Background
For decades, the Apgar scoring system has been used to evaluate neonatal status and
determine need for resuscitation or escalation in care, such as admission to a neonatal
intensive care unit. However, the variation and accuracy of provider-assigned Apgar
scores across neonatal racial groups have yet to be evaluated.
Objective
This study aimed to investigate how provider-assigned Apgar scores vary by neonatal
race independently of clinical factors and umbilical cord gas values.
Study Design
We conducted a retrospective cohort study at an urban academic medical center. All
live births at ≥23 weeks and 0 days of gestation from January 1, 2019 through December
31, 2019 with complete data available were included. Data were queried from the electronic
medical record and included race, ethnicity, gestational age of neonate, umbilical
cord gas values (umbilical artery pH and base deficit), admission to the neonatal
intensive care unit, and presence of maternal–fetal complications. Primary outcome
measures were neonates’ Apgar scores at 1 and 5 minutes. Color Apgar score and admission
to the neonatal intensive care unit served as secondary outcome measures. We performed
3 partially proportional ordinal regression models controlling for an increasing number
of covariates, with Model 1, the baseline model, adjusted for gestational age, Model
2 additionally adjusted for umbilical cord gases, and Model 3 additionally adjusted
for maternal medical conditions and pregnancy complications.
Results
A total of 977 neonates met selection criteria; 553 (56.6%) were Black. Providers
assigned Black neonates significantly lower Apgar scores at 1 minute (odds ratio,
0.63; 95% confidence interval, 0.49–0.80) and 5 minutes (odds ratio, 0.64; 95% confidence
interval, 0.47–0.87), when controlling for umbilical artery gases, gestational age,
and maternal–fetal complications. This difference seemed related to significantly
lower assigned color Apgar scores at 1 minute when controlling for all the above factors
(odds ratio, 0.52; 95% confidence interval, 0.39–0.68). Providers admitted full-term
Black neonates to the neonatal intensive care unit at higher rates than non-Black
neonates when controlling for all factors (odds ratio, 1.29; 95% confidence interval,
0.94–1.77). Black neonates did not have more abnormal cord gas values (mean umbilical
artery pH of 7.259 for Black vs 7.256 for non-Black neonates), which would have supported
their admission to the neonatal intensive care unit.
Conclusion
Providers applied inaccurate Apgar scores to Black neonates given that the umbilical
cord gases were not in agreement with lower Apgar scores. These inaccuracies may be
a factor in unnecessary admissions to neonatal intensive care units, and suggest that
colorism and racial biases exist among healthcare providers.
Key words
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Article info
Publication history
Published online: August 03, 2022
Accepted:
July 28,
2022
Received in revised form:
July 20,
2022
Received:
January 5,
2022
Footnotes
The authors report no conflict of interest.
The project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH; grant number UL1TR002003). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Cite this article as: Edwards SE, Wheatley C, Sutherland M, et al. Associations between provider-assigned Apgar score and neonatal race. Am J Obstet Gynecol 2023;228:229.e1-9.
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