Determinants of Low Fifth Minute Apgar Score among Newborn Delivered at health facilities in Ethiopia,systematic review and meta-analysis

Determinants of Low Fifth Minute Apgar Score among Newborn Delivered at health facilities in Ethiopia,systematic review and meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determinants of Low Fifth Minute Apgar Score among Newborn Delivered at health facilities in Ethiopia,systematic review and meta-analysis Tadele Fentabel Anagaw, Eneyew Talie Fenta, Ousman Adal, Abiyu Abadi Tareke, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4221694/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Apgar score is the most consistently used measure of neonatal health and it provides an accepted and convenient method for reporting the status of newborn infants in the few minutes after birth. Apgar score at 5th minute are better predictor neonatal survival. There is no evidence on pooled magnitude and determinant factors associated with low 5th minute Apgar score among newborns delivered in Ethiopia. Objective This review aimed to estimate the pooled magnitude and associated factors with low 5th minute Apgar score among newborns delivered at health facilities of Ethiopia Method Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist guideline was followed for this review and meta-analysis. Electronic data base (PubMed, EMBASE, Midline, Cochrane library, Web of science, Google scholar and Science direct) were used to retrieve studies. Data were extracted using Microsoft Excel and analyzed using STATA version 17. Publication bias was checked by funnel plot, Beggs and Egger’s regression test. Pooled analysis was conducted using a weighted inverse variance of random effect model. Subgroup and sensitivity analysis was done. Result Nine papers were included from the total of 1982 articles that were retrieved using various electronic databases in order to determine the aggregate magnitude of low five-minute APGAR scores. A total of 23% (95% CI 16–30) of newborns delivered at Ethiopian health facilities had a low 5-minute APGAR score. Factors associated with low Apgar score were Skin incision time > 3 minutes (AOR:4.76,95%CI:1.28–8.25),gestational hypertension (AOR = 5.71, 95%CI: 0.89–10.53), birth weight < 2500 gram (AOR:4.82,95%CI:3.72–5.91) ,induced/augmented labor (AOR:3.21, 95%CI:2.27–4.15),meconium-stained liquor (AOR: 5.36,95%CI: 3.45–7.27), Presentation of fetus non vertex (AOR:3.15,95% CI:1.31–5.01), no ANC follow up (AOR:11.46,95%CI: 3.94–18.97), cesarean section delivery(AOR:15.98,95%CI:14.76–17.22),APH/PPH (AOR:8.92,95%CI:7.87–9.98),and Prolonged labor duration > 24hours (AOR:13.92,95%CI:10.95-16). Conclusion This review revealed that approximately 3 in 10 newborns delivered at health facilities of Ethiopia had low 5th minute Apgar score. Therefore, Comprehensive intervention including enhancing ANC follow up, early identification danger sign and complication of pregnancy and nutritional coursing were recommended for healthcare workers and concerned stakeholders working on maternal, newborn, and child healthcare. Apgar score newborn 5th minute Apgar score Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Apgar score is means of rapid assessment of newborn health status and the most consistently used measure of neonatal health and it provides an accepted and convenient method for reporting the status of newborn infants in the few minutes after birth( 1 , 2 ). Five factors are used to evaluate the baby’s condition and each factor is scored on a scale of 0 to 2, with 2 being the best score for each: the scoring system is an accepted tool for assessing the vitality of newborn infants. The score is based on measures of heart rate, respiratory effort, skin color, muscle tone, and reflex irritability ( 3 ).Scores obtainable are between 0 and 10, with 10 is the highest possible score. A total score of 7–10 is considered “normal,” and a lower Apgar score indicates depressed vitality ( 4 ) Initially, the Apgar score at 1-min is used to assess the need for immediate resuscitation. The 5-minute Apgar score indicates the capacity to recover and the potential need for ongoing management ( 5 ). Low Apgar score was predictors of neonatal mortality and morbidity( 6 , 7 ). low