Proportion and factors associated with low fifth minute Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia.

Back ground: New born babies with low Apgar scores are at an increased risk of perinatal morbidity and mortality. Objective: To assess proportion and factors associated with low 5 th minute Apgar Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia. Methods: A cross-sectional study was conducted on singleton 261 live births from March - May, 2013. Data was collected from mother/newborn index using a structured and pre-tested questionnaire. It was then cleaned, coded and entered using EPI INFO version 3.4.3, then analyzed with IBM SPSS statistics versions 20.0. Logistic regression was used to identify significant variables with low 5 th minute Apgar score. Result: The proportion of low 5 th minute Apgar score in this study was 13.8%. Factors that were significantly associated with low 5 th minute Apgar score were: non-vertex fetal presentation, prolonged labor, presence of meconium stained liquor, induced/ augmented labor and low birth weight. Conclusion: Mainly obstetric factors contribute to low Apgar score. Improving labor management through implementing regular use of partograph, 1:1 midwife-client ratio and advanced electronic fetal monitoring technology is recommended.


Introduction
Childbirth is the period of increased risk of mortality for a mother and her baby 1 . An estimated 42% of the world's 535, 900 annual maternal deaths are intrapartum-related; these deaths are closely linked to the deaths of 1.02 million babies during labor and 904,000 intrapartum related ("birth asphyxia") neonatal deaths [1][2][3] .
The Apgar score, first introduced by Virginia Apgar 4 in 1952, initially was a practical method of systematically assessing newborn infants immediately after birth to help identify those requiring resuscitation 5 . Later, the Apgar scores determined at five minutes after delivery became widely used for the prediction of asphyxia as well as hypoxic-ischemic encephalopathy and cerebral palsy [6][7][8][9] .
It is established that there is association between low Apgar scores and increased perinatal morbidity and mortality 10 . A recent study showed that Apgar scores of less than 7 at five minutes after birth were associated with low cognitive function, neurologic disability and even subtle cognitive impairment as measured by academic performance at 16 years of age 11,12 . However, the value of the Apgar score < 7 is still considered controversial by different studies and many neonatologists across the world 13,14 . Perinatal morbidity and mortality can be reduced if high risk infants can be identified and managed appropriately. The present study therefore aimed to assess the proportion and associated factors with low 5 th minute Apgar score among newborns in Gondar University referral hospital.
The hospital is located in North Gondar zone at about 727 kilometers NorthWest of Addis Ababa, the capital city of Ethiopia. The hospital provides delivery services 24 hours a day, 7 days a week and is staffed with midwives, intern doctors, general practitioners and obstetricians. All mother/neonate index singleton live births after 28 weeks of gestation during the study period were included in the study. Deliveries of unknown gestational age(unknown last normal menstrual Period and no ultrasound estimation) were not included.
A sample size of 261 was calculated using single population proportion formula assuming a 35.7% proportion of 5 th minute low Apgar score from previous study in Ethiopia 15 at a 95% confidence limit, 5% margin of error and correction formula. Systematic random sampling technique was used to reach at each participant. By taking a monthly average of 350 deliveries from preceding year report and considering a skip interval of 4, the calculated sample size was achieved in the three months of data collection period.
Data was collected by five graduating first class degree midwifery students in the delivery and operation rooms. Data collectors were assigned at day and night rotations to address the design. Training on the standard procedures of Apgar score estimation with emphasis on a three scale easily identifiable selection criteria for each Apgar score variables and an interview procedure was provided to data collectors. Each newborn recruited was assessed for Apgar in the 1 st , 5 th and 10 th minutes after birth and weighed only once soon after delivery. Maternal and obstetric information was collected at admission, during first stage of labor and after delivery.
The interview questionnaire consisted of maternal socio-demographic and obstetric variables. In addition, variables related to the newborn were included. Completeness of the data and relative accuracy of Apgar score estimation was evaluated by a senior midwife who was the maternity ward head on daily basis.
All collected questionnaires were checked for completeness and consistency of responses manually. Then data was coded, entered in to EPI INFO version 3.4.3 and analyzed using IBM SPSS statistics versions 20.0. Bivariate crude odds ratio and multivariate adjusted odds ratio was done by Logistic regression model. The presence and strength of association of variables was assessed using odds ratio with 95% confidence interval. Ethical clearance was obtained from department of Midwifery which is a delegate of the institutional review board of Gondar University. Permission to conduct the study was also obtained from Gondar University referral hospital. Participants were informed about the purpose and objective of the study. They were also informed that, they had the right to discontinue or refuse to participate in the study. Verbal consent was obtained from each study participants. Confidentiality of information and privacy was observed.

