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Prevalence and factors associated with low 5th minute APGAR score among mothers who birth through emergency cesarean section: prospective cross-sectional study in Ethiopia

BMC Pregnancy and Childbirth volume 25, Article number: 342 (2025) Cite this article

Abstract

Background

Apgar score is a method to assess the status of the baby immediately after delivery. It also used to assess the response to and overall the prognosis of the resuscitations. In Ethiopia Birth asphyxia is the one leading cause of neonatal mortality and morbidity. The APGAR score especially the 5th minute one has strong prediction of the neonatal outcome than the 1st minute APGAR score so this study focuses on identifying the prevalence and factors associated with of 5th minute APGAR score among mothers who gave birth through cesarean section in Wolkite University specialized hospital in January to June 2023 G.C.

Methods

Institution based prospective cross-sectional study was conducted by using convenience sampling on 270 Mothers, who gave birth through cesarean section in Wolkite University specialized hospital from January 1– June 30 2023 GC. The data collection was conducted through meticulous chart review and interviews. Data were entered using Epi data 7 and analyzed with SPSS 26. The association between independent variables and the 5th minute APGAR was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at P-value < 0.05.

Results

Total of 270 mothers were included and the prevalence of low fifth minute APGAR score 27.4%. multivariate logistic regression analysis showed that the predictors of low 5th minute APGAR score are fetal heart beat before intervention( bradycardia ( AOR = 9.1; 95% CI: 3.8,21.9),tachycardia ( AOR = 3.7; 95% CI: 1.5,9.8)), meconium stained Amniotic fluid (AOR = 3.0; 95% CI: 1.5,6.2), labor duration greater than 24 h ( AOR = 11.2; 95% CI: 3.9, 31.9), low birth weight( AOR = 4.3; 95% CI: 1.7,10.3).

Conclusion

A low APGAR score is highly prevalent. Fetal heart beat before intervention, meconium stained Amniotic fluid, labor duration greater than 24 h, low birth weight are statistically significant predictors of poor APGAR. Enhancing the early obstetric interventions like electronic fetal monitoring, use of partograph, and timely cesarean sections as well as early neonatal resuscitation techniques might mitigate the risk of complications linked with low APGAR scores.

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Back ground

The APGAR score is the method to assess the status of the neonate in the first minutes of life [1]. It has been used in maternity to assess the newborn infant’s overall status and response to resuscitation for more than half a century since its first introduction to delivery practice [2]. The score uses 5 important parameters to evaluate the status, which are breathing, muscle tone, skin color, heart rate, and reflex irritability, each scored on a scale from 0 to 2 [3]. It is a well-known, easy, and accepted method of assessing the neonate so far. The final score of the assessment is out of 10, so if the score is less than 7, it is considered a low APGAR score. Commonly, the 1st and 5th minutes APGAR scores are used to assess the status of the neonate; however, the measurement can be extended to the 10th, 15th, and 20th minutes if a low APGAR score is recorded and further resuscitation is needed [1]. It should not be used to determine the need for initial resuscitation, what steps are next, and when to do them [4]. According to the Neonatal Encephalopathy and Neurologic Outcome report, a 5-minute APGAR score of 7 to 10 is reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is low in the term infant and late-preterm infant [5].

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) recommend the use of the APGAR score along with resuscitative interventions, known as the expanded APGAR score [1]. However, the application of the APGAR score in contemporary obstetric practice has been questioned by many organizations and studies. Concerns include its poor predictability, interobserver variations, and geographic discrepancies in reporting [6]. Additionally, the APGAR score’s applicability to premature infants is problematic, and there is uncertainty about how to score infants during resuscitation. Due to these and other concerns, some scholars advocate for its removal from clinical practice [7, 8]. Nevertheless, until better recommendations and methods that address these limitations are developed, the APGAR score will continue to be used [8]. Despite its limitations, the APGAR score remains widely used in clinical practice. Its simplicity and historical significance make it a valuable tool, especially in settings where advanced resources may not be readily available [1, 9, 10]. However, it is crucial to continue exploring and developing new methods that address the APGAR score’s limitations, ensuring that neonatal assessment practices evolve to provide the best care possible [6, 8].

