Use and implications of the Apgar score in evaluating resuscitation of newborns with birth asphyxia in a lower-middle-income country

Abstract

Background: The Helping Babies Breathe (HBB) programme has been used worldwide to address neonatal mortality due to birth asphyxia in low resource countries. We aimed to use the Apgar score to evaluate the impact of the programme on neonatal mortality in three district and one regional hospital in Ghana, a lower middle-income country.

Methods: We used Apgar scores as an objective measure of newborn infants' condition soon after birth and their response to resuscitation, with the assessment carried out primarily by midwives who were trained in HBB. We analysed correlations between Apgar scores and mortality in newborns ≥34 weeks gestation who had birth asphyxia (BA), i.e. a one-minute Apgar score <7, and severe BA, i.e. a one-minute Apgar score ≤3.

Results: Over the 18-month period from October 2019 to March 2021, 12 995 newborns were delivered at ≥34 weeks gestation or with a birth weight of at least 2000 grams. There were 12 702 live births and 293 stillbirths, of which 134 were intrapartum stillbirths. Among the live births, 2387(18.9%) had BA, including 352 (2.8%) who had severe BA. There was no significant difference in the trend of cases of severe BA or deaths due to BA in the four hospitals, either individually or combined, but there was a 55% decline in intrapartum stillbirths, from 1.6% to 0.89% (P = 0.03). Although many babies with BA showed improvement in Apgar scores with resuscitation efforts, the mortality rate among 352 newborns with severe BA was 15.6% - twenty times higher than in the 2045 newborns with a one-minute Apgar score of 4-6, among whom 0.78% died (P < 0.001). The mortality rate in newborns with severe BA was higher in those whose scores remained ≤3 than in those whose scores rose to 4-6 or more at five minutes (odds ratio = 19.93, 95% confidence interval = 9.4-42.1, P < 0.0001).

Conclusions: The Apgar score provides valuable information about where additional interventions may decrease BA related neonatal mortality in low- and middle-income countries.

Figure 1

Trends in percentage of cases of BA, severe BA, deaths from BA, and intrapartum stillbirths in the four Ghana hospitals combined. BA – birth asphyxia.

Figure 2

Improvement in Apgar score to 7 or more by five minutes in newborns who had one-minute Apgar scores <7 in the four Ghana hospitals over 18 months.

Figure 3

Changes in Apgar scores at 5 minutes of age in newborns who had one minute Apgar scores <7.