Hidden in plain sight in the delivery room – the Apgar score is biased
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Amos Grünebaum
,
Eran Bornstein
Abstract
Objectives
The objective of this study was to compare the maximum 5-min Apgar score of 10 among different U.S. races and Hispanic ethnicity.
Methods
Retrospective population-based cohort study from the National Center for Health Statistics (NCHS), and Division of Vital Statistics natality online database. We included only deliveries where the race and Hispanic ethnicity of the father and mother were listed as either Black, White, Chinese, or Asian Indian and as Hispanic or Latino origin or other. Proportions of 5-Minute Apgar scores of 10 were compared among different races and Hispanic ethnicity for six groups each for mother and father: Non-Hispanic or Latino White, Hispanic or Latino White, Non-Hispanic or Latino Black, Hispanic or Latino Black, Chinese, and Asian Indian.
Results
The study population consists of 9,710,066 mothers and 8,138,475 fathers from the US natality birth data 2016–2019. Black newborns had a less than 50% chance of having a 5-min Apgar score of 10 when compared to white newborns (OR 0.47 for Black mother and Black father; p<0.001). White babies (non-Hispanic and Hispanic) had the highest proportion of Apgar scores of 10 across all races and ethnicities.
Conclusions
The Apgar score introduces a bias by systematically lowering the score in people of color. Embedding skin color scoring into basic data and decisions of health care propagates race-based medicine. By removing the skin color portion of the Apgar score and with it’s racial and ethnic bias, we will provide more accuracy and equity when evaluating newborn babies worldwide.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Not applicable.
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Ethical approval: The local Institutional Review Board deemed the study exempt from review.
References
1. Apgar, V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg 1953;32:260–7. https://doi.org/10.1213/00000539-195301000-00041.Suche in Google Scholar
2. Apgar, V, Holiday, DA, James, LS, Weisbrot, IM, Berrien, C. Evaluation of the newborn infant: second report. JAMA 1958;168:1985–8. https://doi.org/10.1001/jama.1958.03000150027007.Suche in Google Scholar PubMed
3. Committee on Obstetric Practice. ACOG; American Academy of Pediatrics; Committee on Fetus and Newborn, ACOG. ACOG Committee Opinion. The Apgar score. Number 333, May 2006 (replaces No. 174, July 1996). Obstet Gynecol 1996;107:1209–12.10.1097/00006250-200605000-00051Suche in Google Scholar PubMed
4. Casey, BM, McIntire, DD, Leveno, KJ. The continuing value of the Apgar score for the assessment of the newborn infants. N Engl J Med 2001;344:467–71. https://doi.org/10.1056/nejm200102153440701.Suche in Google Scholar PubMed
5. Papile, LA. The Apgar score in the 21st century. N Engl J Med 2001;344:519–20. https://doi.org/10.1056/nejm200102153440709.Suche in Google Scholar
6. Iliodromiti, S, Mackay, DF, Smith, GC, Pell, JP, Nelson, SM. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. Lancet 2014;384:1749–55. https://doi.org/10.1016/s0140-6736(14)61135-1.Suche in Google Scholar PubMed
7. Razaz, N, Cnattingius, S, Joseph, KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ 2019;365:l1656. https://doi.org/10.1136/bmj.l1656.Suche in Google Scholar PubMed PubMed Central
8. Parchem, JG, Rice, MM, Grobman, WA, Bailit, JL, Wapner, RJ, Debbink, MP, et al.. Eunice kennedy shriver national institute of child health human development maternal-fetal medicine units (MFMU) network. Racial and ethnic disparities in adverse perinatal outcomes at term. Am J Perinatol 2021. https://doi.org/10.1055/s-0041-1730348 [Epub ahead of print].Suche in Google Scholar PubMed PubMed Central
