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Abstract

Objective:

To evaluate the prevalence and factors associated with low fifth-minute Apgar scores in central Sudan.

Methods:

A cross-sectional study (enrolled 438 newborns) was conducted at Wad Medani Hospital, Sudan. A questionnaire was used to collect sociodemographic, obstetric, clinical, and neonatal data. Apgar scores were calculated. A multivariate analysis was performed.

Results:

Thirty-five (8.0%) newborns had low fifth-minute Apgar scores. The multivariate analysis showed that low birth weight was the only factor associated with a low fifth-minute Apgar score (AOR = 17.61; 95% CI: 5.98-51.88). Maternal age, parity, education level, history of miscarriage, residence, maternal body mass index, mode of delivery, maternal anemia, time of the membrane’s rupture, color of liquor, and newborn sex were not associated with a low fifth-minute Apgar score.

Conclusion:

The present study showed that 8.0% of newborns delivered at anonymized peer review had a low fifth-minute Apgar score, which was associated with low birth weight.

Keywords

low fifth-minute Apgar score prevalence age newborn Sudan

Introduction

In 2022, the World Health Organisation (WHO) reported 2.3 million neonatal deaths worldwide, with the highest mortality rate (27 deaths per 1000 live births) reported in sub-Saharan Africa.¹ Preterm birth, birth asphyxia, birth trauma, neonatal infections, and congenital anomalies are the reported leading causes of neonatal death.¹ In sub-Saharan Africa, it has been estimated that approximately 280 000 neonatal mortalities occur during the first day of life because of birth asphyxia.² In addition to the high mortality rate, birth asphyxia is responsible for considerable neonatal morbidities due to severe hypoxic-ischemic multi-organ damage.³ The immediate effects of birth asphyxia include neonatal hypoxia, hypercarbia, acidosis, hypotension, and ischemia. Long-term morbidities include cerebral palsy, motor disorders, developmental delays, speech delays, hearing impairments, blindness, feeding impairment, learning disabilities, mental retardation, and behavioral and emotional disorders.³

In 1952, Dr. Virginia Apgar invented a scoring system for assessing the clinical status of newborn infants. This system provides a standardized assessment for infants after delivery to identify those who require resuscitation.^4,5 The Apgar score assesses 5 variables: heart rate, breathing effort, muscle tone and movement, skin color or oxygenation, and reflex response to irritable stimuli. Each variable receives a score of 0, 1, or 2, with a total score ranging from 0 to 10. A total Apgar score of 7 to 10 is considered “normal,” while a total score below 7 is considered a “low score.” Low Apgar scores indicate reduced vitality and a need for medical assistance.⁶

Apgar scores are typically recorded at 1 minute and 5 minutes after birth. The 1-minute Apgar score determines the need for immediate resuscitation efforts, and the 5-minute score assesses the baby’s response to the performed resuscitation attempts.⁷ Low fifth-minute Apgar scores are more frequent and are associated with increased risks of neonatal mortality and morbidity.⁶ A low fifth-minute score has also been connected to long-term neurologic disability, reduced cognitive function, and even subtle cognitive impairment.⁸ In one particular study, Njie et al⁹ reported lower Apgar scores among neonates with birth asphyxia compared to those without the condition. The fifth-minute Apgar score has also been found to be a better predictor of neonatal outcomes than the Apgar score at the first minute.^6,10

A range of what could be considered lower fifth-minute Apgar score rates has been reported in African countries.^8,11
-13 Several factors, such as low birth weight (LBW),^6
-8,11,12 sex of the newborn^14,15 and medical disorders during pregnancy have been associated with low fifth-minute Apgar scores.

There are no published data on low fifth-minute Apgar scores in Sudan. In 2022, the prevalence of neonatal mortality in Sudan was reported at 21.9%, and approximately 21.0% of these cases were due to birth asphyxia.¹⁶ Although the levels of child and infant mortality in Sudan are among the highest in the region and the world,¹⁷ the prevalence of low fifth-minute Apgar scores and their determinants have not yet been investigated in this context. Accordingly, this study aimed to identify the prevalence and factors associated with low fifth-minute Apgar scores among newborns delivered at Medani Maternity Hospital in Gezira State, central Sudan. The findings of this study will help design contextual interventions to improve maternal and neonatal care, reduce the risk of low Apgar scores, and improve newborn outcomes.

