摘要：Objectives . We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city of Belo Horizonte, Brazil. Methods . 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. Results . 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. Conclusions . 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. Brazil has a persistently high infant mortality rate (22.5 deaths/1000 live births in 2003) 1 that disproportionately affects the disadvantaged population. Most of the country’s infant and perinatal deaths are because of conditions originating during the perinatal period that are considered preventable through access to quality health care. Although there are important regional disparities, most births (97%) take place in hospitals, and 77% are assisted by doctors. A high proportion of perinatal and infant deaths occur within the first hours after birth (30% in the first 24 hours of life), which suggests the importance of the level of hospital care. Brazil’s Universal Public Health System (Sistema Único de Saúde, or SUS), which covers the medical expenses of almost 80% of the country’s population, relies on private hospitals contracted to SUS (37%), as well as hospitals run by the philanthropic sector (27%) and the government (36%). 2 Private hospitals not contracted to SUS (non-SUS) provide care for the remaining minority who can afford private health insurance or direct payment. Consequently, there is a clear association between socioeconomic status and the type of health facility used. Hospital type can therefore be a marker for socioeconomic status, 3 , 4 and it can also be an indicator of health care quality. 5 Socioeconomic disparities in the quality of hospital care may in turn explain perinatal mortality differentials. Few studies have examined socioeconomic inequalities in perinatal mortality in Brazil, however, and quality of hospital care has not yet been systematically assessed. We analyzed the role of hospital quality at the time of delivery and birth and its contribution to the high perinatal mortality rates in the city of Belo Horizonte. Situated in the more developed southeast region of Brazil, Belo Horizonte is the country’s fourth largest city, with 2.2 million inhabitants. We focused on the differential in perinatal mortality rate between hospital categories (SUS vs non-SUS hospitals) and quality of hospital care. Our ultimate goal was to provide public health policymakers with information that can guide the planning and implementation of measures to improve the health care system and reduce disparities in infant and perinatal mortality.