9. Hegyi, T, Carbone, T, Anwar, M, Ostfeld, B, Hiatt, M, Koons, A, et al.. The Apgar score and its components in the preterm infant. Pediatrics 1998;101:77–81. https://doi.org/10.1542/peds.101.1.77.Suche in Google Scholar PubMed
10. Yama, AZ, Marx, GF. Race and apgar scores. Anaesthesia 1991;46:330–1. https://doi.org/10.1111/j.1365-2044.1991.tb11538.x.Suche in Google Scholar PubMed
11. Marx, GF, Mahajan, S, Miclat, MN. Correlation of biochemical data with Apgar scores at birth and at one minute. Br J Anaesth 1977;49:831–3. https://doi.org/10.1093/bja/49.8.831.Suche in Google Scholar PubMed
12. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS). Division of vital statistics, Natality public-use data 2016-2019, on CDC WONDER online database; 2020. Available from: http://wonder.cdc.gov/natality-expanded-current.html on 10/18/2021.Suche in Google Scholar
13. Office of Management and Budget. Revisions to the standards for the classification of federal data on race and ethnicity. Fed Regist 1997;62:58782–90.Suche in Google Scholar
14. Centers for Disease Control and Prevention (CDC). Data use restrictions. Available from: https://wonder.cdc.gov/datause.html [Accessed 18 Oct 2021].Suche in Google Scholar
15. User guide to the 2019 Natality public use file. Available from: https://ftp.cdc.gov/pub/health_statistics/nchs/dataset_documentation/DVS/natality/UserGuide2019-508.pdf [Accessed 15 Oct 2021].Suche in Google Scholar
16. Bland, M. An introduction to medical statistics, 3rd ed. Oxford: Oxford University Press; 2000.Suche in Google Scholar
17. O’Donnell, CP, Kamlin, CO, Davis, PG, Carlin, JB, Morley, CJ. Interobserver variability of the 5-minute Apgar score. J Pediatr 2006;149:486–9. https://doi.org/10.1016/j.jpeds.2006.05.040.Suche in Google Scholar PubMed
18. Crameri, F, Shephard, GE, Heron, PJ. The misuse of colour in science communication. Nat Commun 2020;11:5444. https://doi.org/10.1038/s41467-020-19160-7.Suche in Google Scholar PubMed PubMed Central
19. Goyal, N, De Keersmaecker, J. Cultural dyes: cultural norms color person perception. Curr Opin Psychol 2021;43:195–8. https://doi.org/10.1016/j.copsyc.2021.07.009.Suche in Google Scholar PubMed
20. Jablonski, NG. Skin color and race. Am J Phys Anthropol 2021;175:437–47. https://doi.org/10.1002/ajpa.24200.Suche in Google Scholar PubMed PubMed Central
21. Nelson, B. Color blindness in the medical workplace. Cancer Cytopathol 2019;127:209–10. https://doi.org/10.1002/cncy.22127.Suche in Google Scholar PubMed
22. Skolnick, AA. Apgar quartet plays perinatologist’s instruments. JAMA 1996;276:1939–40. https://doi.org/10.1001/jama.1996.03540240017009.Suche in Google Scholar
23. Wikipedia. Demographic history of New York City. Available from: https://en.wikipedia.org/wiki/Demographic_history_of_New_York_City.Suche in Google Scholar
24. Rüdiger, M, Rozycki, HJ. It’s time to reevaluate the apgar score. JAMA Pediatr 2020;174:321–2.10.1001/jamapediatrics.2019.6016Suche in Google Scholar PubMed
25. Crawford, JS, Davies, P, Fearson, JF. Significance of the individual components of the Apgar score. Br J Anaesth 1973;45:148–58. https://doi.org/10.1093/bja/45.2.148.Suche in Google Scholar PubMed
26. Arri, SJ, Mühlemann, T, Fauchére, JC, Bucher, HU. Assessment of the interobserver variability of the Apgar score using video sequence. Z Geburtshilfe Neonatol 2008;212:150.10.1055/s-2008-1079053Suche in Google Scholar
27. Cnattingius, S, Johansson, S, Razaz, N. Apgar score and risk of neonatal death among preterm infants. N Engl J Med 2020;383:49–57. https://doi.org/10.1056/nejmoa1915075.Suche in Google Scholar PubMed
28. Grünebaum, A, McCullough, LB, Brent, RL, Arabin, B, Levene, MI, Chervenak, FA. Justified skepticism about Apgar scoring in out-of-hospital birth settings. J Perinat Med 2015;43:455–60. https://doi.org/10.1515/jpm-2014-0003.Suche in Google Scholar PubMed
