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Journal of Perinatal Medicine

Official Journal of the World Association of Perinatal Medicine

Editor-in-Chief: Dudenhausen, MD, FRCOG, Joachim W.

Hrsg. v. Bancalari, Eduardo / Chappelle, Joseph / Chervenak, Frank A. / D'Addario , Vincenzo / Genc, Mehmet R. / Greenough, Anne / Grunebaum, Amos / Konje, Justin C. / Kurjak M.D., Asim / Romero, Roberto / Zalud, MD PhD, Ivica

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Band 43, Heft 4


Justified skepticism about Apgar scoring in out-of-hospital birth settings

Amos Grünebaum
  • Korrespondenzautor
  • Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY, USA
  • E-Mail
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/ Laurence B. McCullough
  • Education Center for Medical Ethics and Health Policy Baylor College of Medicine, Houston, TX, USA
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/ Robert L. Brent
  • Thomas Jefferson University, Alfred I. DuPont Hospital for Children, Wilmington, DE, USA and Adjunct Professor of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY, USA
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/ Birgit Arabin / Malcolm I. Levene
  • Division of Pediatrics and Child Health, University of Leeds, General Infirmary of Leeds, Leeds, UK
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/ Frank A. Chervenak
  • Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY, USA
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Online erschienen: 16.04.2014 | DOI: https://doi.org/10.1515/jpm-2014-0003


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.

Keywords: Apgar score; birth center; home birth; hospital birth; midwives; patient safety


  • [1]

    Ackermann-Liebrich U, Voegeli T, Gunter-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team. Br Med J. 1996;313:1313–8.CrossrefGoogle Scholar

  • [2]

    Amelink-Verburg MP, Verloove-Vanhorick SP, Hakkenberg RM, Veldhuijzen IM, Bennebroek Gravenhorst J, Buitendijk SE. Evaluation of 280,000 cases in Dutch midwifery practices: a descriptive study. BJOG. 2008;115:570–8.Google Scholar

  • [3]

    American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. The Apgar Score. Pediatrics. 2006;117:1444.Google Scholar

  • [4]

    American College of Nurse-Midwives. Position statement on Home Births. Washington, DC. http://www.washingtonmidwives.org/for-consumers/position-statements-home-birth.html. Accessed 7 November, 2013.

  • [5]

    Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32:260.CrossrefWeb of SciencePubMedGoogle Scholar

  • [6]

    Apgar V. The newborn (Apgar) scoring system: reflections and advice. Pediatr Clin North Am. 1965;13:699.Google Scholar

  • [7]

    Apgar V, Holaday DA, James LS, Weisbrot IM, Berrien C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958;168:1985–8.PubMedCrossrefGoogle Scholar

  • [8]

    Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209:325.e1–8.Google Scholar

  • [9]

    Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epidemiologic statistics for public health, version 2.3.1. Updated June 23, 2011. Available at: www.OpenEpi.com. Accessed 18 July, 2013.

  • [10]

    DiGiuseppe DL, Aron DC, Ranbom L,Harper DL, Rosenthal GE. Reliability of birth certificate data: a multi-hospital comparison to medical records information. Mat Child Health J. 2002;6:169–79.Google Scholar

  • [11]

    Eastman NJ, Hellman LM. Williams Obstetrics. 13th ed. New York: Appleton-Century-Crofts; 1966.Google Scholar

  • [12]

    Fujita. The process of childbirth and the neonatal APGAR score. Kango. 1966;18:121–9. [In Japanese].PubMedGoogle Scholar

  • [13]

    Grünebaum A, McCullough LB, Sapra KJ, Brent RL, Levene MI, Arabin B, 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.Google Scholar

  • [14]

    Krokfors E, Wist A, Hirvensalo M. Effect of duration of labour, age and parity on the Apgar score of the newborn infant. Ann Chir Gynaecol Fenn Suppl. 1963;52:1–14.PubMedGoogle Scholar

  • [15]

    MacDorman ME, Declercq E, Menacker F. Trends and Characteristics of home births in the United States by race and ethnicity, 1990–2006. Birth. 2011;38:17–23.Google Scholar

  • [16]

    Mehl LE, Peterson GH, Whitt M, Hawes WE. Outcomes of elective home births: a series of 1,146 cases. J Reprod Med. 1977;19:281–90.Google Scholar

  • [17]

    Northam S, Knapp TR. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs. 2006;35:3–12.PubMedCrossrefGoogle Scholar

  • [18]

    Nove A, Berrington A, Matthews Z. The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death. Midwifery. 2012;28:619–26.Web of SciencePubMedCrossrefGoogle Scholar

  • [19]

    Olsen O. Meta-analysis of the safety of home birth. Birth. 1997;24:4–13.PubMedGoogle Scholar

  • [20]

    Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012;9:CD000352.Web of ScienceGoogle Scholar

  • [21]

    Royal College of Midwives (RCM) and the Royal College of of Obstetricians and Gynaeologists. Joint Statement No. 2, April, 2007.Google Scholar

  • [22]

    Shearer JM. Five year prospective survey of risk of booking for a home birth in Essex. Br Med J (Clin Res Ed). 1985;291:1478–80.Google Scholar

  • [23]

    Teczyńska T, Matusiak J. Value of the Apgar score in determining the prognosis of the infant’s health and life. Ginekol Pol. 1965;36:1033–8.Google Scholar

  • [24]

    van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktasş S, Steegers EA, et al. Planned home compared with planned hospital births in the Netherlands: intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol. 2011;118:1037–46.CrossrefGoogle Scholar

  • [25]

    Vinikoor LC, Messer LC, Laraia BA, Kaufman JS. Reliability of variables on the North Carolina birth certificate: a comparison with directly queried values from a cohort study. Paediatr Perinat Epidemiol. 2010;24:102–112.PubMedWeb of ScienceCrossrefGoogle Scholar

  • [26]

    Weyers H. The standardized evaluation of newborn infants using the Apgar score. Dtsch Schwesternztg. 1966;19:320–2. [In German].PubMedGoogle Scholar

  • [27]

    Wiegers TA, Keirse MJ, Berghs GA, van der Zee J. An approach to measuring quality of midwifery care. J Clin Epidemiol. 1996;49:319–25.CrossrefGoogle Scholar

  • [28]

    Wiegers TA, Keirse MJ, van der Zee J, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in The Netherlands. BMJ. 1996;23:1309–13.Google Scholar

  • [29]

    Zollinger TW, Przybylski MJ, Gamache RE. Reliability of Indiana birth certificate data compared to medical records. Ann Epidemiol. 2006;16:1–10.PubMedCrossrefGoogle Scholar


Corresponding author: Amos Grünebaum, MD, Department of Obstetrics and Gynecology, Weill Cornell Medical Center 525 East 68th Street-J130, New York, NY 10065, USA, Tel.: +1 212 746 0714, Fax: +1 212 746 8727, E-mail:

Erhalten: 01.01.2014

Angenommen: 24.02.2014

Online erschienen: 16.04.2014

Erschienen im Druck: 01.07.2015

Quellenangabe: Journal of Perinatal Medicine, Band 43, Heft 4, Seiten 455–460, ISSN (Online) 1619-3997, ISSN (Print) 0300-5577, DOI: https://doi.org/10.1515/jpm-2014-0003.

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