Letter to the Editors
org
Improving neonatal care by advancing the Apgar
scoring system
Grünebaum et al’s1 perspective “Is it time to modify the
Apgar score?,” written in response to our article, “Associations
between provider-assigned Apgar score and neonatal race,”
was thought-provoking and a step in the right direction.2
Our study demonstrated that providers assigned lower
Apgar scores in Black neonates than in non-Black neonates
when controlling for other factors (ie, umbilical cord gases,
gestational age, and maternal and fetal complications). This
difference seemed to be driven by lower scores assigned to
Black neonates on their Apgar color subscore. However, the
lower scores assigned to Black neonates did not seem to be
clinically indicated and may have contributed to increased
neonatal intensive care stays for these offspring.2
In their response to our article, Grünebaum and colleagues1
assert that the lower Apgar scores may stem from inherent
flaws in the Apgar scoring system. The authors further argue
that continued use of the Apgar score violates Section 1557 of
the Patient Protection and Affordable Care Act, which man-
dates nondiscrimination in the use of clinical algorithms.
We concur with Grünebaum and colleagues1 and assert
that the Apgar color subscore may not be beneficial for the
care of neonates. As they point out, the creator of the Apgar
score herself recognized these limitations.3 We encourage
replication of our study, and we are eager to read about
crucial examinations of the clinical benefit of the color sub-
score. Furthermore, future research on the extent to which
inaccurately low Apgar scores are caused by individual pro-
vider bias or inherent bias in the Apgar algorithm is needed.
We hope that our article and Grünebaum et al’s1 call-to-
action response speed future research in this area. Physi-
cians should seek to provide unbiased care and address this
issue with urgency. Grünebaum and colleagues1 rightly point
out the additional urgency mandated by the Patient Protec-
tion and Affordable Care Act, whose legal obligation to
S990 American Journal of Obstetrics & Gynecology MARCH 2024
ajog.
eliminate discriminatory clinical algorithms would certainly
seem to apply here.
Given that other more objective tools, such as pulse ox-
imetry, have also been demonstrated to be racially biased,4 we
agree with Grünebaum and colleagues1 suggestion to replace
the current Apgar score with a new version without the color
subscore. -
Sara E. Edwards, MD
Quetzal A. Class, PhD
Department of Obstetrics and Gynecology
University of Illinois Hospital
820 S. Wood St., M/C 808
Chicago, IL, 60612
qaclass@uic.edu
The authors report no conflict of interest.
This study was supported by the National Center for Advancing
Translational Sciences, National Institutes of Health (NIH; grant number
UL1TR002003). The content of this study is solely the responsibility of the
authors and does not necessarily represent the official views of the NIH.
REFERENCES
1. Grünebaum A. Is it time to modify the Apgar score? Am J Obstet
Gynecol 2023.
2. Edwards SE, Wheatley C, Sutherland M, Class QA. Associations be-
tween provider-assigned Apgar score and neonatal race. Am J Obstet
Gynecol 2023;228:229.e1–9.
3. Apgar V. A proposal for a new method of evaluation of the newborn
infant. Curr Res Anesth Analg 1953;32:260–7.
4. Valbuena VSM, Merchant RM, Hough CL. Racial and ethnic bias in
pulse oximetry and clinical outcomes. JAMA Intern Med 2022;182:
699–700.
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2023.03.029