29. Siddiqui, A, Cuttini, M, Wood, R, Velebil, P, Delnord, M, Zile, I, et al.. Euro-peristat scientific committee. Can the apgar score be used for international comparisons of newborn health? Paediatr Perinat Epidemiol 2017;31:338–45. https://doi.org/10.1111/ppe.12368.Suche in Google Scholar PubMed
30. Haeny, AM, Holmes, SC, Williams, MT. Applying anti-racism to clinical care and research. JAMA Psychiatr 2021;78:1187–8. https://doi.org/10.1001/jamapsychiatry.2021.2329.Suche in Google Scholar PubMed PubMed Central
31. American College of Obstetricians and Gynecologists. Committee opinion no. 649: racial and ethnic disparities in obstetrics and gynecology. Obstet Gynecol 2015;126:e130–4. https://doi.org/10.1097/AOG.0000000000001213.Suche in Google Scholar PubMed
32. Zeitlin, EAJH. Quality of care and disparities in obstetrics. Obstet Gynecol Clin N Am 2017;44:13–25. https://doi.org/10.1016/j.ogc.2016.10.002.Suche in Google Scholar PubMed PubMed Central
33. Willis, E, McManus, P, Magallanes, N, Johnson, S, Majnik, A. Conquering racial disparities in perinatal outcomes. Clin Perinatol 2014;41:847–75. https://doi.org/10.1016/j.clp.2014.08.008.Suche in Google Scholar PubMed
34. Vyas, DA, Eisenstein, LG, Jones, DS. Hidden in plain sight – reconsidering the use of race correction in clinical algorithms. N Engl J Med 2020;383:874–82. https://doi.org/10.1056/nejmms2004740.Suche in Google Scholar PubMed
35. Williams, WW, Hogan, JW, Ingelfinger, JR. Time to eliminate health care disparities in the estimation of kidney function. N Engl J Med 2021;385:1804–6. https://doi.org/10.1056/nejme2114918.Suche in Google Scholar PubMed
36. Grobman, WA, Sandoval, G, Rice, MM, Bailit, JL, Chauhan, SP, Constantine, MM, et al.. Eunice kennedy shriver national institute of child health and human development maternal-fetal medicine units network. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol 2021;225:664.e1–7. https://doi.org/10.1016/j.ajog.2021.05.021.Suche in Google Scholar PubMed PubMed Central
37. Ehrenstein, V, Pedersen, L, Grijota, M, Nielsen, GL, Rothman, KJ, Sørensen, HT. Association of Apgar score at five minutes with long-term neurologic disability and cognitive function in a prevalence study of Danish conscripts. BMC Pregnancy Childbirth 2009;9:14. https://doi.org/10.1186/1471-2393-9-14.Suche in Google Scholar PubMed PubMed Central
38. Sjoding, MW, Dickson, RP, Iwashyna, TJ, Gay, SE, Valley, TS. Racial bias in pulse oximetry measurement. N Engl J Med 2020;383:2477–8. https://doi.org/10.1056/nejmc2029240.Suche in Google Scholar PubMed PubMed Central
39. Bailey, ZD, Feldman, JM, Bassett, MT. How structural racism works – racist policies as a root cause of U.S. Racial health inequities. N Engl J Med 2021;384:768–73. https://doi.org/10.1056/nejmms2025396.Suche in Google Scholar PubMed
40. American Medical Association (AMA). New AMA policy recognizes racism as a public health threat. Available from: https://www.ama-assn.org/press-center/press-releases/new-ama-policy-recognizes-racism-public-health-threat [Accessed 23 Oct 2021].Suche in Google Scholar
41. Sherif, J. It’s time for general practice to act on racism in health care. Br J Gen Pract 2020;70:499. https://doi.org/10.3399/bjgp20x712829.Suche in Google Scholar PubMed PubMed Central
42. Adebowale, V, Rao, M. Racism in medicine: why equality matters to everyone. BMJ 2020;368:m530. https://doi.org/10.1136/bmj.m530.Suche in Google Scholar PubMed
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Artikel in diesem Heft
- Frontmatter
- Reviews
- Disquiet concerning cesarean birth
- Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis
- Corner of Academy
- Does COVID-19 infection acquired in different pregnancy trimester influence placental pathology?