Materials and Methods

Study Setting and Design

Wad Medani Maternity Hospital is located in Wad Medani, Gezira State. It lies on the west bank of the Blue Nile, 186 km southeast of Khartoum, the capital of the state. It is the largest government-run maternity hospital in Gezira State. The hospital provides services to all women in the state, and the hospital staff provides antenatal and postnatal clinics free of charge.

This cross-sectional study of newborns delivered at Wad Medani Maternity Hospital anonymized peer review from October to December 2023. The guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative were strictly followed.¹⁸

Outcome Measures

The main outcome measure was the prevalence of newborns with a fifth-minute Apgar score ˂ 7 in the study population. The secondary outcome was the sociodemographic, obstetric, and clinical factors associated with an Apgar score ˂ 7 in the fifth minute.

Inclusion and Exclusion Criteria

All live singleton newborns delivered at Wad Medani Maternity Hospital after 24 weeks of gestation during the study period were enrolled in the study. Multiple pregnancies, stillbirths, newborns referred from other institutions, those with unknown gestational age at birth, those with incomplete records, and newborns with gross congenital anomalies were excluded.

Sample Size Calculation

The sample size of 438 newborns was computed using the OpenEpi Menu.¹⁹ Since there were no data on the prevalence of low fifth-minute Apgar scores in Sudan, we assumed that 18.0% of the newborns would have low fifth-minute Apgar scores. Our assumption was based on the prevalence of low fifth-minute Apgar scores in Ethiopia.^8,11 We then assumed that 30.0% and 50.0% of the newborns who were delivered vaginally and by cesarean, respectively, would have low fifth-minute Apgar scores. The calculated sample size 500 had 80.0% power, a 95.0% confidence interval (CI), and a P-value of .05.

Sampling Technique

A systematic random sampling technique was used to enroll the desired sample size. According to the hospital’s records, 1800 live newborns were delivered during the 3 months preceding the study. Therefore, a sampling interval of 4 was calculated by dividing the expected number of deliveries (1800) by the sample size (1800/438 = 4). Eligible newborns were therefore included in the study at 4 intervals during the study period until the required sample size (438) was reached.

Data Collection

All women who delivered during the study period and whose newborns fulfilled the inclusion criteria were interviewed within 24 hours after delivery. Before the interviews, participants were informed about the study’s purpose and procedures and signed a written consent form.

Data were collected daily. The general hospital policy was to discharge women 4 to 6 hours after vaginal delivery and 3 to 7 days after cesarean delivery. A questionnaire was used to collect sociodemographic, clinical, and obstetrical data via face-to-face interviews (Additional File 1). Two medical doctors received 2 days of theoretical and practical training on data collection tools, interview techniques, confidentiality, and the study’s objective and relevance. The sociodemographic, medical, obstetric, and newborn characteristics collected included age, parity, residence, educational level, occupation, history of miscarriage, history of stillbirth, medical disorders during the current pregnancy (pregnancy-induced hypertension, preeclampsia or superimposed preeclampsia, and gestational diabetes), hemoglobin level at term, time of rupture of membranes (intrapartum/pre-labor), presence of meconium-stained liquor, mode of delivery (vaginal delivery, elective cesarean delivery, or emergency cesarean delivery), neonatal birth weight, and newborn gender. The last normal menstrual period date was used to determine the gestational age at delivery. The women’s weight and height were measured using standard procedures, and their body mass index (BMI) was computed.

The Apgar score was assessed in terms of the heart rate (≥100 beats/minute = 2 points, ˂100 = 1 point, none = 0 points), respiratory rate (good crying = 2 points, weak crying = 1 point, none = 0 points), muscle tone (active = 2 points, some flexion of extremities = 1 point, limp = 0 points), reflex irritability (active = 2 points, grimace = 1 point, no response = 0 points), and skin color/oxygenation (pink = 2 points, bluish extremities = 1 point, totally blue = 0 point). After calculating the Apgar score, it was then classified as “low” if <7 and “normal” if ≥7.

