Abstract
Background: The Apgar score is used worldwide to assess the newborn infant shortly after birth. Apgar scores, including mean scores and those with high cut-off scores, have been used to support claims that planned home birth is as safe as hospital birth. The purpose of this study was to determine the distribution of 5 min Apgar scores among different birth settings and providers in the USA.
Methods: We obtained data from the National Center for Health Statistics of the US Centers for Disease Control birth certificate data for 2007–2010 for all singleton, term births of infants weighing ≥2500 g (n=13,830,531). Patients were then grouped into six categories by birth setting and birth attendant: hospital-based physician, hospital-based midwife, freestanding birth center with either certified nurse midwife and/or other midwife, and home-based delivery with either certified nurse midwife or other midwife. The distribution of each Apgar score from 0 to 10 was assessed for each group.
Results: Newborns delivered by other midwives or certified nurse midwives (CNMs) in a birthing center or at home had a significantly higher likelihood of a 5 min maximum Apgar score of 10 than those delivered in a hospital [52.63% in birthing centers, odds ratio (OR) 29.19, 95% confidence interval (CI): 28.29–30.06, and 52.44% at home, OR 28.95, 95% CI: 28.40–29.50; CNMs: 16.43% in birthing centers, OR 5.16, 95% CI: 4.99–5.34, and 36.9% at home births, OR 15.29, 95% CI: 14.85–15.73].
Conclusions: Our study shows an inexplicable bias of high 5 min Apgar scores of 10 in home or birthing center deliveries. Midwives delivering at home or in birthing centers assigned a significantly higher proportion of Apgar scores of 10 when compared to midwives or physicians delivering in the hospital. Studies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with skepticism by obstetricians and midwives, by pregnant women, and by policy makers. The continued use of studies using higher mean or high cut-off 5 min Apgar scores, and a bias of high Apgar score, to advocate the safety of home births is inappropriate.
Funding source: Funding: Funding was provided by the Department of Obstetrics and Gynecology at New York Weill Cornell Medical Center.
Acknowledgments
We thank Kate Sapra for her support in the statistical analysis.
References
[1] Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team. Br Med J. 1996;313:1313–8.10.1136/bmj.313.7068.1313Search in Google Scholar PubMed PubMed Central
[2] Amelink-Verburg MP, Verloove-Vanhorick SP, Hakkenberg RM, Veldhuijzen IM, Bennebroek Gravenhorst J, Buitendijk SE. Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG. 2008;115:570–8.10.1111/j.1471-0528.2007.01580.xSearch in Google Scholar PubMed
[3] American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. The Apgar Score. Pediatrics. 2006;117:1444.10.1542/peds.2006-0325Search in Google Scholar PubMed
[4] American College of Nurse-Midwives. Position statement on Home Births. Washington, DC. http://www.washingtonmidwives.org/for-consumers/position-statements-home-birth.html. Accessed 7 November, 2013.Search in Google Scholar
[5] Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32:260.10.1213/00000539-195301000-00041Search in Google Scholar
[6] Apgar V. The newborn (Apgar) scoring system: reflections and advice. Pediatr Clin North Am. 1965;13:699.10.1016/S0031-3955(16)31874-0Search in Google Scholar
[7] Apgar V, Holaday DA, James LS, Weisbrot IM, Berrien C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958;168:1985–8.10.1001/jama.1958.03000150027007Search in Google Scholar PubMed
[8] Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209:325.e1–8.10.1016/j.ajog.2013.06.022Search in Google Scholar PubMed
[9] Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epidemiologic statistics for public health, version 2.3.1. Updated June 23, 2011. Available at: www.OpenEpi.com. Accessed 18 July, 2013.Search in Google Scholar