Low APGAR scores are related to neonatal mortality and morbidity, as well as a significantly higher future risk of cerebral palsy, ranging from 20 to 200-fold [11]. Although APGAR score methods are not intended to predict individual neurologic outcomes of the neonate, babies with low APGAR scores have 4.02 odds of adverse neurologic outcomes such as cerebral palsy [11], epilepsy, mental retardation, and lower academic achievement in secondary school [12]. Infants with low APGAR scores have 3.0, 2.5, and 9.5 higher odds of neonatal respiratory distress, the use of mechanical ventilation, and admission to the neonatal intensive care unit, respectively [13], as well as a 46% higher risk of childhood cancer [14]. There are many factors that can influence the APGAR score, such as prematurity, congenital anomalies, maternal drugs, hypovolemia, hypoxia, and infection [2]. Birth asphyxia is the most common cause and contributes to around 38% of cases of low APGAR scores, especially when the score is below four [15]; however, it should not be diagnosed based on the presence of a low APGAR score alone [1]. The score measured at the 5th minute has a stronger prediction of long- and short-term neonatal outcomes than the first-minute APGAR score [3, 16].

According to one study from the USA that was conducted across different races, the prevalence of low APGAR scores among term babies was 1.1% [17]. However, the reality is different in reports from African countries, with a prevalence of 9.5% in Tanzania [18], 23% in Kenya [8], 16.6% in Nigeria [19], and 2.27% in Rwanda [20]. The prevalence of low APGAR scores in the Ethiopian system ranges from 11% in Jimma and Hawassa [21, 22], 13.8% in Gondar [23], 18.1% in Debre Tabor [24], 31.85% in Arbaminch town [25], with an overall prevalence in the country of 23% [26]. There are many different antepartum and intrapartum factors associated with low APGAR scores in Ethiopia and other African countries, such as meconium-stained amniotic fluid [24], emergency cesarean Sects. [26, 27], antepartum hemorrhage [27], birth weight [23, 28], gestational age [24], duration of labor [21], fetal presentation [24], lack of ANC follow-up [29], and skin incision to delivery time [26, 27, 30].

After extensive work done by global institutions and local governments through the expansion of emergency obstetric care services across the countries, there has been a substantial improvement in neonatal care. However, Ethiopia still has a high neonatal mortality rate of 30 per 1,000 live births, as stated in the demographic health survey of the country, with regional variabilities [31]. Ethiopia is far behind in achieving the sustainable development goal [27]. In developed and high-income countries, it has been shown that improving intrapartum care significantly enhances maternal and neonatal outcomes. Key strategies include performing early cesarean sections when indicated, using partographs to monitor labor progress, employing electronic fetal monitoring to track fetal well-being, and scaling up early neonatal resuscitation services by training healthcare professionals and adequately equipping health institutions [32]. These measures collectively reduce complications and improve overall health outcomes for mothers and their newborns. Since a low 5th-minute APGAR score is a good predictor of neonatal mortality and morbidity, it is very important to identify factors associated with it to design strategies that can be applied to the Ethiopian system to reduce neonatal mortality and morbidity.

Methodology

Study area, design, sampling and populations

An institution-based prospective cross-sectional study was conducted at Wolkite University Specialized Hospital (WUSH) from January 1 to June 30, 2023. The hospital is located in the Gurage zone of south-central Ethiopia, 160 km southwest of Addis Ababa. It serves a population of over 5 million people in south-central Ethiopia, including the Gurage zone. The average monthly delivery rate was 150, with a 38% emergency cesarean section rate. All mothers who gave birth through emergency cesarean section and were eligible were included in the study. The sample size was calculated using a single population proportion, with a prevalence of low 5th-minute APGAR scores of 19% [24], a 95% confidence interval, and a margin of error of 5% from other studies in Ethiopia, resulting in a total sample size of 270, including the non-response rate. All mothers who gave birth through emergency cesarean section were selected using a convenience sampling technique.

Exclusion criteria: Mothers who gave birth by emergency cesarean delivery with one of the following conditions were excluded from the study: those who had a fetus with a gross lethal congenital anomaly that was diagnosed pre-operatively or post-operatively, breech presentations, those with a negative fetal heartbeat on admission, and mothers who declined or were unable to provide medical history due to any medical disease or obstetric complication.

Duty hours: Any hours beyond 8:00 AM -5:00 PM are considered duty hours, during which only emergency cases are managed.

