth, Aberdeen, Tulip, ReCoDe and International Classification of Diseases-perinatal mortality (ICD-PM) classifications and the rates of unclassified stillbirths were 59.2%, 46.6%, 16.6%, 11.6% and 7.5%, respectively. An autopsy was performed in 9.1% of cases reflecting local religious and cultural sensitivities. This study highlighted the modifiable risk factors among the Middle Eastern population. The most appropriate classification was the ICD-PM. The low rates of autopsy prevented a detailed evaluation of stillbirths, therefore it is suggested that a minimally invasive autopsy [postmortem magnetic resonance imaging (MRI)] may improve the quality of care.

The Change of Perinatal Mortality Over Three Decades in a Reference Centre in the Aegean Region: Neonatal Mortality has decreased but Foetal Mortality Remains Unchanged.

Background:Perinatal, foetal and neonatal mortality statistics are important to show the development of a health care system in a country. However, in our country there are very few national and regional data about the changing pattern of perinatal neonatal mortality along with the development of new technologies in this area.Aims:Evaluation of the changes in mortality rates and the causes of perinatal and neonatal deaths within years in a perinatal reference centre which serves a high-risk population.Study Design:Cross-sectional retrospective study.Methods:The perinatal, neonatal and foetal mortality rates in the years 1979-1980 (1st time point) and 1988-1989 (2nd time point) were compared with the year 2008 (3rd time point). The causes of mortality were assessed by Wigglesworth classification and death reports. The neonatal mortality in the neonatal intensive care unit was also calculated.Results:Foetal mortality rates were 44/1000, 31.4/1000 and 41.75/1000 births, perinatal mortality rates were 35.6/1000, 18.8/1000 and 9/1000 births, and neonatal mortality rates were 35.6/1000, 18.8/1000 and 9/1000 live births for the three study time points, respectively. The mortality rate in neonatal intensive care unit decreased consistently from 33%, to 22.6% and 10%, respectively, together with decreasing neonatal mortality rates. The causes of perinatal deaths were foetal death 85%, immaturity 4%, and lethal congenital malformations 8% according to Wigglesworth classification in 2008, showing the high impact of foetal deaths on this high perinatal mortality rate. Infectious causes of neonatal deaths decreased but congenital anomalies increased in the last decades.Conclusion:Although neonatal mortality rate decreased significantly; foetal mortality rate has stayed unchanged since the late eighties. In order to decrease foetal and perinatal mortality rates more efficiently, reducing consanguineous marriages and providing better antenatal care for high risk pregnancies are needed.

Assesment of perinatal mortality in two different periods: results of a single center

This study aimed to investigate the perinatal mortality rate with 37 864 deliveries which occured in two different periods in a single center, to compare the components of perinatal mortality and affecting factors with the results of the study related with perinatal mortality which we conducted in 1999 and to emphasize the precautions directed to reduce mortality rates. All live births and stillbirths which occurred in Bakırköy Obstetrics and Pediatrics Training and Research Hospital between January 2007 and December 2007 were evaluated. The results were compared with the results of the study conducted in 1999. Newborns with a weight above five hundred grams and a gestational age above 22 weeks were enrolled in the study. The stillbirth rate, early neonatal mortality rate, late neonatal mortality rate, perinatal mortality rate and corrected perinatal mortality rate were calculated. Modified Wigglesworth Classification was used for evaluating the perinatal mortality and the subjects were examined in 7 groups. The characteristics belonging to the years of 2007 and 1999 were examined, the differences were recorded and the results were discussed. When the two periods were compared, it was observed that the perinatal mortality rate increased from 23.5‰ to 26‰. When the causes were investigated, it was observed that the stillbirth rate was increased in 2007 (84%) and especially congenital anomalies had an important role in this increment. The early neonatal mortality rate declined from 0.8% in 1999 to 0.4% in 2007. It was found that especially the premature mortality rate (Group 3) and the mortality rate related with perinatal asphyxia (Group 4) were significantly decreased. The decrease in early neonatal mortality rate could be best explained by productive operation of the new neonatal intensive care unit which had been established after 2002.

