Advertisement

Associations between provider-assigned Apgar score and neonatal race

Published:August 03, 2022DOI:https://doi.org/10.1016/j.ajog.2022.07.055

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Apgar V.A.
        A proposal for a new method of evaluation of the newborn infant.
        Anesth Analg. 2015; 120 (Originally published in July 1953, volume 32, pages 250-259): 1056-1059
        • Apgar V.A.
        • Holaday D.A.
        • James L.S.
        • Weisbrot I.M.
        • Berrien C.
        Evaluation of the newborn infant; second report.
        J Am Med Assoc. 1958; 168 (–8): 1985
        • Ehrenstein V.
        Association of Apgar scores with death and neurologic disability.
        Clin Epidemiol. 2009; 1: 45-53
        • American Academy of Pediatrics Committee on Fetus and Newborn, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE
        The Apgar score.
        Pediatrics. 2015; 136: 819-822
        • Committee Opinion No
        644: the Apgar score.
        Obstet Gynecol. 2015; 126: e52-e55
        • Weinberger B.
        • Anwar M.
        • Hegyi T.
        • Hiatt M.
        • Koons A.
        • Paneth N.
        Antecedents and neonatal consequences of low Apgar scores in preterm newborns: a population study.
        Arch Pediatr Adolesc Med. 2000; 154: 294-300
        • Davis D.A.
        Obstetric racism: the racial politics of pregnancy, labor, and birthing.
        Med Anthropol. 2019; 38: 560-573
        • Yang C.
        • Chen X.
        • Zu S.
        • He F.
        Retrospective analysis of risk factors for low 1-minute Apgar scores in term neonates.
        Braz J Med Biol Res. 2019; 52e9093
        • Alkozei A.
        • McMahon E.
        • Lahav A.
        Stress levels and depressive symptoms in NICU mothers in the early postpartum period.
        J Matern Fetal Neonatal Med. 2014; 27: 1738-1743
        • Vanderbilt D.
        • Bushley T.
        • Young R.
        • Frank D.A.
        Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit: a preliminary study.
        J Dev Behav Pediatr. 2009; 30: 50-56
        • Busse M.
        • Stromgren K.
        • Thorngate L.
        • Thomas K.A.
        Parents’ responses to stress in the neonatal intensive care unit.
        Crit Care Nurse. 2013; 33: 52-59
        • Kim Y.
        • Ganduglia-Cazaban C.
        • Chan W.
        • Lee M.
        • Goodman D.C.
        Trends in neonatal intensive care unit admissions by race/ethnicity in the United States, 2008-2018.
        Sci Rep. 2021; 1123795
        • Peterson B.L.
        • Harrell F.E.
        Partial proportional odds models for ordinal response variables.
        Applied Statistics. 1990; 39: 205-217
        • Harrison W.
        • Goodman D.
        Epidemiologic trends in neonatal intensive care, 2007-2012.
        JAMA Pediatr. 2015; 169: 855-862
        • Ziegler K.A.
        • Paul D.A.
        • Hoffman M.
        • Locke R.
        Variation in NICU admission rates without identifiable cause.
        Hosp Pediatr. 2016; 6: 255-260
        • Harrison W.N.
        • Wasserman J.R.
        • Goodman D.C.
        Regional variation in neonatal intensive care admissions and the relationship to bed supply.
        J Pediatr. 2018; 192: 73-79.e4
        • Sjoding M.W.
        • Dickson R.P.
        • Iwashyna T.J.
        • Gay S.E.
        • Valley T.S.
        Racial bias in pulse oximetry measurement.
        N Engl J Med. 2020; 383: 2477-2478
        • Monk Jr., E.P.
        Colorism and physical health: evidence from a national survey.
        J Health Soc Behav. 2021; 62: 37-52
        • Meissner C.A.
        • Brigham J.C.
        Thirty years of investigating the own-race bias in memory for faces: a meta-analytic review.
        Psychol Public Policy Law. 2001; 7: 3-35