Am J Perinatol
DOI: 10.1055/a-2259-0472
Original Article

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores

1   Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
Kaitlyn E. James
1   Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
Thomas H. McCoy
2   Massachusetts General Hospital, Center for Quantitative Health, Boston, Massachusetts
Roy H. Perlis
2   Massachusetts General Hospital, Center for Quantitative Health, Boston, Massachusetts
Anjali J. Kaimal
3   Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
1   Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
› Author Affiliations
Funding M.A.C.'s work was supported by the American Association of Obstetricians and Gynecologists Foundation/American Board of Obstetricians and Gynecologists Research Scholar Award. The funder had no role in this work's design, analysis, writing, or submission.


Objective Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity.

Study Design Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to “low-risk” term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots.

Results A total of 14,497 maternal–neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated.

Conclusion A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries.

Key Points

  • EOCS had moderate discrimination for Apgar <7.

  • Predictive performance declined when limited to low-risk term singletons.

  • Relationship between EOCS and Apgar <7 was likely driven by prematurity.


The abstract was presented as a Poster Presentation at the 42nd Annual Meeting for the Society of Fetal Medicine (SMFM Abstract #744), which was held virtually from January 31 to February 5, 2022.

Supplementary Material

Publication History

Received: 29 September 2023

Accepted: 30 January 2024

Accepted Manuscript online:
01 February 2024

Article published online:
01 March 2024

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