Unravelling caesarean delivery as a risk factor for antepartum stillbirth.

Caesarean delivery rates have remained persistently high in many high-income countries (Gibbons, World Health Report (2010) Background Paper, No 30). The performance of a caesarean delivery impacts the management of subsequent pregnancies, increasing the likelihood of repeat caesarean delivery. This article reports intriguing results indicating that caesarean delivery in the first pregnancy is an independent risk factor for unexplained antepartum stillbirth in the second pregnancy. The few studies examining previous caesarean delivery as a risk factor for stillbirth have had conflicting results and have limited information available on the cause of the stillbirth. The authors found in a cohort of 128 585 singleton births, an overall 1.5-fold increased risk for unexplained stillbirth at 24 weeks of gestation and beyond in women with previous caesarean delivery and 1.9-fold increase for stillbirth at or after 34 weeks of gestation. A database of all births in Scotland with information on clinical, demographic characteristics and outcomes was linked to the Scottish Stillbirth and Infant Death Survey, a national registry that routinely classifies all perinatal deaths in Scotland based on clinical information obtained from local coordinators and pathologists. The association between previous caesarean delivery and unexplained stillbirth persisted when limited to women whose first birth was at term and regardless of labour duration. In addition to the use of databases containing high-quality data on important covariates, there are other strengths of this study. The cause of stillbirth was uniformly classified using a modification of the Wigglesworth classification. Deaths were classified by a single medically qualified individual, who had access to postnatal investigations and autopsy when performed. Furthermore, small-for-gestational-age birthweight was not regarded as a cause of stillbirth, which is important because in some classification systems it is considered a cause without regard to the true ‘cause’, i.e. the underlying condition that led to small for gestational age resulting in stillbirth. Confirmation through a meta-analysis of three other adequate quality studies bolsters the findings of this study of previous caesarean delivery as a risk factor for antepartum stillbirth. As the authors correctly point out, the absolute risk difference is only 0.1%; 1000 caesarean deliveries would need to be avoided to prevent one additional antepartum stillbirth. However, there are important avenues of future research with potential clinical impact resulting from this study. The potential biological plausibility of an underlying mechanism of abnormal placentation resulting in the increased risk of antepartum stillbirth is important. Caesarean delivery involves the creation of a uterine scar, which is associated with abnormalities of the placenta (e.g. abruption and morbidly adherent placenta), and may affect implantation. Therefore, it is possible that previous caesarean delivery could lead to abnormal placental function leading to stillbirth. The very few women in whom the scar induces impaired placentation could be investigated by ultrasound in their next pregnancy, which might serve to identify women at increased risk. Understanding the physiological changes in uterine blood flow in a subsequent pregnancy in women with a previous caesarean delivery may shed light on placentally based adverse pregnancy outcomes in general. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Trends in Perinatal Mortality in Tribhuvan University Teaching Hospital: 13 Years Review

Introduction: The perinatal mortality rate (PMR) in Nepal is still very high. In major hospitals of Nepal, it is still ranging from 20-30 per thousand births. This study was carried out with the objective to review PMR and classifying it according to Wigglesworth classification to identify the causes of perinatal deaths at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal over the past 13 years and assess need for improvement in care. Material and Methods: It was a retrospective study carried out in TUTH. Data of all stillbirths from 28 weeks of pregnancy and neonatal deaths within first seven days of life in the hospital was taken from monthly perinatal audit and annual mortality review. All the perinatal deaths were then classified according to Wigglesworth classification. Results: Over a 13 year period, there were total 42,746 births and 921 perinatal deaths giving a perinatal mortality of 21.5 per thousand births. Over this period PMR has decreased from 31 to 18 per thousand births. Still births contributed almost 50% of the perinatal deaths; deaths related to prematurity show an increasing trend and have increased by almost 70% in past 5 years. Deaths due to perinatal asphyxia were static. Conclusion: PMR over the years has shown declining trend at TUTH. There is need to improve antenatal, obstetric as well as intrapartum services to further reduce the still birth as well as deaths due to prematurity and perinatal asphyxia. J. Nepal Paediatr. Soc. 32(2) 2012 150-153 doi: http://dx.doi.org/10.3126/jnps.v32i2.6898