[10] DiGiuseppe DL, Aron DC, Ranbom L,Harper DL, Rosenthal GE. Reliability of birth certificate data: a multi-hospital comparison to medical records information. Mat Child Health J. 2002;6:169–79.10.1023/A:1019726112597Search in Google Scholar
[11] Eastman NJ, Hellman LM. Williams Obstetrics. 13th ed. New York: Appleton-Century-Crofts; 1966.Search in Google Scholar
[12] Fujita. The process of childbirth and the neonatal APGAR score. Kango. 1966;18:121–9. [In Japanese].Search in Google Scholar
[13] Grünebaum A, McCullough LB, Sapra KJ, Brent RL, Levene MI, Arabin B, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209:323.e1–6.10.1016/j.ajog.2013.06.025Search in Google Scholar PubMed
[14] Krokfors E, Wist A, Hirvensalo M. Effect of duration of labour, age and parity on the Apgar score of the newborn infant. Ann Chir Gynaecol Fenn Suppl. 1963;52:1–14.Search in Google Scholar
[15] MacDorman ME, Declercq E, Menacker F. Trends and Characteristics of home births in the United States by race and ethnicity, 1990–2006. Birth. 2011;38:17–23.10.1111/j.1523-536X.2010.00444.xSearch in Google Scholar PubMed
[16] Mehl LE, Peterson GH, Whitt M, Hawes WE. Outcomes of elective home births: a series of 1,146 cases. J Reprod Med. 1977;19:281–90.Search in Google Scholar
[17] Northam S, Knapp TR. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs. 2006;35:3–12.10.1111/j.1552-6909.2006.00016.xSearch in Google Scholar PubMed
[18] Nove A, Berrington A, Matthews Z. The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death. Midwifery. 2012;28:619–26.10.1016/j.midw.2012.07.009Search in Google Scholar
[19] Olsen O. Meta-analysis of the safety of home birth. Birth. 1997;24:4–13.10.1111/j.1523-536X.1997.tb00330.xSearch in Google Scholar
[20] Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012;9:CD000352.10.1002/14651858.CD000352.pub2Search in Google Scholar
[21] Royal College of Midwives (RCM) and the Royal College of of Obstetricians and Gynaeologists. Joint Statement No. 2, April, 2007.Search in Google Scholar
[22] Shearer JM. Five year prospective survey of risk of booking for a home birth in Essex. Br Med J (Clin Res Ed). 1985;291:1478–80.10.1136/bmj.291.6507.1478Search in Google Scholar
[23] Teczyńska T, Matusiak J. Value of the Apgar score in determining the prognosis of the infant’s health and life. Ginekol Pol. 1965;36:1033–8.Search in Google Scholar
[24] van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktasş S, Steegers EA, et al. Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol. 2011;118:1037–46.10.1097/AOG.0b013e3182319737Search in Google Scholar
[25] Vinikoor LC, Messer LC, Laraia BA, Kaufman JS. Reliability of variables on the North Carolina birth certificate: a comparison with directly queried values from a cohort study. Paediatr Perinat Epidemiol. 2010;24:102–112.10.1111/j.1365-3016.2009.01087.xSearch in Google Scholar
[26] Weyers H. The standardized evaluation of newborn infants using the Apgar score. Dtsch Schwesternztg. 1966;19:320–2. [In German].Search in Google Scholar
[27] Wiegers TA, Keirse MJ, Berghs GA, van der Zee J. An approach to measuring quality of midwifery care. J Clin Epidemiol. 1996;49:319–25.10.1016/0895-4356(95)00549-8Search in Google Scholar
[28] Wiegers TA, Keirse MJ, van der Zee J, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ. 1996;23:1309–13.10.1136/bmj.313.7068.1309Search in Google Scholar PubMed PubMed Central
[29] Zollinger TW, Przybylski MJ, Gamache RE. Reliability of Indiana birth certificate data compared to medical records. Ann Epidemiol. 2006;16:1–10.10.1016/j.annepidem.2005.03.005Search in Google Scholar PubMed
The authors stated that there are no conflicts of interest regarding the publication of this article.
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