Data collection instruments

The data collection instruments were created following a thorough review of the literature. The study included the following variables: sociodemographic characteristics, obstetric details, and perioperative and peripartum factors. After developing the structured questionnaire, we pre-tested it at Butajira Hospital with a sample comprising 5% of the study’s intended sample size. This pre-test allowed us to make necessary modifications to improve the questionnaire. The purpose and significance of the study were thoroughly explained to the participants by the data collectors. Following the acquisition of informed consent, data collection commenced. Data collectors with previous experience in data collection were specifically recruited and trained by the principal investigator. For this purpose, three midwives were selected. They received comprehensive training and were supervised daily by the authors. Data collection involved chart reviews and in-depth interviews with the mothers, ensuring a thorough and reliable gathering of information.

Data processing and analysis

The analysis was conducted using EPI Info for data entry and cleansing, followed by exporting the data to SPSS 26 for further analysis and association. By running frequency distribution, data were rechecked for any missing variables during entry. The results were presented through descriptive analysis, frequency distribution, tables, and chi-square. Each variable was independently analyzed through bivariate logistic regression to check for any association with the outcome variable, which is the low fifth-minute APGAR score. Variables that showed a significant association in the bivariate analysis (p-value < 0.05 and 95% CI) were then included in a multivariate analysis to further assess the strength of these associations. Model fitness was evaluated using the Hosmer and Lemeshow goodness of fit test and the Nagelkerke R Square, with values of 0.64 and 0.58, respectively. To check for multicollinearity among the explanatory variables, the Variance Inflation Factor (VIF) was used, with a threshold of VIF > 10 indicating potential multicollinearity. No significant multicollinearity was detected, ensuring the reliability of the regression coefficients.

Result

Sociodemographic characteristics

A total of 270 patients participated in the study, resulting in a 100% response rate. The prevalence of low 5th-minute APGAR scores was 27.4% (74). The majority of participants were aged between 20 and 35 years (92%) and were married (98%). Nearly two-thirds of the participants resided in urban areas (see Table 1).

Table 1 Social demographic characteristics of mothers among those mothers who gave birth through emergency Cesarean section at WKUSH from January -June 2023
Full size table

Health institution and obstetric related factors

Term pregnant mothers comprises the majority (84%) of the participants. Almost all (99%) mother had antenatal care follow up (ANC) of whom, 74% had ANC follow up at health center or private clinics. (Table 2). More than half of the mothers were admitted to the hospital as referral case from other institutions and 60% of the cases were referred from the government hospitals. (Table 2)

Table 2 Health institution and obstetric related factors among those mothers who gave birth through emergency Cesarean section at WKUSH from January -June 2023
Full size table

Intrapartum and operation related factors

Most emergency surgeries were performed during duty hours (56%), in the latent phase of labor (51%), under spinal anesthesia (93%), and for vertex presentations (89%). While half of the cases had a decision-to-delivery time within 30 to 60 min, more than half of the cases had a skin incision-to-delivery time of less than 5 min. (Table 3)

Table 3 Intrapartum and operation related factors among those mothers who gave birth through emergency Cesarean section at WKUSH from January -June 2023
Full size table

Factors associated with low 5th minute APGAR scores

All the factors were analyzed individually for any significance of association with low APGAR score so upon bivariate analysis, only factors like fetal weight, gestational age, labor duration, fetal heart beat abnormalities, type of anesthesia, stage of labor, labor duration, and meconium stained amniotic fluid showed strong association with low 5th minutes APGAR score. Subsequently the above variables were analyzed further by using multivariate analysis then only the following factors fetal heart beat before intervention( bradycardia ( AOR = 9.1; 95% CI: 3.8,21.9),tachycardia ( AOR = 3.7; 95% CI: 1.5,9.8)), meconium stained Amniotic fluid (AOR = 3.0; 95% CI: 1.5,6.2), labor duration greater than 24 h ( AOR = 11.2; 95% CI: 3.9, 31.9), low birth weight( AOR = 4.3; 95% CI: 1.7,10.3). The results of the study indicate that a low fifth-minute APGAR score is strongly associated with intrapartum-related factors. This underscores the crucial importance of providing high-quality intrapartum obstetric care and immediate postpartum neonatal care. These measures play a paramount role in reducing the prevalence of low APGAR scores and their associated complications. Enhancing intrapartum and immediate postpartum care can lead to better health outcomes for both mothers and their newborns, ultimately contributing to the overall improvement of maternal and neonatal health. (Table 4).

