![]() ![]() In modern practice, the Apgar score is calculated at 1 and 5 minutes after birth, and again at 10 minutes if the 5-minute Apgar was low. The score comprises 5 categories (skin color, heart rate, reflex irritability, activity/flexion, and respiratory effort) that are each scored from 0 to 2, resulting in an overall range of 0 to 10, with 10 indicating that the highest score was given for each clinical indicator of neonatal well-being. Epidemiologists likewise quickly adopted the Apgar score as an outcome in perinatal research, because it is straightforward, easily understood, and almost universally recorded in birth-related data sources. Virginia Apgar created her namesake score in 1953 ( 1), and its use quickly became ubiquitous in maternity care settings throughout high-resource countries, including the United States. ![]() Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear.ĭr. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not comparing median Apgars between groups might be an analytical alternative to dichotomizing. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. We used 3 different criteria to determine optimal cutpoints. We treated 5-minute Apgars as clinical “tests,” compared against 18 known outcomes we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 2 data sets to explore this issue: one contained planned community births from across the United States ( n = 52,877 2012–2016), and the other contained hospital births from California ( n = 428,877 2010). Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). ![]()
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