Apgar Wars ~ AJOG study claims 10-fold increase in zero Apgar @ 5 min for PHB midwives: Numbers only ~ 1st in series

by faithgibson on September 18, 2013

in Contemporary Childbirth Politics

LInk to the original article as posted on Medscape

This is the first of series of rebuttal articles by me on this general topic. Today I’m providing a link to the original Medscape version of a journal paper that will be (maybe already is) published in the Am Journal of Obstetrics and Gynecology (AJOG)

The study was undertaken by Amos Grünebaum, MD, chief of labor and delivery, New York–Presbyterian/Weill Medical College of Cornell University, New York City, and study coauthor Frank Chervenak, MD, a and director of maternal-fetal medicine at New York–Presbyterian/Weill Cornell.  These two men and their unnamed colleagues used data from the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) to assess deliveries by both physicians and midwives in hospitals, freestanding birth centers, and homes.

According to the Medscape report, all babies in the study were of 37 weeks’ gestation or more and weighed at least 2500 g at birth.

Five-minute Apgar scores of zero and neonatal seizures or serious neurologic dysfunction were analyzed according to where the births took place and whether the delivery was performed by a hospital physician, a hospital midwife, a freestanding birth center midwife, or a home midwife.

This post only re-states the statistics provided in the original article, translating them from probility percentages to a ratio. Assuming the data in the study is accurate (and I personally question it), what number of birth would on average result in a live-born baby having a zero Apgars @ 5-minutes relative to the? Would one predict an average of 1 out of a hundred, 1 out of a thousand, etc?

I find dealing with the data stated as a ratio as an easier way to understand the risks, which also makes it easier to talk about or explain to others.

Personally, I found these numbers more helpful in making a mental picture out of this data.

Reported zero 5-min Apgars by Place of Birth/all parity

midwives/PHB –>                                        98/60,296 =      one per      615 live births

midwives/freestanding birth centers     23/42,000 =        one per     1,826

hospital-midwife                                       95/1,115,794 =    one per     11,745   (19 Xs less PHB)

MD-attended hospital –>                 1943/12,615, 996 =    one per    6,493

Authors suggest the critical factor is the location of the birth, not the training of the professional involved in delivery


5-minute Apgar score of zero for nulliparous patients

home deliveries                                                 35/14,801 births

physician-attended hospital delivery     856/5,155,779 births


neonatal seizures or serious neurologic disorders

home births attended by midwives —            42/49,091     births

freestanding birth centers                               14/33,188     births

hospital midwives                                         121/727,395    births

hospital delivery by physicians —       1823/8,102,337  births

In my research using the most recent (2009) nativity data — linked birth and death certificates for 2009 — it identifies about 8,700 deaths of term neonate wt. over 2500 with pregnancies of 37-41, with another 600 NN deaths for pregnancies of wk 42 (about 9,300 total).

Out of 4,000,000 births that year (2009) the 9,300 NN deaths represents a ratio of one term baby death out of every 430 live births of normal wt babies. Since PHB is slightly less that 1% (around 30,000), that would result in an average NNM of for hospital births (total 3,970,000) would be one NND per 426 birth or a rate nearly 2.5 per 1,000.

When i read that doctors attending hospital births for mothers 37-42 wks only encounter ONE 5-min. Apgar of zero out of 6,493 births, which would have included 15.24 NN deaths with ONLY one such critically low Apgar score,  I can’t help but wonder how that could be. 

Stay tuned for additional critique of an article that the news media is characterizing as “alarming”.

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