Apgar Score and Neonatal Mortality in China: an Observational Study from a National Surveillance System

Background: To examine the association between the Apgar score and neonatal mortality over gestational age in China and to explore whether this association changed when Apgar scores were combined at 1 and 5 min.

Methods: Data for all singleton live births collected from 438 hospitals between 2012 and 2016 were used in this study. Poisson regression with a robust variance estimator adjusted for a complete set of confounders was used to describe the strength of the association between the Apgar score and neonatal mortality.

Results: The relative risks of neonatal death-associated intermediate Apgar score at 5 min peaked at 39-40 weeks of gestation and subsequently decreased if the gestational age increased to 42 weeks or above, in contrast to the low Apgar score. Among both preterm and term new-borns with Apgar scores at 5 min, new-borns that were not small for gestational age had a lower mortality rate than those that were small for gestational age. The association between Apgar score and the neonatal mortality was even stronger when scores at 1 and 5 min were combined.

Conclusions: Apgar score is not only meaningful for preterm new-borns but also useful for term new-borns, especially term new-borns that are not small for gestational age. Once the baby's Apgar score worsens, timely intervention is needed. There is still a gap between China and high-income countries in terms of sustained treatment of new-borns with low Apgar scores.