Prevalence and Associated Factors for Low Apgar Score in Central Sudan: A Cross-Sectional Study

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.

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 al ⁹ 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
	Characters	Number = 35	Number = 403
		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
	Less than secondary	25 (71.4)	241 (59.8)	1.68 (0.79-3.59)
Residence	Urban	11 (31.4)	194 (48.1)	1	.062
	Rural	24 (68.6)	209 (51.9)	2.03 (0.97-4.24)
Maternal employment status	Housewife	32 (91.4)	346 (85.9)	1	.364
	Employed	3 (8.6)	57 (14.1)	0.57 (0.17-1.92)
Medical disorders	No	30 (85.7)	375 (93.1)	1	.123
	Yes	5 (14.3)	28 (6.9)	2.23 (0.80-6.20)
Anemia	No	19 (54.3)	154 (38.2)	1	.066
	Yes	16 (54.7)	249 (61.8)	0.52 (0.26-1.04)
Meconium-stained liquor	No	32 (91.4)	385 (95.5)	1	.285
	Yes	3 (8.6)	18 (4.5)	2.01 (0.56-7.17)
Time of membrane rupture	Intrapartum	31 (88.6)	346 (85.9)	1	.657
	Pre-labor	4 (11.4)	57 (14.1)	0.78 (0.27-2.30)
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
	Yes	4 (11.4)	78 (19.4)	0.54 (0.18-1.57)
History of stillbirth	No	33 (94.3)	378 (93.8)	1	.908
	Yes	2 (5.7)	25 (6.2)	0.92 (0.21-4.04)
Low birth weight	No	4 (11.4)	279 (69.2)	1	˂.001
	Yes	31 (88.6)	124 (30.8)	17.44 (6.03-50.46)
Sex of the newborn	Male	15 (42.9)	198 (49.1)	1	.477
	Female	20 (57.1)	205 (50.9)	1.29 (0.64-2.59)

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
	<Secondary	0.93	0.34-2.52
Residence	Urban	1		.129
	Rural	2.08	0.81-5.38
Medical disorders	No	1		.076
	Yes	2.94	0.89-9.67
Anemia	No	1		.392
	Yes	0.71	0.32-1.56
Low birth weight	No	1		˂.001
	Yes	17.61	5.98-51.88

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 al ²⁹ 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 al ³⁰ 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.