Statistical Analysis

Data were analyzed in version 24.0 of the Statistical Package for the Social Sciences® (SPSS®) for Windows (SPSS Inc., New York, United States). Categorized data were expressed as frequencies (%). A Shapiro–Wilk test was used to evaluate the normality of the continuous variables, which were not normally distributed and expressed as medians (interquartile range [IQR]). Univariate analysis was conducted with a low Apgar score (yes, no) as the dependent variable. The independent variables were age, parity, BMI, residence, educational level, occupation, history of miscarriage, history of stillbirth, medical disorders during the current pregnancy, hemoglobin level at term, time of membrane rupture, presence of meconium-stained liquor, mode of delivery, LBW, and newborn sex. We used those variables with a P-value <.2 to build a binary multivariate model and thus rule out confounders. Odds ratios (ORs) and 95% CIs were calculated as they were applied. A two-sided P-value of <.05 was considered statistically significant.

Ethics approval and consent to participate: The study received ethical approval from the Research Board of the Faculty of Medicine, University of Gezira, Sudan (reference number 2023, #6). Written informed consent was obtained from all enrolled women in accordance with the Human Rights Declaration of Helsinki.

Results

General Characteristics

During the study period, 438 women with newborns were recruited. The median (IQR) of the maternal age, parity, and BMI were 28.5 (18.0-45.0) years, 3 (2-4), and 31.80 (26.70-43.80) kg/m², respectively. Out of the 438 participants, 172 (39.3%) women had secondary education or more, 205 (46.8%) were living in urban areas, 60 (13.7%) were employed, 82 (18.7%) had a history of miscarriage, and 27 (6.2) had a history of stillbirth.

Of the 438 women, 26 (5.9%) had hypertensive disorders (PIH, preeclampsia, or superimposed preeclampsia), 7 (1.6%) had gestational diabetes, 265 (60.5%) had maternal anemia (hemoglobin less than 11 g/dl), 61 (13.9%) had pre-labor rupture of membranes, 21 (4.8%) had meconium-stained amniotic fluid, and 262 (59.8%) had delivered by cesarean (both emergency and elective). One hundred and fifty-five (35.4%) newborns had a birth weight ˂ 2.5 kg (LBW), and 213 (48.6%) were males.

Prevalence and Factors Associated with Low Apgar Score

Of the 438 newborns, 35 (8.0%) had a fifth-minute Apgar score ˂ 7.

Table 1 shows the univariate analysis of the participants’ sociodemographic, medical, and obstetric characteristics and their associations with a low fifth-minute Apgar score. The results revealed that only LBW was associated with a low fifth-minute Apgar score (OR = 17.44; 95% CI: 6.03-50.46), while age, parity, BMI, residence, educational level, occupation, history of miscarriage, history of stillbirth, medical disorders, maternal anemia, mode of delivery, time of rupture of membranes, presence of meconium-stained liquor, and newborn gender were not associated with a low score.

Table 1.

Univariate Analysis of Factors Associated with a Fifth-minute Apgar score ˂ 7 in 438 Newborns in Gezira State, Central Sudan, 2023 Anonymized Peer Review.

