Peer-reviewed article

Prediction of low 5-minute Apgar scores: development and internal validation of parity-stratified clinical prediction models for sub-Saharan Africa.

Franzén-Malmros M, Daraiseh S, Schmauder S, Akuze J, Wanduru P et al. · 25 Apr 2026

Summary

Written by AI, not yet AICS's view · claude-haiku-4-5-20251001

This study developed two clinical prediction models to identify newborns at risk of low Apgar scores at 5 minutes after birth in sub-Saharan Africa. Using data from over 124,000 births across hospitals in Benin, Malawi, Tanzania and Uganda, the researchers created separate models for first-time mothers and experienced mothers, including factors like antepartum haemorrhage and severe anaemia. The models showed moderate ability to predict which babies would have low Apgar scores, which could help healthcare workers in busy or resource-limited settings identify newborns needing urgent care.

Key points

6.3% of newborns in the study population received a low 5-minute Apgar score
The parous (experienced mother) model showed better predictive ability (C-statistic 0.732) than the nulliparous model (C-statistic 0.663)
Antepartum haemorrhage and severe anaemia were the strongest risk factors in both models
The models included 14 predictors for first-time mothers and 19 for experienced mothers
Both models demonstrated excellent calibration, meaning predicted risks closely matched actual outcomes

Limitations

The study only conducted internal validation using bootstrapping from the same dataset; external validation in different populations and settings is needed to determine whether these models work reliably in other contexts. The study does not report whether using these prediction models actually led to better clinical outcomes or interventions for newborns.

Abstract

BACKGROUND: Low 5-minute Apgar scores remain an important indicator of compromised neonatal status and may assist in identifying high-risk newborns in resource-constrained or high-volume labour ward settings. Accurate prediction of newborns at risk could guide timely intrapartum and immediate postpartum interventions. Because risk factors vary by maternal parity, prediction models may benefit from a parity-specific approach. This study aimed to develop and internally validate two prognostic models for predicting low 5-minute Apgar scores, stratified by parity. METHODS: The analysis used data from 124,376 singleton births at or beyond 28 weeks of gestation, recorded between July 2021 and December 2023 across 16 hospitals in Benin, Malawi, Tanzania and Uganda. Model predictors were selected using a knowledge-based approach, and multivariable logistic regression was performed. Model performance was assessed through calibration and discrimination with internal validation conducted using bootstrapping. The predicted outcome was the 5-minute Apgar score, categorised as low (< 7) or normal (≥ 7). RESULTS: In the overall study population, 6.3% of newborns received a low Apgar score. The final nulliparous and parous models included 14 and 19 predictor parameters, respectively, with country included as an additional fixed effect. The models demonstrated moderate optimism-adjusted performance, with C-statistics of 0.663 for the nulliparous model (95% CI: 0.654–0.675) and 0.732 for the multiparous model (95% CI: 0.724–0.740). Calibration was excellent in both models, with calibration-in-the-large (CITL) values of 0.000–0.001 and calibration slopes of 0.989–0.995. Antepartum haemorrhage and severe anaemia were the strongest contributors in both models. CONCLUSIONS: Two prediction models for low 5-minute Apgar scores, one for nulliparous and one for parous women, demonstrated moderate predictive ability. External validation and further testing are necessary to assess the generalisability and clinical utility of these models.

Findings the Hub has extracted

Each claim below is labelled by its type of design and links back to this report.

Survival

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Problem

Low 5-minute Apgar scores indicating compromised neonatal status, particularly in resource-constrained high-volume labour ward settings in sub-Saharan Africa

Intervention: Two parity-stratified clinical prediction models using maternal and clinical risk factors to predict risk of low 5-minute Apgar scores
Population: 124,376 singleton births at or beyond 28 weeks of gestation across 16 hospitals in Benin, Malawi, Tanzania and Uganda (July 2021 - December 2023)

Key finding

Nulliparous model C-statistic: 0.663 (95% CI: 0.654–0.675)