Table 4 Bivariate and multivariate factors related with low 5th minute APGAR among those mothers who gave birth through emergency Cesarean section at WKUSH from January -June 2023
Full size table

Discussion

The prevalence of low 5th-minute APGAR scores in this study is 27.4% (95% CI 26.4–28.4), which is higher than other studies conducted in Ethiopia: 11% in Jimma and Hawassa [21, 22], 13.8% in Gondar [23], and 18.1% in Debre Tabor [24]. However, it is lower than one study in Arbaminch town, which reported a prevalence of 31.85% [25]. According to a systematic review, the overall prevalence in Ethiopia is 23% (95% CI 16–30), positioning our study’s prevalence at the upper margin of this range. Compared to international studies, the prevalence observed in this study is higher than those reported in the USA (1.1%) [17], Tanzania (9.5%) [18], Kenya (23%) [8], Nigeria (16.6%) [19], and Rwanda (2.27%) [20].

The higher prevalence observed in this study compared to other studies conducted in Ethiopia can be attributed to its unique focus. Specifically, this study is likely the only one that exclusively examines mothers who underwent emergency cesarean sections. Emergency procedures often involve different risk factors and complications compared to planned cesarean sections and vaginal deliveries, which can contribute to the observed higher prevalence. As stated in numerous studies, emergency cesarean sections are strongly associated with low APGAR scores [24, 26, 27, 33, 34]. Therefore, the elevated prevalence of low APGAR scores in this study can be attributed to our selection of mothers who underwent emergency cesarean sections, who have an elevated baseline risk for low APGAR scores.

In this study, mothers with a total labor duration greater than 24 h have higher odds of having a low APGAR score compared to those with a labor duration of less than 24 h. This finding aligns with other studies conducted in Ethiopia [21, 23, 26]. Labor is a complex process associated with the release of various stress and inflammatory hormones, resulting in uterine contractions, cervical dilatation, and the delivery of the fetus. If labor is abnormally prolonged, it exposes the fetus to stressful conditions for an extended duration, compromising placental oxygen delivery and leading to poor neonatal outcomes [22, 35].

This study showed that fetal heartbeat abnormalities (fetal bradycardia and fetal tachycardia) are strongly related to the prevalence of low APGAR scores at the 5th minute of life. This finding is supported by studies conducted in various countries, including Ethiopia [25], Ghana [34], and Brazil [13, 36]. Non-reassuring fetal status (either bradycardia or tachycardia) is an indicator of fetal jeopardy in utero and is strongly associated with fetal hypoxia [22]. Moreover, as mentioned, more than 35% of low APGAR scores are attributed to fetal hypoxia [19].

Meconium-stained amniotic fluid is another factor in this study, with higher odds of having a low 5th-minute APGAR score compared to mothers without meconium-stained amniotic fluid. This finding is similar to studies conducted in other areas [22,23,24, 26]. Meconium release is associated with stressful conditions during pregnancy, which are indirectly measured by a poor APGAR score. Any type of stress on the uterus makes it easier for the anal sphincters to relax, potentially leading to fetal hypoxia and consequently the release of meconium. The release of meconium into the amniotic fluid can have several negative effects. Firstly, it can lead to fetal hypoxia (a lack of oxygen), which is a critical condition that can significantly impact the newborn’s health. Fetal hypoxia can occur because the stress on the uterus affects placental blood flow, reducing the oxygen supply to the fetus. Secondly, the presence of thick meconium can obstruct the oropharynx, making it difficult for the fetus to breathe properly. This obstruction, combined with ongoing hypoxic insult, can result in a low APGAR score at the 5th minute [29, 35].

The study indicates that neonates with low birth weight have significantly higher odds of having a low 5th-minute APGAR score compared to their normal weight counterparts. This finding aligns with several other reports [21, 24, 33, 34, 37]. The inverse relationship between birth weight and APGAR score is attributed to the challenges low birth weight infants face in achieving a smooth cardiorespiratory transition after birth. These challenges include a higher risk of hypothermia, respiratory distress syndrome, and complications related to prematurity [1, 16, 33, 34, 38]. Low birth weight infants have less body fat and a larger surface area relative to their weight, making them more prone to heat loss and metabolic complications. Additionally, their immature lung development increases the likelihood of respiratory distress syndrome, which can lead to inadequate oxygenation and difficulty breathing. Premature infants, who are often low birth weight, have underdeveloped organs and systems, further complicating their ability to adapt after birth [16, 22, 23].