Variables		Newborns with the fifth-minute Apgar score ˂ 7	Newborns with a fifth-minute Apgar score ≥ 7	Odds ratio (95% confidence interval)	P-value
Variables	Characters	Number = 35	Number = 403	Odds ratio (95% confidence interval)	P-value
		Median (interquartile of)
Maternal age, years		27.0 (18.0-42.0)	29.0 (18.0-45.0)	0.96 (0.91-1.01)	.130
Parity		3 (1-4)	3 (2-4)	0.88 (0.71-1.09)	.228
Body mass index, kg/m²		31.25 (26.50-33.40)	31.89 (26.70-34.85)	0.98 (0.91-1.04)	.454
	Frequency (proportion) of
Maternal education level	Secondary or more	10 (28.6)	162 (40.2)	1	.181
Maternal education level	Less than secondary	25 (71.4)	241 (59.8)	1.68 (0.79-3.59)	.181
Residence	Urban	11 (31.4)	194 (48.1)	1	.062
Residence	Rural	24 (68.6)	209 (51.9)	2.03 (0.97-4.24)	.062
Maternal employment status	Housewife	32 (91.4)	346 (85.9)	1	.364
Maternal employment status	Employed	3 (8.6)	57 (14.1)	0.57 (0.17-1.92)	.364
Medical disorders	No	30 (85.7)	375 (93.1)	1	.123
Medical disorders	Yes	5 (14.3)	28 (6.9)	2.23 (0.80-6.20)	.123
Anemia	No	19 (54.3)	154 (38.2)	1	.066
Anemia	Yes	16 (54.7)	249 (61.8)	0.52 (0.26-1.04)	.066
Meconium-stained liquor	No	32 (91.4)	385 (95.5)	1	.285
Meconium-stained liquor	Yes	3 (8.6)	18 (4.5)	2.01 (0.56-7.17)	.285
Time of membrane rupture	Intrapartum	31 (88.6)	346 (85.9)	1	.657
Time of membrane rupture	Pre-labor	4 (11.4)	57 (14.1)	0.78 (0.27-2.30)	.657
Mode of delivery	Vaginal	26 (74.3)	150 (37.2)	1
	Elective cesarean	7 (20.0)	228 (56.6)	2.17 (0.48-9.70)	.312
	Emergency cesarean	2 (5.7)	25(6.2)	0.38 (0.08-1.95)	.248
History of miscarriage	No	31 (88.6)	325 (80.6)	1	.256
History of miscarriage	Yes	4 (11.4)	78 (19.4)	0.54 (0.18-1.57)	.256
History of stillbirth	No	33 (94.3)	378 (93.8)	1	.908
History of stillbirth	Yes	2 (5.7)	25 (6.2)	0.92 (0.21-4.04)	.908
Low birth weight	No	4 (11.4)	279 (69.2)	1	˂.001
Low birth weight	Yes	31 (88.6)	124 (30.8)	17.44 (6.03-50.46)	˂.001
Sex of the newborn	Male	15 (42.9)	198 (49.1)	1	.477
Sex of the newborn	Female	20 (57.1)	205 (50.9)	1.29 (0.64-2.59)	.477

In the multivariate logistic regression analysis, LBW (AOR = 17.61; 95% CI: 5.98-51.88) was found to be associated with a low fifth-minute Apgar score, while other factors (age, educational level, residence, medical disorders, and hemoglobin level at term) were not connected with a low score (Table 2).

Table 2.

Multivariate Analysis of Factors Associated with Fifth-minute Apgar Score ˂ 7 in 438 Newborns in Gezira State, Central Sudan, 2023 Anonymized Peer Review.

Variable	Characters	Adjusted odds ratio	95% confidence interval	P-value
Maternal age		0.99	0.94-1.05	.809
Maternal education level	≥Secondary	1		.878
Maternal education level	<Secondary	0.93	0.34-2.52	.878
Residence	Urban	1		.129
Residence	Rural	2.08	0.81-5.38	.129
Medical disorders	No	1		.076
Medical disorders	Yes	2.94	0.89-9.67	.076
Anemia	No	1		.392
Anemia	Yes	0.71	0.32-1.56	.392
Low birth weight	No	1		˂.001
Low birth weight	Yes	17.61	5.98-51.88	˂.001

