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

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

Author information

INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris-Descartes University, Paris, France.
Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy.
Information Services Division, NHS National Services Scotland, Edinburgh, Scotland, UK.
Institute for the Care of Mother and Child, Prague, Czech Republic.
Centre for Disease Prevention and Control of Latvia, Riga, Latvia.
ISPUP-EPI Unit, Universidade do Porto, Porto, Portugal.
THL National Institute for Health and Welfare, Helsinki, Finland.
Department Child Health, Netherlands Organisation for Applied Scientific Research, TNO Healthy Living, Leiden, the Netherlands.
Faculty of Medical Sciences, Department Public Health, Anton de Kom University of Suriname, Paramaribo, Suriname.



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.


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.


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).


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.


Apgar Score; health indicators; neonatal morbidity; neonatal mortality

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