Association Between Five-minute Apgar Scores and Adverse Short-term Outcomes in Neonates in the Clinical Information Network Hospitals in Kenya, 2018-2022 - a Retrospective Cohort Study

Abstract

Background-The Apgar score is a good indicator of the quality of obstetric and newborn care. More than two-thirds of neonates with a low Apgar score die in the early neonatal period (0-7 days). There is therefore a need to look at the distribution of Apgar scores in primary referral centres in Kenya and to determine the prognosis of neonates in the neonatal period in relation to the Apgar score. Methodology- This was a retrospective cohort study carried out in 22 neonatal units that are part of the CIN across 14 counties in Kenya. Singleton inborn neonates admitted to the neonatal unit on the first day of life between the years 2018-2022 were included. Those with major congenital defects, hose born in twin/multiple pregnancy and those with a recorded score of less than zero or greater than ten were excluded. Data was abstracted from the Neonatal Admission Record and Newborn Unit Exit Form and captured into the REDCap tool. It was then exported to an excel file and analysed using R software version 4.1.2. Descriptive statistics were summarized as means, medians and proportions while inferential analysis was done using the Cox proportional hazards model, linear and logistic regression. Results-The study found that 77%, 20% and 3% of neonates had normal, intermediate and low Apgar scores, respectively. The Apgar score was statistically significantly associated with mortality; an increase in the Apgar score by one led to a 37% reduction in the risk of death (HR 0.63 95% CI 0.61-0.64). The crude hazard ratio of death among those with a low and intermediate score were 12.44 (95% CI 11.6-13.35) and 4.02 (95% CI 3.83-4.22), respectively. The adjusted hazard ratios of death among those with low and intermediate Apgar scores were 10.97 (95% CI 9.45-12.73) and 3.6 (95% CI 3.26-3.97), respectively. When compared with the normal Apgar score, the odds of developing encephalopathy were 5.73 (95% CI 5.37-6.12) and 15.87 (95% CI 13.9-17.6) higher in intermediate and low Apgar score categories, respectively. With every unit increase in the Apgar score, the duration of stay was shortened by 0.34 days (95% CI -0.39 -0.30). ii Conclusion- Most neonates had a normal Apgar score. The Apgar score was found to be an important determinant of neonatal mortality, encephalopathy and hospital stay. Recommendation- There is need to continue monitoring the proportions of neonates with low and intermediate Apgar scores to inform targeted education and skills needs for the improvement of perinatal and neonatal care. Proper risk assessment and management of mothers in the antenatal period and planning for labour and delivery is important in order to mitigate against delivery of neonates with poor Apgar scores. Timely interventions for care of newborns scoring a less than normal Apgar score are necessary in order to reduce the occurrence of adverse outcomes