Risk factors for a low five-minute Apgar score at a provincial referral hospital in southern Mozambique: A secondary analysis of a matched case-control study

Perinatal asphyxia is a leading cause of neonatal death in Mozambique and the main cause of early neonatal death in the referral hospitals of Gaza Province. Where blood gas analysis is unavailable, a low five-minute Apgar score remains a key marker of intrapartum compromise. This study aimed to identify maternal, obstetric, fetal and institutional factors associated with a low five-minute Apgar score at Xai-Xai Provincial Hospital, Mozambique. We conducted a secondary analysis of the records of 471 newborns delivered between January 2016 and December 2018, drawn from a matched case-control study of early neonatal death. The outcome was a five-minute Apgar score below 7. Associations were estimated with bivariate and multivariable conditional logistic regression and are reported as odds ratios with 95% confidence intervals. Of the 471 newborns, 76 (16.1%) had a low five-minute Apgar score. In the multivariable model, a gestational age of 42 weeks or more (adjusted odds ratio 4.04; 95% confidence interval 1.18-13.82) and ruptured membranes on admission (adjusted odds ratio 3.69; 95% confidence interval 1.37-9.96) were associated with higher odds of a low score, whereas partograph use during labour was associated with lower odds (adjusted odds ratio 0.07; 95% confidence interval 0.01-0.31). The association with preterm birth was attenuated after adjustment for birth weight. Post-term birth and ruptured membranes on admission were associated with a low five-minute Apgar score, and partograph use with lower odds. Because the sample was drawn from a study of early neonatal death, these associations should be confirmed in unselected birth cohorts. They nonetheless support strengthening intrapartum monitoring in Mozambican referral maternities.