Apgar score at 5 minute are predictors of neonatal survival( 8 ) and In recognition of low Apgar score at 5 minute score of < 7, are associated with an increased risk of neonatal respiratory distress, need for mechanical ventilation and admission to neonatal intensive care unit( 9 , 10 ) a higher risk of childhood cancers( 11 ) and high risk of cerebral palsy( 10 , 12 ). Infant and child mortality rates are basic indicators of a country’s socio-economic situation and quality of life ( 13 ). In recent years there is a continuous decline in infant and under 5-mortality but neonatal mortality remains stable especially in a country like Ethiopia ( 14 ). In the first 20 days of life, 2.3 million children worldwide perished in 2022. Roughly 6500 neonatal fatalities occur each day, making up 47% of all child deaths under the age of five. Since 1990, there has been a significant global improvement in child survival. Neonatal deaths decreased from 5.0 million in 1990 to 2.3 million in 2022 on a global scale. However, compared to post-neonatal under-5 mortality, the drop in neonatal death from 1990 to 2022 has been slower. Where a child is born still affects their odds of surviving; sub-Saharan Africa and southern and central Asia account for the majority of newborn mortality. With 27 deaths per 1000 live births in 2022, Sub-Saharan Africa had the highest rate of newborn mortality, followed by central and southern Asia with 21 deaths per 1000 live births( 15 ). One of the key focuses of the Sustainable Development Goals (SDG) is newborn health, with nations aiming to meet the target of lowering neonatal mortality to 12 deaths per 1,000 live births by 2030. In order to fulfill the SDG objective (SDG 3.2.1) for under-five mortality by 2030, 54 countries—three quarters of which are in the WHO African Region must drastically lower their under-five mortality rates ( 16 ). Neonatal mortality rates in sub-Saharan African nations were notable, despite the fact that a lot of work has been done. The Apgar score is one of the first instruments used to evaluate a newborn's health. The early prevention of morbidity and mortality in neonates thus depends critically on recognizing the factors that contribute to a low Apgar score. In Ethiopia there is no comprehensive evidence on magnitude and determinants of low Apgar score. Therefore, this systematic review and metanalysis aimed to assess the estimated pooled magnitude and determinant factors associated with low fifth minute Apgar score among newborn delivered at health facilities in Ethiopia. This study findings provide evidence for health care professionals, policy makers and concerned stakeholders working on maternal, newborn and child health care for development of appropriate intervention measure. Method Research question What are the determinants factors of low fifth minute Apgar score among newborns delivered at public health facilities in Ethiopia? Search strategies This systematic review and meta-analysis were conducted to estimate the pooled magnitude of low APGAR score at 5th minutes among newborn delivered at health facilities in Ethiopia and to summarize associated factors with low APGAR score at 5th minutes. Preferred reporting items of systematic review and meta-analysis (PRISMA)( 17 , 18 ) flow diagram standards (Fig. 1 ) and a PRISMA checklist were used during the review process. Electronic databases such as PubMed, EMBASE, Midline, Scopus, Web of Science, Google Scholar, and Science Direct were used to retrieve studies reported in the English language with publication years from inception to date. The search was conducted from February 20 to 30, 2024. The search strategies were conducted by combining keywords using AND/OR Boolean terms. “Low APGAR score at 5th minutes, " APGAR score”, “APGAR score at 5th minutes”, AND newborn/neonate/ ‘AND/OR "determinant/associated/risk factors “are both in the medical subject heading and free text terms. To prevent further duplication, we have looked up published or current projects relating to the topic in the PROSPERO database ( http://www.library.ucsf.edu ). As a result, the conclusion showed that there were neither ongoing nor published articles on this review. Therefore, the protocol for this systematic review and