The primary limitation of this study is its design as a single-institution and cross-sectional study, which may limit the generalizability of the findings to other settings. Additionally, the use of convenience sampling methods could introduce selection bias, which affects the representativeness of the sample and may lead to biased results. To overcome these limitations, it is recommended that future studies employ larger sample sizes and utilize randomized sampling strategies. This approach would help to ensure a more representative sample and enhance the generalizability of the findings. Furthermore, conducting studies across multiple centers or locations can provide a more diverse and comprehensive dataset, thereby reducing the potential for location-specific biases. By implementing these recommendations, researchers can achieve more reliable and robust results.

Furthermore, due to resource constraints, arterial blood gas analysis was not conducted. While this test can provide valuable physiological insights, it is not routinely recommended in all obstetric settings, and its absence should be considered in the interpretation of the results. Despite the limitations, this study has several strengths. Notably, it includes a comprehensive range of obstetric variables, allowing for a detailed exploration of factors associated with the outcomes of interest. By encompassing as many relevant variables as possible, the study enhances the robustness of its findings and contributes valuable insights to the field of obstetrics.

Conclusion and recommendation of the study

A low APGAR score is highly prevalent. The meconium-stained amniotic fluid, fetal heartbeat abnormalities (bradycardia and tachycardia), prolonged labor duration greater than 24 h, and low birth weight are statistically significant predictors of a poor 5th-minute APGAR score. All the factors associated with low 5th-minute APGAR scores were intrapartum-related factors. Therefore, enhancing the quality of intrapartum obstetric care is essential. This can be achieved through stringent electronic monitoring of fetal heartbeats during labor, timely cesarean sections in cases of labor abnormalities, using a partograph to follow labor progress, and empowering health professionals and health institutions with effective neonatal resuscitation techniques and materials, especially for babies with meconium-stained amniotic fluid. Additionally, developing management protocols for emergency obstetric conditions is crucial. These recommendations can significantly mitigate the risk of complications associated with low 5th-minute APGAR scores. Such improvements are vital for enhancing newborn outcomes and reducing related complications.

Data availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.123.

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Acknowledgements

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Funding

The authors received no specific funding for this work.

Author information

Authors and Affiliations

  1. Obstetrics and gynecology in Wolkite University College of medicine and health sciences, Wolkite, Ethiopia

    Temesgen tantu

  2. Department of obstetrics and gynecology, University of Rwanda, Kigali, Rwanda

    Temesgen tantu

  3. Human nutrition, Hawassa, Sidama region, Ethiopia

    Tayech tantu

  4. Surgery at SPHMMC, College of medicine and health sciences, Addis Ababa, Ethiopia

    Yohanna Hailu

  5. Department of surgery, University of Rwanda, Kigali, Rwanda

    Yohanna Hailu & Dereje Gashaw

  6. Surgery at Bahirdar University College of medicine and health sciences, Bahirdar city, Ethiopia

    Dereje Gashaw

  7. Surgery in Wachamo University College of medicine and health sciences, Hosanna city, Ethiopia

    Biruk Melkamu

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  3. Yohanna Hailu
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Contributions

TT, TT, BM, and YH wrote the manuscript text and DG prepared figures and tables. all authors reviewed the manuscript.

Corresponding author

Correspondence to Temesgen tantu.

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Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, Wolkite University, Ethiopia, with ethical clearance letter no. IRB/305/23. The IRB has given ethical clearance for written informed consent. After obtaining ethical clearance from the Institutional Review Board of Wolkite University, data collection was started. Patients’ names or other personal information were not used in data collection or analysis. All methods were performed in accordance with the relevant guidelines and regulations of the Declaration of Helsinki.

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tantu, T., tantu, T., Hailu, Y. et al. Prevalence and factors associated with low 5th minute APGAR score among mothers who birth through emergency cesarean section: prospective cross-sectional study in Ethiopia. BMC Pregnancy Childbirth 25, 342 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07456-9

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07456-9

Keywords

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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