1368 Perinatal Mortality Rate of SelÇUK ÜNiversity Faculty of Medicin in Year of 2008

ObjectiveOur purpose was to determine the perinatal mortality rate of our hospital in 2008.Material and MethodsWe evaluated newborns who were born alive or dead with a birth weight of more...

The study of etiological and demographic characteristics of neonatal mortality and morbidity - a consecutive case series study from Pakistan.

BackgroundTo determine the etiology, management, bacteriological spectrum and outcome of neonatal patients admitted in Civil Hospital Karachi (CHK) and to examine the factors associated with it.MethodsThis hospital based descriptive study of 1463 patients from both sexes who were admitted to Paediatric department, CHK from 1st January 2008 till 31st December 2010 with an established cause according to modified Wigglesworth classification and fulfilling other inclusion criteria were included in the study. Data regarding their demographic profile and potential risk factors was collected on a well structured proforma. Cases were followed until discharge or expiry. Data was analyzed using descriptive statistics.ResultsThe male to female ratio in our study was 1.12:1. Seven hundred and thirty-four patients were delivered at home (50.2%) and 1010 were less than 7 days old (69%). Out of the total cohort of expired subjects, 89 participants (74.8%) were < 7 days of life. Mortality was more in neonates born at home in rural areas to illiterate mother; 74 patients (62.2%). Most of the deaths; 57 were in neonates suffering from specific infections (47.9%) followed by 38 deaths in immaturity group (31.9%) and 19 related to asphyxial conditions (15.9%). The most common isolates were Staphylococcus aureus (28.7%) followed by Klebsiella (24.8%) and Pseudomonas aeruginosa (16.6 ). One hundred and nineteen (8.13%) of the neonates died in our study group.ConclusionsThese results suggest that neonates with illiterate mothers with high parity and below average socioeconomic level were more susceptible to mortality in the early neonatal period. Most of the cases of mortality were due to specific infections.

Cause-specific neonatal mortality in a neonatal care unit in Northern Tanzania: a registry based cohort study

BackgroundThe current decline in under-five mortality shows an increase in share of neonatal deaths. In order to address neonatal mortality and possibly identify areas of prevention and intervention, we studied causes of admission and cause-specific neonatal mortality in a neonatal care unit at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.MethodsA total of 5033 inborn neonates admitted to a neonatal care unit (NCU) from 2000 to 2010 registered at the KCMC Medical Birth Registry and neonatal registry were studied. Clinical diagnosis, gestational age, birth weight, Apgar score and date at admission and discharge were registered. Cause-specific of neonatal deaths were classified by modified Wigglesworth classification. Statistical analysis was performed in SPSS 18.0.ResultsLeading causes of admission were birth asphyxia (26.8%), prematurity (18.4%), risk of infection (16.9%), neonatal infection (15.4%), and birth weight above 4000 g (10.7%). Overall mortality was 10.7% (536 deaths). Leading single causes of death were birth asphyxia (n = 245, 45.7%), prematurity (n = 188, 35.1%), congenital malformations (n = 49, 9.1%), and infections (n = 46, 8.6%). Babies with birth weight below 2500 g constituted 29% of all admissions and 52.1% of all deaths. Except for congenital malformations, case fatality declined with increasing birth weight. Birth asphyxia was the most frequent cause of death in normal birth weight babies (n = 179/246, 73.1%) and prematurity in low birth weight babies (n = 178/188, 94.7%). The majority of deaths (n = 304, 56.7%) occurred within 24 hours, and 490 (91.4%) within the first week.ConclusionsBirth asphyxia in normal birth weight babies and prematurity in low birth weight babies each accounted for one third of all deaths in this population. The high number of deaths attributable to birth asphyxia in normal birth weight babies suggests further studies to identify causal mechanisms. Strategies directed towards making obstetric and newborn care timely available with proper antenatal, maternal and newborn care support with regular training on resuscitation skills would improve child survival.