meta-analysis is registered in the International Prospective Register of Systematic Reviews (PROSPERO)(Ongoing). Inclusion and exclusion criteria A cross-sectional study, a cohort study, quasi experimental studies, experimental and a case study that reports APGAR score at 5th minutes among newborn delivered at health facilities of Ethiopia are included. Publication year from inception to date, English language and study area are in Ethiopia are other inclusion criteria. Exclusion criteria were language other than English, duplicated articles, and not measuring the outcome variable. Two authors (TFA and ETF) independently searched and screened the studies based on the title and abstract at the initial steps. In the next step, both authors select the full text based on the eligibility criteria independently. In cases of disagreement, the third author (EKB they were resolved by making decision. Study quality Assessment The quality of the studies included in this systematic review and meta-analysis was done using the Joanna Briggs institute ( 19 ) checklist for analytical cross-sectional studies( 20 ). The JBI critical appraisal cheek list had eight parameters with the options of Yes, No, unclear and not applicable. The quality checklist parameters include the following questions:( 1 ) Were the criteria for inclusion in the sample clearly defined?, ( 2 ) Were the study subjects and the setting described in detail?,( 3 ) Was the exposure measured in a valid and reliable way?,( 4 ) Were objective, standard criteria used for measurement of the condition?,( 5 ) Were confounding factors identified?,( 6 ) Were strategies to deal with confounding factors stated?,( 7 ) Were the outcomes measured in a valid and reliable way?, and ( 8 ) Was an appropriate statistical analysis used? Studies were considered low risk if there was a score of 50% and above of the quality assessment indicators and included in the final analysis( 19 ) (Table 1 ). Table 1 Quality assessment of included studies in this systematic review and meta-analysis Authors name Criteria for inclusion Study subject and setting Measure of exposure Identify of confounding factors Strategy to deal with confounding Measure of outcome Objective for measurement of the condition statistical analysis used Total percent (100%) Level of quality Obsa. MS et al( 21 ) Yes Yes Yes Yes Yes Yes Yes Yes 7 87.5% High Mersha.A et al( 22 ) Yes Yes N/A Yes No Yes Yes Yes 6 75% High Zewude.SB et al( 23 ) Yes Yes N/A Yes Yes Yes Yes Yes 7 87.5% High Abebe. M, et al( 24 ) Yes Yes Yes No Yes Yes Yes Yes 6 75% High Gudayu. TW, et al ( 25 ) Yes Yes N/A No No Yes No Yes 6 62.5% High Yeshaneh. A, et al ( 26 ) Yes Yes Yes Yes No Yes Yes Yes 7 87.5% High Getachew. B et al( 27 ) Yes Yes N/A Yes No Yes No Yes 5 62.5% High Gebremedhin.MM et al( 18 ) Yes Yes Yes Yes No Yes Yes Yes 7 87.5% High Ajibo.BD. et al( 17 ) Yes Yes Yes Yes Yes Yes Yes Yes 8 100% High Selection of the study The articles were initially found based on the study's objectives and screened based on their titles and abstracts. In the second step, the article that did not meet the inclusion requirements was eliminated. After this, the eligible articles were further screened by reading the full texts, and those that did not meet the inclusion criteria were excluded. Finally, the eligible full-text articles that fulfilled the inclusion criteria were included in the review. Data extraction Data were extracted on a Microsoft Excel spreadsheet from the included studies. Information was extracted based on the study's characteristics: name of the first author, publication year, study settings, study design, sample size, sampling technique, data collection technique, Magnitude of low APGAR score at 5 minute and determinant factors associated with low APGAR score at 5 minutes were extracted. Outcome measurement The main outcome is the magnitude of low Apgar score at fifth minute among newborns delivered in health facilities of Ethiopia. The Apgar scores computed by using five components. 1. Appearance: two points for pink, 1 point for bluish extremities, 0 points for blue. 2. Pulse rate: 2 points for ≥ 100 beats/minute, 1 point for < 100, and 0 points for none. 3. Grimace: 2 points for crying, 1 point for whimpering, and 0 points for silence. 