Discussion

The present study showed 8.0% of newborns had low fifth-minute Apgar scores. The prevalence of low fifth-minute Apgar scores in this study is similar to the rate (9.5%) of low fifth-minute Apgar scores reported in North Tanzania.²⁰ At the same time, our results are lower than other regional results from northwest Ethiopia (ie, 13.8% and 18.1%),^8,11 Southwest Ethiopia (11.5%),¹² and Nigeria (16.6%).¹³ However, the prevalence of low fifth-minute Apgar scores in the prevalence study is higher than the rate of 1.9% reported in Ghana.²¹ A nationwide Dutch study revealed a significant increase in the proportion of infants with low fifth-minute Apgar scores over the last decade from 1.04% to 1.42%,²² but these figures remain much lower than the rate detected in this study. Another large nationwide survey conducted in 96 hospitals from 24 Chinese provinces found substantial regional differences in the incidence of low Apgar scores and suggested region-specific maternal and obstetric risk factors as a cause for these differences.²³ Likewise, other studies have suggested racial and regional variations when describing the prevalence and association of neonatal asphyxia and low Apgar scores with infant mortality.^24,25 Perhaps ethnic, sociodemographic, and cultural factors also play essential roles in these regional disparities.

This study showed that LBW was associated with a low fifth-minute Apgar score. Several researchers have also reported this association.^{6
-8,11,12,20} In Ghana, both preterm delivery (<37 weeks gestation) and LBW are associated with increased odds of a low fifth-minute Apgar score.¹⁵ Besides prematurity and intrauterine growth restriction, the known causes of LBW,²⁶ other factors, such as low antenatal care attendance, lacking iron/folic acid supplementation, and maternal anemia,²⁷ may play an important role. Generally, the pathophysiology of LBW is unclear, but insufficient placental perfusion and fetal nutrition may affect the fetus’s overall anthropometric parameters,²⁸ thereby resulting in increased newborn liability to complications.

Although maternal age, education, residence, anemia, and medical disorders (hypertensive disorders and gestational diabetes) were not associated with low fifth-minute Apgar scores in our cohort, they were found to be connected in previous studies. For instance, Almeida et al²⁹ found that maternal educational level was associated with the risk of a low fifth-minute Apgar score. Male gender of the newborn and cesarean delivery were also associated with increased odds of a low fifth-minute Apgar score in other studies.^14,15 Pregnancy-induced hypertension and preeclampsia have been connected to low fifth-minute Apgar scores by many researchers.^4,6,11 However, Susilo et al³⁰ found no significant association between hypertensive disorders and the fifth-minute Apgar score. Nevertheless, they did demonstrate an association between severe preeclampsia and early onset preeclampsia with low Apgar scores at 1 minute.³⁰ Rural residence and anemia during pregnancy have also been reported as determinants of low fifth-minute Apgar scores in Ethiopia.⁷

Limitations

This single hospital-based study might not reflect the exact situation in other hospitals in the community or other regions. The questionnaire was not pilot-tested. Furthermore, fetal or neonatal arterial blood gas was not accessed. We also did not obtain specific details about labor or assess the effects of a low fifth-minute Apgar score on perinatal morbidity and mortality.

Conclusion

The prevalence of a low fifth-minute Apgar score in the present study was 8%, lower than the records from neighboring African countries. LBW was found to be an independent determinant of a low fifth-minute Apgar score. Other factors, such as age, parity, BMI, residence, educational level, occupation, history of miscarriage, history of stillbirth, medical disorders, maternal anemia, mode of delivery, time of rupture of membranes, presence of meconium-stained liquor, and newborn gender, that have been reported in other studies were not associated with low fifth-minute Apgar scores in our study. In designing interventions to improve the general survival and thus the Apgar scores of newborns, measures to diagnose and prevent LBW should be of great concern. Nevertheless, further research on other low Apgar score determinants is still needed.

Supplemental Material

sj-docx-1-gph-10.1177_30502225251324290 – Supplemental material for Prevalence and Associated Factors for Low Apgar Score in Central Sudan: A Cross-Sectional Study

Supplemental material, sj-docx-1-gph-10.1177_30502225251324290 for Prevalence and Associated Factors for Low Apgar Score in Central Sudan: A Cross-Sectional Study by Nagat B. Elhag, Albagir M. Hassan, Khalid Nasralla, Nadiah AlHabardi and Ishag Adam in Sage Open Pediatrics

Footnotes

Acknowledgements

We want to thank all the women who participated in the study.