The changing pattern of perinatal mortality and causes of death in central Anatolian region of Turkey

In this study, the perinatal mortality is presented in 2009 compared to 1998. Changing patterns of the perinatal mortality rate (PNMR), the stillbirth rate (SBR), early neonatal mortality rate (ENMR) and the causes of the perinatal mortality in Zekai Tahir Burak Women’s Health Education and Research Hospital (ZTBH) were described. This is the largest maternity hospital of Ankara in the central Anatolian region of Turkey. The total deliveries were 22,777 and 18,567 in 1998 and 2009, respectively. PNMR was 27.7 per 1000, and SBR was 23.7 per 1000 total births. ENMR was 4 per 1000 in 1998. PNMR is 20.7 per 1000, and SBR was 16.3 per 1000 and ENMR was 4.6 per 1000 total births in 2009. It is important to know the causes of mortality. In this study, the causes of perinatal deaths were classified according to the Wigglesworth classification. Antepartum stillbirth (62.3%) was the most frequent cause in 1998. Perinatal asphyxia is the majority (46.6%) of the perinatal deaths in 2009. This study shows that even prenatal care is getting better, obstetric care as well as close follow-up throughout the intrapartum period and diminishing the preterm delivery rate is also important for preventing and reducing perinatal mortality.

P1-153 Assessment of the leading causes of infant mortality in Brazil in 1998 and 2008

Brazil had an estimated infant mortality rate (IMR) of 30.4 per 1000 live births in 1998 which declined to 19.8 in 2008; in the latter 68% of all infant deaths...

The usefulness of blood tests for investigating cause of stillbirth: do they provide additional information to postmortem and placental pathology?

AimTo examine the usefulness of blood tests in classifying cause of stillbirth by providing new, supplementary or confirmatory information to gold standard postmortem and placental pathology.MethodsRetrospective study of 204 consecutive...

Socio-economic inequalities in the rate of stillbirths: a population based study

To investigate socioeconomic inequalities in stillbirth rates in England national population data were used on all singleton stillbirths 1997–2007. Causes of stillbirth were coded according to the extended Wigglesworth classification...

Ulcerative tracheitis among intubated neonates—A clinicopathologic study

Objective To determine frequency of ulcerative tracheitis (UT) among intubated neonates and identify groups of neonates at greater risk of UT. Methods Medical histories and autopsy findings from 232 neonates between 1995 and 2006 were reviewed retrospectively. All neonates were treated at the Department of Neonatology, Clinical Hospital Center Split. Autopsies and histological examinations were performed at the Clinical Department of Pathology, Forensic Medicine and Cytology. Neonates were classified into groups based on their sex, gestational age, survival time and cause of death, duration and reasons for intubation. Simplified Wigglesworth classification was used to determine cause of death. C hi-squared test and multiple logistical regression analysis were used for statistical analysis. Results UT was found in 44 cases (18.96%). The main risk factor for UT development was duration of intubation, especially if it lasted over 96 h ( P = 0.005). Higher frequency of UT was noted in neonates with gestational age over 37 weeks ( P = 0.002) and birth weight over 2500 g ( P = 0.115). Conclusion Our study has shown that the main risk factor for UT development was intubation duration exceeding 96 h. Term-borns, and neonates with normal birth weight both have higher risk of UT. High risk groups should be observed carefully and alternative respiratory support treatment, such as continues positive airway pressure (CPAP) may be considered.