- Original Articles – Obstetrics
- Did the first wave of the COVID-19 pandemic impact the cesarean delivery rate? A retrospective cohort study at a primary care center in Switzerland
- Hypertensive disorders of pregnancy and severe acute respiratory syndrome coronavirus-2 infection
- Hidden in plain sight in the delivery room – the Apgar score is biased
- Comparison of phase rectified signal averaging and short term variation in predicting perinatal outcome in early onset fetal growth restriction
- Serum levels of kynurenine in pregnancies with fetal growth restriction and oligohydramnios
- Effect of third trimester maternal vitamin D levels on placental weight to birth weight ratio in uncomplicated pregnancies
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- Chorioangioma: a single tertiary care center retrospective study
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- Original Articles – Fetus
- Fetal left brachiocephalic vein diameters in normal and growth restricted fetuses
- Functional assessment of atrial wall excursion and foramen ovale flap tracings in 3rd trimester as predictor of short-term hemodynamic stability in congenital heart defects fetuses
- Original Articles – Neonates
- Developing a new pediatric extracorporeal membrane oxygenation (ECMO) program
- Patterns of placental injury in various types of fetal congenital heart disease
- Short Communication
- Prenatal care in the era of economic collapse
- Letters to the Editor
- Does fetus feel stress or pain on uterine contraction?
- Pregnancy associated plasma protein-A for the prediction of small for gestational age
- Reply to: Pregnancy associated plasma protein-A for the prediction of small for gestational age
Artikel in diesem Heft
- Frontmatter
- Reviews
- Disquiet concerning cesarean birth
- Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis
- Corner of Academy
- Does COVID-19 infection acquired in different pregnancy trimester influence placental pathology?
- Original Articles – Obstetrics
- Did the first wave of the COVID-19 pandemic impact the cesarean delivery rate? A retrospective cohort study at a primary care center in Switzerland
- Hypertensive disorders of pregnancy and severe acute respiratory syndrome coronavirus-2 infection
- Hidden in plain sight in the delivery room – the Apgar score is biased
- Comparison of phase rectified signal averaging and short term variation in predicting perinatal outcome in early onset fetal growth restriction
- Serum levels of kynurenine in pregnancies with fetal growth restriction and oligohydramnios
- Effect of third trimester maternal vitamin D levels on placental weight to birth weight ratio in uncomplicated pregnancies
- One-third of patients with eclampsia at term do not have an abnormal angiogenic profile
- Chorioangioma: a single tertiary care center retrospective study
- A prospective cohort study: can advanced ultrasonography replace magnetic resonance imaging in the diagnosis of placental adhesion disorders?
- Original Articles – Fetus
- Fetal left brachiocephalic vein diameters in normal and growth restricted fetuses
- Functional assessment of atrial wall excursion and foramen ovale flap tracings in 3rd trimester as predictor of short-term hemodynamic stability in congenital heart defects fetuses
- Original Articles – Neonates
- Developing a new pediatric extracorporeal membrane oxygenation (ECMO) program
- Patterns of placental injury in various types of fetal congenital heart disease
- Short Communication
- Prenatal care in the era of economic collapse
- Letters to the Editor
- Does fetus feel stress or pain on uterine contraction?
- Pregnancy associated plasma protein-A for the prediction of small for gestational age
- Reply to: Pregnancy associated plasma protein-A for the prediction of small for gestational age
