Can the Apgar Score be Used for International Comparisons of Newborn Health?

Paediatr Perinat Epidemiol. 2017 Jul;31(4):338-345. doi: 10.1111/ppe.12368. Epub 2017 Jun 16.


Background: The Apgar score has been shown to be predictive of neonatal mortality in clinical and population studies, but has not been used for international comparisons. We examined population-level distributions in Apgar scores and associations with neonatal mortality in Europe.

Methods: Aggregate data on the 5 minute Apgar score for live births and neonatal mortality rates from countries participating in the Euro-Peristat project in 2004 and 2010 were analysed. Country level associations between the Apgar score and neonatal mortality were assessed using the Spearman rank correlation coefficient.

Results: Twenty-three countries or regions provided data on Apgar at 5 minutes, covering 2 183 472 live births. Scores <7 ranged from 0.3% to 2.4% across countries in 2004 and 2010 and were correlated over time (ρ = 0.88, P < 0.01). There were large differences in healthy baby scores: scores of 10 ranged from 8.8% to 92.7% whereas scores of 9 or 10 ranged from 72.9% to 96.8%. Countries more likely to score 10 s, as opposed to 9 s, for healthy babies had lower proportions of Apgar <7 (ρ = -0.43, P = 0.04). Neonatal mortality rates were weakly correlated with Apgar score <7 (ρ = -0.06, P = 0.61), but differences over time in these two indicators were correlated (ρ =0.56, P = 0.02).

Conclusions: Large variations in the distribution of Apgar scores likely due to national scoring practices make the Apgar score an unsuitable indicator for benchmarking newborn health across countries. However, country-level trends over time in the Apgar score may reflect real changes and merit further investigation.

Keywords: Apgar Score; health indicators; neonatal morbidity; neonatal mortality.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Apgar Score*
  • Europe / epidemiology
  • Health Status Indicators
  • Humans
  • Infant
  • Infant Health* / statistics & numerical data
  • Infant Mortality
  • Infant, Newborn