ORCID iD

Nagat B. Elhag

Statements and Declarations

References

WHO. Newborn Mortality. WHO. Published 2024. Accessed May 25, 2024. https://www.who.int/news-room/fact-sheets/detail/newborn-mortality

Gebregziabher

Hadgu

Abebe

HT.

Prevalence and associated factors of perinatal asphyxia in neonates admitted to Ayder Comprehensive Specialized Hospital, Northern Ethiopia: a cross-sectional study. Int J Pediatr. 2020;2020:1-8. doi:10.1155/2020/4367248

Bayih

Birhane

Belay

, et al. The state of birth asphyxia in Ethiopia: an umbrella review of systematic review and meta-analysis reports, 2020. Heliyon. 2021;7(10):e08128. doi:10.1016/J.HELIYON.2021.E08128

Abebe

Tebeje

Gugsa

, et al. Factors associated with low fifth minute Apgar score among newborns delivered at public health facilities of Dilla town, southern Ethiopia, 2022. Int J Afr Nurs Sci. 2024;20:100656. doi:10.1016/J.IJANS.2024.100656

Simon

Shah

Bragg

. APGAR score. [Updated 2024 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. https://www.ncbi.nlm.nih.gov/books/NBK470569/

Ajibo

Wolka

Aseffa

, et al. Determinants of low fifth minute Apgar score among newborns delivered by cesarean section at Wolaita Sodo University Comprehensive Specialized Hospital, southern Ethiopia: an unmatched case control study. BMC Pregnancy Childbirth. 2022;22(1):665. doi:10.1186/S12884-022-04999-Z

Yeshaneh

Kassa

, et al. The determinants of 5th minute low Apgar score among newborns who delivered at public hospitals in Hawassa City, South Ethiopia. BMC Pediatr. 2021;21(1):266. doi:10.1186/S12887-021-02745-6/TABLES/6

Gudayu

TW.

Proportion and factors associated with low fifth minute Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia. Afr Health Sci. 2017;17(1):1-6. doi:10.4314/AHS.V17I1.2

Njie

Nyandiko

Ahoya

Moutchia

JS.

A comparative analysis of APGAR score and the gold standard in the diagnosis of birth asphyxia at a tertiary health facility in Kenya. PLoS One. 2023;18(5):e0285828. doi:10.1371/JOURNAL.PONE.0285828

10.

Jeganathan

Karalasingam

Hussein

Allotey

Reidpath

DD.

Factors associated with recovery from 1 minute Apgar score <<4 in live, singleton, term births: an analysis of malaysian national obstetrics registry data 2010-2012. BMC Pregnancy Childbirth. 2017;17(1):110. doi:10.1186/S12884-017-1293-9

11.

Zewude

Ajebe

Gessesse

Wassie

TH.

Proportion and predictive factors of low apgar score at five minute among singleton term neonates delivered in Debre Tabor specialized hospital, northwest Ethiopia: a cross-sectional study. Int J Afr Nurs Sci. 2021;15:100322. doi:10.1016/J.IJANS.2021.100322

12.

Getachew

Etefa

Asefa

Terefe

Dereje

Determinants of low fifth minute Apgar score among newborn delivered in Jimma University Medical Center, Southwest Ethiopia. Int J Pediatr. 2020;2020:9896127. doi:10.1155/2020/9896127

13.

Makinde

Awotundun

Osegi

Rate and determinants of low fifth minute Apgar score at the federal medical centre Yenagoa, Bayelsa State, Nigeria. Int J Reprod Contracept Obstet Gynecol. 2023;12(7):1960-1968. doi:10.18203/2320-1770.IJRCOG20231904

14.

Junior

LCM

Pinto

Gerencer

Pro

ECG

de Carvalho

. Association of maternal, fetal and labor variables with a low apgar score in the fifth minute in term pregnancy: a case–control study. Arch Gynecol Obstet. 2023;308(5):1473-1483. doi:10.1007/S00404-022-06832-6/TABLES/5

15.

Abukari

Awuni

Yakubu

Mohammed

Yakubu

Factors associated with low fifth minute Apgar score in term and preterm singleton live births in a Ghanaian hospital. J Neonatal Nurs. 2021;27(6):476-482. doi:10.1016/J.JNN.2021.06.011

16.

