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Editor,—In São Paulo, Brazil, 0.6% of all births do not occur in a hospital. Although neonatal mortality in home deliveries in the UK is higher than that in hospital deliveries, it is accepted that home births consist of two different groups: those who planned to deliver at home with higher average birth weight and low neonatal mortality, and those who either booked a hospital delivery or did not book, with lower birth weight and extremely high neonatal mortality.1 In São Paulo, home deliveries are not encouraged and there is no policy of booking in the state sector.
As part of a study of neonatal mortality in the city of São Paulo, a case-control study is being undertaken to investigate maternal and hospital risk factors. For the first six months of 1995, birth certificates were identified and linked to all neonatal deaths and a 10% sample of children who survived up to 28 days. Children with birth weight under 500 g were excluded.
The study included 9583 births with known place of birth, of which 64 did not occur in a hospital. In our data, children who were not born in a hospital had an increased risk of neonatal death (odds ratio 1.93 with 95% confidence intervals 1.02, 3.63; χ2=4.88; p<0.03). A significantly higher proportion of mothers of children not born in a hospital were teenagers (<20 years) and had not completed primary education (eight years). There were no statistically significant differences according to the proportion of low birth weight, prematurity, and whether a father was named in the birth certificate, but the study may not have had enough power (table1).
The risk associated with delivery not in a hospital was restricted to mothers of lower educational status and much more marked in younger mothers. In Chile, home deliveries presented a higher neonatal mortality and were more frequent in teenagers.2 Campbellet al 3 suggests a pattern similar to ours in England and Wales and quotes the example of illegitimate births at home to women aged under 20, who had 5% chance neonatal death.4 It seems that the risk of neonatal mortality in deliveries not in a hospital is complex and further studies are needed before we can establish when home deliveries are safe in São Paulo.
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