4. Activity: two points for active, 1 point for moderate, and 0 points for limp. 5. Respiration: 2 points for regular breathing, 1 point for irregular and < 30 breath/ minute, and 0 points for none. Low fifth-minute Apgar scores were determined as a score of < seven at the fifth minute after summing the scores (Reference). The authors used adjusted odds ratio to determine associated factors of low 5-minute Apgar score. Statistical analysis and Publication bias Data analysis was conducted using STATA version 17 (Sta-ta Corp., College Station, TX, USA). A random effect model meta-analysis was employed to estimate the pooled magnitude of low APGAR score at 5 minutes on neonates of mothers who gave birth at health facilities in Ethiopia. The heterogeneity among effect sizes of the included studies was evaluated using the Q test results with a significance difference of P 75%( 28 ) and Potential publication bias was assessed by using a funnel plot. The factors associated with low APGAR score at 5 minutes were summarized using qualitative thematic analysis. The risk of publication bias for this systematic reviews and meta-analyses was tested using an subjective judgment funnel plot symmetry ,and objectively by Egger’s test( 29 , 30 ). Result Search outcomes In all, 1982 articles were obtained from the selected databases and registrations. After 996 items were eliminated for being duplicates, 986 articles were screened using title and abstract and exclude 889. Finally, 97 articles were screened by full text and 88 articles were excluded using inclusion and exclusion criteria. Ultimately, 9 articles with a total of 3508 participants were included in the qualitative and quantitative synthesis (Fig. 1 ). Characteristics of included studies Table 2 presents a summary of the study characteristics, major quantitative and overall findings of the studies included in the review. Nine articles were included in this review fulfilled the inclusion and exclusion criteria and measure the magnitude of low 5th minute APGAR score of newborns delivered at public health facilities in Ethiopia. From total of nine articles 3508 newborns delivered at public health facilities of Ethiopia were included. The study design used for the included study were 4 articles unmatched case control( 17 , 18 , 24 , 26 ) ,4 cross sectional study design( 22 , 23 , 25 , 27 ) and 1 article cohort study( 21 ).Six studies used systematic random sampling technique( 18 , 21 – 25 ) ,while three use simple random sampling technique( 17 , 26 , 27 ).The included studies was done six regions of Ethiopia 2 in each regions of Amhar( 23 , 25 ), Sidama ( 24 , 26 ) and Southern nation nationality( 17 , 22 ) and 1each region of Tigray( 18 ), Oromia( 27 ) and Addis Ababa( 21 ).The sample size ranges from lowest 261( 25 ) study done in Gonder and Highest 662( 18 ) in Lemlem Karl hospital Tigray region. Most 77.7% (7/9) of the studies published in the last 4 years and the rest 2 published since 2017 this suggesting recent increase interest of subject area in Ethiopia. All the studies use the same measurement criteria of APGAR score of newborns delivered immediately at 5 minutes. Table 2 Characteristics of included studies in the review Author year Study area Region Study design Sample size Sampling technique Magnitude of low APGAR score at 5th minutes Obsa. MS et al( 21 ) 2020 Addis Ababa Addis Ababa Cohort 354 SRS 12.8 Mersha.A et al( 22 ) 2019 Arba Minch SNNP Cross sectional 286 SRS 17.8 Zewude.SB et al( 23 ) 2021 Debre Tabor Amhara Cross sectional 315 SRS 18.1 Abebe. M, et al( 24 ) 2024 Dilla Sidama Case control 534 SRS 33.3 Gudayu. TW, et al ( 25 ) 2017 Gondar Amhara Cross sectional 261 SRS 13.8 Yeshaneh. A, et al ( 26 ) 2021 Hawassa Sidama Case control 401 Srs 33.4 Getachew. B et al( 27 ) 2020 Jimma Oromia Cross sectional 366 Srs 11.5 Gebremedhin.MM et al( 18 ) 2020 Lemlem Karle Tigray Case control 662 SRS 33.38 Ajibo.BD. et al( 17 ) 2022 Wolaita Sodo SNNP Case control 329 srs 33.4 Note : SNNP: Southern nation nationalities of people, SRS: systematic random sampling, srs: simple random sampling Meta analysis results Pooled magnitude of low 5th minute APGAR score In this review, the pooled magnitude of low 5th minute Apgar score using random effect