Características biológicas e evitabilidade de óbitos perinatais em uma localidade na cidade do Rio de Janeiro, 1999 a 2003

OBJETIVOS: analisar os óbitos perinatais de uma maternidade pública do município do Rio de Janeiro, Brasil, quanto à características biológicas, critérios de evitabilidade, causas básicas e mortalidade por faixas de peso. MÉTODOS: o estudo de coorte foi realizado de 1999 a 2003, na Maternidade Leila Diniz do Hospital Municipal Raphael de Paula Souza, que é responsável por 50% dos partos de uma área programática 4 (Jacarepaguá e Barra da Tijuca). Foram incluídos óbitos perinatais com peso igual ou superior a 500 g. O instrumento principal de coleta de dados foi a Ficha de Investigação de Óbito Perinatal. Foi aplicada a Classificação de Wigglesworth para avaliar evitabilidade. RESULTADOS: houve 512 óbitos perinatais (377 fetais e 135 neonatais precoces). Os óbitos neonatais se concentraram nos primeiros três dias de vida. Vinte e quatro por cento dos óbitos cursaram com retardo de crescimento intra-uterino. As principais causas foram afecções maternas (hipertensão e sífilis) e complicações de membrana, placenta e cordão. Foram considerados evitáveis cerca de 50% dos óbitos. CONCLUSÕES: o percentual de óbitos evitáveis foi elevado, mais concentrado nos óbitos fetais ocorridos antes do parto, sugerindo inadequação do pré-natal.

Ethnic differences in perinatal mortality: A perinatal audit on the role of substandard care

Objectives The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality. Study design Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA—28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard. Results In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks’ gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups ( p = 0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements). Conclusions The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates.

A Placental Cause of Intra-uterine Fetal Death Depends on the Perinatal Mortality Classification System Used

Different classification systems for the cause of intra-uterine fetal death (IUFD) are used internationally. About two thirds of these deaths are reported as unexplained and placental causes are often not addressed. Differences between systems could have consequences for the validity of vital statistics, for targeting preventive strategies and for counselling parents on recurrence risks. Our objective was to compare use of the Tulip classification with other currently used classification systems for causes of IUFD. We selected the extended Wigglesworth classification, modified Aberdeen and the classifications by Hey, Hovatta, de Galan-Roosen and Morrison. We also selected the ReCoDe system for relevant conditions, comparable to contributing factors in the Tulip classification. Panel classification for 485 IUFD cases in the different systems was performed by assessors after individual investigation of structured patient information. Distribution of cases into cause of death groups for the different systems varied, most of all for the placental and unknown groups. Systems with a high percentage of cases with an unknown cause of death and death groups consisting of clinical manifestations only are not discriminatory. Our largest cause of death group was placental pathology and classification systems without placental cause of death groups or minimal subdivision of this group are not useful in modern perinatal audit as loss of information occurs. The most frequent contributing factor was growth restriction. This illustrates the vital role of the placenta in determination of optimal fetal development. In the Tulip classification, mother, fetus and placenta are addressed together. The system has a clear defined subclassification of the placenta group, a low percentage of unknown causes and is easily applied by a multidisciplinary team. A useful classification aids future research into placental causes of IUFD.

Social Inequalities in Perinatal Mortality in Belo Horizonte, Brazil: The Role of Hospital Care

We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city of Belo Horizonte, Brazil. We used a cohort study of all births (40953) and perinatal deaths (826) in Belo Horizonte in1999. After adjusting for maternal education and birthweight, we compared mortality rates according to hospital category--defined by a hospital's relation to the national Universal Public Health System (SUS)--and quality of care. We used the Wigglesworth Classification to examine perinatal deaths. After we controlled for birthweight and maternal education, the highest perinatal death rates were observed in private and philanthropic SUS-contracted hospitals (relative to private, non-SUS-contracted hospitals). Hospital quality was also directly associated with perinatal death rates. Mortality rates were especially high for normal-birthweight babies born in private SUS-contracted hospitals. Intrapartum asphyxia was the leading cause of preventable death. In a class-segregated health care system, such as Brazil's, disparities in quality of care between SUS-contracted and non-SUS-contracted hospitals contribute to the unacceptably high rates of perinatal mortality.