Result
A total of 261 neonate/mother pairs were involved in this study. About 82% of the mothers were aged 20 -34 years, with a range between 18 -42 years and a median age of 25 years. Nearly three quarters were urban dwellers. Majority (95.0%) were married and 55.9% house wives (Table 1).  The results of multivariate analysis (Table 3)indicated a significant association between fetal presentation and low 5 th minute Apgar score. Fetuses who adapted non-vertex presentation were 4.46 times (AOR (CI) = 4.46 (1.41, 14.08)) more likely to have a low Apgar score than those who adapted vertex presentation.
Other factors that remained significantly associated on multivariate analysis include; induced/augmented labor, labor duration > 24 hours, the presence of meconium and low birth weight (Table 3).

Discussion
The purpose of this study was to assess the proportion and associated factors of low 5 th minute Apgar score among newborns in Gondar University referral hospital. The proportion of low 5 th minute Apgar score in this study was 13.8%. This result is lower than another institution-based study in South-West Ethiopia (35.7%) 15 . This difference might be explained by the time gap between these two studies. In the earlier time, institutional delivery was only utilized by a small (5% with 31-39.5% urban residents) proportion of the population in the country 25,26 ; from this we can extrapolate that the then institutional deliveries might be self referred obstetric complications with high neonatal morbidity. In other studies done among West, North and sub-Saharan African emigrants and in Uganda 16,17 ; 3.9%, 1.8% and 8.4% proportion of low 5 th minute Apgar score was reported. The disparity in the proportion from current study might be due to better utilization of institutional delivery 27 (36.6% with 79.2% urban residents) and probably better obstetric care even in the case of emigrants.
In the analysis of associated factors, non-vertex fetal presentation was significantly associated with low 5 th minute Apgar score. A study done in Uganda 17 showed similar findings. This similarity might be due to the fact that in non-vertex fetal presentation, there will be chance of caesarean 18 or manipulative vaginal deliveries, which could further affect Apgar score.
One of the factors that were associated with 5 th minute low Apgar score in this study, prolonged labor, was similar to other studies 19 . In addition, induced/augmented labor and the presence of meconium stained liquor in this study were significantly associated with low Apgar score. In the case of prolonged labor, induction/augmentation and meconium stained liquor, there will be a chance of fetal distress, which could affect mode of delivery and subsequently distressed fetuses will have low Apgar scores. Studies also supported that tachy-systole and uterine rupture are among identified side effects of induction/augmentation of labor which can result in fetal distress, then passage of meconium and eventually end up in caesarean delivery or hysterectomy 20,21 .
The current study also revealed that newborn babies with low birth weight were about 4.5 times more likely to have low 5 th minute Apgar score compared to those with normal birth weight. The findings from other studies 18, 22 also showed consistent results with current study. Different from the finding in this study, one study 23 showed low Apgar score associated with extremely low birth weight. This could be explained by the fact that small babies might suffer from difficult birthing and might develop difficulty in cardiopulmonary transition and perinatal asphyxia 24 .

Limitations
This study did not consider some potential risk factors for low Apgar score such as placental factors, multiple pregnancy, congenital syndromes and intra-uterine infections since the conditions were unavailable at the time of study.

Conclusion and recommendation
In this study 13.8% neonates had low Apgar score at 5 th minute of life. Mainly obstetrics factors (non-vertex fetal presentation, prolonged labor, presence of meconium stained liquor, induced/augmented labor and low birth weight) were significantly associated with low 5 th minute Apgar score. Improving labor management through implementing regular use of partograph, 1:1 midwife-client ratio and advanced electronic fetal monitoring technology is recommended. In addition, in order to address other potential variables and to identify immediate and long term outcomes of low apgar score, a large scale study is recommended.