Ahmed

MAA

Mahgoub

Al-Nafeesah

Al-Wutayd

Adam

. Neonatal mortality and associated factors in the neonatal intensive care unit of Gadarif Hospital, Eastern Sudan. Child. 2022;9(11):1725. doi:10.3390/CHILDREN9111725

17.

Bashir

Ibrahim

Bashier

Adam

Neonatal mortality in Sudan: analysis of the Sudan household survey, 2010. BMC Public Health. 2013;13(1):287. doi:10.1186/1471-2458-13-287

18.

von Elm

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

JP.

The strengthening the reporting of observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-349. doi:10.1016/j.jclinepi.2007.11.008

19.

OpenEpi Menu. Accessed January 1, 2022. https://www.openepi.com/Menu/OE_Menu.htm

20.

Tarimo

Bhuyan

Zhao

, et al. Prediction of low Apgar score at five minutes following labor induction intervention in vaginal deliveries: machine learning approach for imbalanced data at a tertiary hospital in North Tanzania. BMC Pregnancy Child-birth. 2022;22(1):275. doi:10.1186/S12884-022-04534-0/FIGURES/6

21.

Dassah

Odoi

Opoku

BK.

Stillbirths and very low apgar scores among vaginal births in a tertiary hospital in Ghana: a retrospective cross-sectional analysis. BMC Pregnancy Childbirth. 2014;14(1):289. doi:10.1186/1471-2393-14-289/TABLES/3

22.

Tacke

Onland

Bakker

PCAM

, et al. Increasing trends in a low 5-min Apgar score among (near) term singletons: a Dutch nationwide cohort study. J Perinatol. 2024;44(2):217-223. doi:10.1038/S41372-023-01786-2

23.

Wang

Chen

Ming

, et al. Epidemiology and region-specific risk factors for low apgar scores in China: a nationwide study. World J Pediatr. 2022;18(2):135-141. doi:10.1007/S12519-021-00497-Y/METRICS

24.

Gillette

Boardman

Calvert

John

Stock

SJ.

Associations between low Apgar scores and mortality by race in the United States: a cohort study of 6,809,653 infants. PLoS Med. 2022;19(7):e1004040. doi:10.1371/JOURNAL.PMED.1004040

25.

Workineh

Semachew

Ayalew

Animaw

Tirfie

Birhanu

Prevalence of perinatal asphyxia in East and Central Africa: systematic review and meta-analysis. Heliyon. 2020;6(4):e03793. doi:10.1016/j.heliyon.2020.e03793

26.

Kale

Fonseca

SC.

Intrauterine growth restriction, prematurity, and low birth weight: risk phenotypes of neonatal death, Rio de Janeiro State, Brazil. Cad Saude Publica. 2023;39(6):e00231022. doi:10.1590/0102-311XPT231022

27.

Khanal

Bista

Lee

AH.

Examining the combined effect of antenatal care visits and iron-folic acid supplementation on low birth weight: a pooled analysis of two national data sets from Nepal. BMC Pregnancy Childbirth. 2024;24(1):612. doi:10.1186/S12884-024-06807-2

28.

Lubrano

Parisi

Coco

Marelli

Burello

Cetin

Associations between maternal nutritional status, hemodynamic parameters, and delivery outcomes in low-risk pregnancies: a prospective observational study. Nutrients. 2024;16(2):183. doi:10.3390/NU16020183

29.

Almeida

NKO

Pedreira

Almeida

RMVR

. Impact of maternal education level on risk of low Apgar score. Public Health. 2016;140:244-249. doi:10.1016/J.PUHE.2016.04.009

30.

Susilo

Pratiwi

Fattah

ANA

Irwinda

Wibowo

Determinants of low APGAR score among preeclamptic deliveries in Cipto Mangunkusumo Hospital: a retrospective cohort study in 2014. Med J Indones. 2015;24(3):183-189. doi:10.13181/MJI.V24I3.1229

Supplementary Material

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