The apgar score and infant mortality

PLoS One. 2013 Jul 29;8(7):e69072. doi: 10.1371/journal.pone.0069072. Print 2013.


Objective: To evaluate if the Apgar score remains pertinent in contemporary practice after more than 50 years of wide use, and to assess the value of the Apgar score in predicting infant survival, expanding from the neonatal to the post-neonatal period.

Methods: The U.S. linked live birth and infant death dataset was used, which included 25,168,052 singleton births and 768,305 twin births. The outcome of interest was infant death within 1 year after birth. Cox proportional hazard-model was used to estimate risk ratio of infant mortality with different Apgar scores.

Results: Among births with a very low Apgar score at five minutes (1-3), the neonatal and post-neonatal mortality rates remained high until term (≥ 37 weeks). On the other hand, among births with a high Apgar score (≥7), neonatal and post-neonatal mortality rate decreased progressively with gestational age. Non-Hispanic White had a consistently higher neonatal mortality than non-Hispanic Black in both preterm and term births. However, for post-neonatal mortality, Black had significantly higher rate than White. The pattern of changes in neonatal and post-neonatal mortality by Apgar score in twin births is essentially the same as that in singleton births.

Conclusions: The Apgar score system has continuing value for predicting neonatal and post-neonatal adverse outcomes in term as well as preterm infants, and is applicable to twins and in various race/ethnic groups.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • African Americans / statistics & numerical data
  • Apgar Score*
  • Ethnic Groups / statistics & numerical data
  • European Continental Ancestry Group / statistics & numerical data
  • Female
  • Gestational Age
  • Humans
  • Infant
  • Infant Mortality*
  • Infant, Newborn
  • Infant, Premature
  • Pregnancy
  • Pregnancy, Twin / statistics & numerical data
  • Survival Analysis
  • Term Birth
  • United States / epidemiology

Grant support

The work was funded by the Ministry of Education of China (NCET program), the National Science Foundation of China (81000592, 81222012, 91232706 and 81273091), the National Basic Research Program of China (973 Project, 2013CB835100), the Science and Technology Commission of Shanghai Municipality (10DZ2272200, 09DZ2200900, 10PJ1407500, 10PJ1403500, 10231203903 and 10JC1411200), the Shanghai Municipal Education Commission (11ZZ103), the Shanghai Municipal Health Bureau (2010004), the Morning Star Rewarding Fund (Category B, 2011) of Shanghai Jiao Tong University, and the Xingbairen plan of Shanghai Jiao Tong University School of Medicine. And the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.