Objectives <p>The WHO recommends implementing the Maternal and Perinatal Death Surveillance and Response (MPDSR) cycle to evaluate and reduce perinatal mortality. We aimed to (1) assess Suriname’s national perinatal mortality rate (PMR), (2) classify perinatal death causes, (3) investigate contributing modifiable factors.</p> Methods <p>A nationwide, prospective cohort study of perinatal deaths in Suriname (June - December 2022). We conducted surveillance, classified causes of death and conducted audits, as part of the MPDSR cycle. We audited a random selection of cases and used quantitative analysis to report modifiable factors.</p> Results <p>We identified 83 (53%) stillbirths and 72 (47%) neonatal deaths. The PMR was 28.2 per 1000 total births. Stillbirths occurred antenatally in 80% (<i>n</i> = 66/83), of which 49% (<i>n</i> = 32/66) of unknown cause. Leading causes of antepartum stillbirth were placental insufficiency and placental abruption (combined 37.8%, <i>n</i> = 25), often linked to hypertensive disorders of pregnancy (HDP) (<i>n</i> = 19). In 23 neonatal death cases, missing files hindered cause classification. Congenital anomalies (29%, <i>n</i> = 14/49) and infections (22%, <i>n</i> = 11/49) were primary causes of neonatal deaths. We reviewed 63 cases and identified 150 modifiable factors, half of which related to quality-of-care, including suboptimal antenatal care and substandard neonatal life support. Delays in seeking care and shortages of supplies and staff also contributed significantly.</p> Conclusions <p>To decrease perinatal mortality, we suggest enhancing antenatal and neonatal care, by improved ultrasound, better triage, mitigating the impact of HDP, and upgrading neonatal respiratory support. Furthermore, policymakers should prioritize improving access to care, availability of trained staff and sustainable implementation of the MPDSR cycle.</p>