Apgar Score of Zero at Five Minutes and Neonatal Seizures or Serious Neurologic Dysfunction in Relation to Birth Setting.
ABSTRACT To examine the occurrence of 5-minute Apgar scores of zero and seizures or serious neurologic dysfunction for four groups by birth setting and birth attendant (hospital physician, hospital midwife, free-standing birth center midwife, and home midwife) in the United States from 2007-2010.
Data from the United States Centers for Disease Control's National Center for Health Statistics birth certificate data files were used to assess deliveries by physicians and midwives in and out of the hospital for the 4-year period from 2007-2010 for singleton term births (≥37 weeks gestation) and ≥2,500 grams. Five-minute Apgar scores of zero and neonatal seizures or serious neurologic dysfunction were analyzed for four groups by birth setting and birth attendant (hospital physician, hospital midwife, free-standing birth center midwife, and home midwife).
Home births (RR 10.55) and births in free-standing birth centers (RR 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of zero (p<.0001) than hospital births attended by physicians or midwives. Home births (RR 3.80) and births in free-standing birth centers attended by midwives (RR 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (p<.0001) than hospital births attended by physicians or midwives.
The increased risk of 5-minute Apgar score of zero and seizures or serious neurologic dysfunction of out-of-hospital births should be disclosed by obstetric practitioners to women who express an interest in out-of-hospital birth. Physicians should address patients' motivations for out-of-hospital delivery by continuously improving safe and compassionate care of pregnant, fetal, and neonatal patients in the hospital setting.
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ABSTRACT: 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.Journal of Perinatal Medicine 04/2014; · 1.43 Impact Factor
- American journal of obstetrics and gynecology 11/2013; · 3.97 Impact Factor
Article: Reply to Ms.Cohain.American journal of obstetrics and gynecology 11/2013; · 3.97 Impact Factor
Apgar score of 0 at 5 minutes and neonatal seizures or serious
neurologic dysfunction in relation to birth setting
TO THE EDITORS: I read with interest the article by
Grünebaum et al.1The article concludes that all women
should deliver in hospital to prevent 1/625 intrapartum
deaths 2007 through 2010 that occurred during home births
attended by a midwife or doctor. The conclusion that these
deaths could have been avoided if the women delivered in
hospital is in direct conflict with the data, which found the
deaths may have been antepartum stillbirths.
1. The article claims that hospital births resulted in 0.16
stillbirths per 1000 full-term births after 37 weeks, which
means the perinatal mortality rate of the United States
2007 through 2010 would have been 0.2/1000 instead of
what it was: 7/1000.2
2. The article claims an implausible high prematurity rate for
2007 through 2010 in the United States of 17% when the
actual rate was 12%.
3. The Centers for Disease Control and Prevention reports
approximately 29,000 home births per year for the years
2007 through 2010; about 62% of home births were
attended by midwives.3Over a 4-year period, that would
amount to 72,000 home births attended by midwives, not
60,000 home births, as the article reports.
4. The authors fail to give a single conjecture as to what
complication(s) could account for 1 in every 625 intra-
partum fetal deaths at the hands of licensed doctors and
midwives. The reason no guess or speculation is given is
because none exists. The reported attended home birth
perinatal mortality rate including antepartum stillbirths
is 1/3000.4The only 2 possible emergencies that have
been documented to cause intrapartum stillbirth at
planned attended home births of low-risk births
(excluding vaginal births after cesarean and breech) is
cord prolapse, which occurs at a rate of either 1/5000 or
1/10,000 at home birth due to the restriction on
amniotomy; and shoulder dystocia, which may account
for another 1/10,000 stillbirths at home births, because it
rarely results in stillbirth, but rather birth asphyxia.
There are no complications of planned home birth
attended by a trained professional that could account for
a 1/625 intrapartum stillbirth rate. This means that most
if not all of the stillbirths were antepartum. The con-
clusions of this article that fetuses/newborns would have
better outcomes at planned hospital births are spurious.
No reference is made to the relatively poor outcomes of
the women who would have delivered in hospital
compared to the better outcomes at planned attended
Judy Slome Cohain, CNM
No institutional affiliation
32-29 Parsons Blvd.
Flushing NY 11354-3153
The author reports no conflict of interest.
1. Grünebaum A, McCullough LB, Sapra KJ, 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.
2. MacDorman MF, Kirmeyer S. Fetal and perinatal mortality, United
States, 2005. Natl Vital Stat Rep 2009;57:1-19.
3. MacDorman M, Mathews MS, Declercq E. NCHS Data Brief no. 84.
Jan 2012. Home Births in the United States, 1990-2009. Available at:
http://www.cdc.gov/nchs/data/databriefs/db84.htm. Accessed Nov. 22,
4. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Out-
comes of planned home birth with registered midwife vs planned hospital
birth with midwife or physician. CMAJ 2009;181:377-83.
ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.
We thank Ms Cohain for her letter on our article on 5-minute
Apgar scores of 0 in relation to birth setting and attendant.
Ms Cohain makes 4 points by way of criticism.1All fail to be
1. Ms Cohain says: “The article claims that hospital births
resulted in 0.16 stillbirths per 1000 full-term births after
37 weeks, which means the perinatal mortality rate of the
United States 2007 through 2010 would have been 0.2/
1000 instead of what it was: 7/1000.” Our article reported
on the 5-minute Apgar score of 0, not the stillbirth rate. In
addition, stillbirths are but 1 component of the perinatal
mortality rate, which also includes neonatal mortality,
which we did not report in our article. The comment
shows that Ms Cohain has a basic misunderstanding of
2. We do not understand the relevance of Ms Cohain’s
comment about prematurity rates. Our inclusion criteria
of ?37 weeks’ gestational age and ?2500 g birth weight
without twins explicitly exclude premature deliveries. The
supposed 17% prematurity figure appears nowhere in our
3. According to Centers for Disease Control and Prevention
data that we reported there were a total of 60,296 home
births that fulfilled our criteria of singleton term birth,
APRIL 2014 American Journal of Obstetrics & Gynecology 377
Letters to the Editors