Introduction
The neonatal period is the most vulnerable period for a child’s
survival. The child’s risk of dying is the highest in the first 28 days
of life. One of the leading causes of neonatal death is birth asphyxia.
The World Health Organization (WHO) defines birth asphyxia as “the
failure to initiate and sustain breathing at birth”.(1) In birth
asphyxia, the marked impairment of blood flow or gas exchange to or from
the fetus in the period before, during or directly after birth, leads to
progressive hypoxemia, hypercapnia, and significant metabolic acidosis.
Globally, birth asphyxia is responsible for an estimated 900,000
neonatal deaths each year, and it is the main cause of death in term
infants admitted to the neonatal intensive care unit (NICU).(2, 3)
Furthermore, birth asphyxia is a major cause of morbidity with both
significant short and long-term consequences.(4, 5)
The Apgar score provides a rapid assessment of the infant’s clinical
status immediately after birth and of the response to resuscitation if
needed.(6, 7) In term infants without severe congenital malformations, a
low 5-minute Apgar score has the best predictive value for neonatal
mortality and is highly associated with subsequent neurological
disability such as cerebral palsy, cognitive impairment, attention
deficit/hyperactivity disorder, and epilepsy even in the era of
therapeutic hypothermia.(8-12)
Previous studies showed that the risk of a low 5-minute Apgar score
<7 among term singletons slightly decreased in the period
1999-2009 in the Netherlands, but significantly increased in the
subsequent period (from 9.9/1000 in 2010 to 10.9/1000 in 2014,p< 0.001).(13-15) This latter observation is worrisome.
An association with epidural analgesia was suggested, because the study
presenting data from 2010-2014 also showed that the strongest risk
factor for an Apgar score <7 was the use of epidural
analgesia.(14) To the best of our knowledge, there are no studies
presenting more recent trends in the Netherlands for a low Apgar score
in the Netherlands, including Apgar score <4.
The primary aim of the present study was to investigate recent trends in
indicators of birth asphyxia over the last decade (2010-2019) in the
Netherlands, with a low 5-minute Apgar score as main outcome measure.
The secondary aim was to identify risk factors for a low Apgar score,
and to describe trends over time in low Apgar scores in subgroups of
infants based on obstetric interventions and level of care.