model restricted maximum likelihood model was found 23% (95% CI 16–30) (Fig. 2 ). Heterogeneity of Result The hetrogeniety between the studies included in the review was high(I 2 = 95.82%,t = 6.88) and it was significant (P = 0.00) with 95% CI(Fig. 2 ).The sources of high hetrogenity is not identified.However an increase hetrogenity is expected in the meta analysisof the magnitude of low 5th minute Apgar score of newborn delivered at health facilities in different regions and study design and the results could be interpreted sequentially and with caution. Moreover, the study tested a wide prediction interval, which was a direct and easily interpretable indicator compared to the CI, suggesting high heterogeneity. Publication bias and sensitivity analysis The publication bias was assessed using Begg’s test(P = 00.3481) and Egger’s regression test(P = 0.1664) non-significant, both of which shows there is publication bias. The review also revealed asymmetry in the funnel plot (Fig. 3 ). To identify the source of heterogeneity that affects the pooled magnitude of low 5th minute Apgar score among newborns delivered at health facilities of Ethiopia, we conducted a sensitivity analysis. According to the findings of the sensitivity analysis, the pooled magnitude of low 5th minute Apgar score among newborns obtained when every study was excluded from the analysis was within the 95% CI of the pooled magnitude of low 5th minute Apgar score when all studies fitted together. Furthermore, the sensitivity analysis result showed that the pooled magnitude of low 5th minute Apgar score ranges from 21.76%(95%CI,14.92–28.60) and 24.50(95%CI,17.811–31.18) when each study was left out of the sensitivity analysis (Fig. 4 ). Subgroup analysis Since there is substantial heterogeneity among the pooled magnitude of low 5th minutes of Apgar score, subgroup analysis was done based on publication year, study region, sample size 350, study design and sampling technique. Subgroup analysis based on publication year shows that there is high magnitude of low 5th minutes of Apgar score publication year from 2021–2024 with 29.55% (95%CI, 22.069–37.03). Sub group analysis using sample size revealed that there was high magnitude of low 5th minutes of Apgar score with sample size > 350 with 24.87% (95%CI, 14.685–35.067) and subgroup analysis using study design shows that unmatched case control was high 33.369% (95%CI, 33.322–22.416) and low using Cohort study design 12.8% (95%CI, 12.765–12.835) (Table 3 ). Table 3 Subgroup analysis-based on publication year, region, sample size, study design and sampling technique on low 5th minute Apgar score in Ethiopia Subgroup No. studies Estimates Heterogeneity Magnitude 95%CI I 2 p-value Publication year 2017–2020 5 17.86 9.974–25.738 99.99 0.00 2021–2024 4 29.55 22.069–37.031 99.98 0.00 Region Addis Ababa 1 12.8 12.765–12.835 - 0.00 Amhara 2 15.95 11.736–20.164 99.99 0.00 SNNP 2 25.6 10.312–40.888 100 0.00 Sidama 2 33.349 33.251–33.447 90.27 0.00 Oromia 1 11.5 11.467–11.533 - 0.00 Tigray 1 33.38 33.334–33.416 - 0.00 Sample size 350 5 24.876 14.685–35.067 100 0.00 Study design Cohort 1 12.8 12.765–12.835 - 0.00 Cross sectional 4 15.3 12.161–18.439 100 0.00 Unmatched case control 4 33.369 33.322–22.416 79.44 0.00 Sampling technique Systematic random sampling 6 21.53 14.019–29.041 100 0.00 Simple random sampling 3 26.1 11.792–40.408 100 0.00 Determinant factors associated with low 5th minute Apgar score From the total retrieved articles included in this review, eight studies reported factors associated with low 5th minute Apgar score ( 17 , 18 , 21 , 23 – 27 ).The pooled effects of two studies ( 17 , 21 ) demonstrate that newborn delivered by cesarean section with Skin incision time > 3 minutes were 4.76 times(AOR:4.76,95%CI: 1.28–8.25) more likely to have low 5th minute Apgar score as compared to skin incision time < 3 minutes among newborn delivered at public health facilities in Ethiopia The pooled effects of five studies( 17 , 18 , 21 , 23 , 24 ) showed that newborns delivered from gestational hypertension mothers were 5.71times (AOR = 5.71, 95%CI: 0.89–10.53) more likely to have low 5th minute Apgar score as compared to no gestational hypertension. The pooled effects of seven studies( 17 , 18 , 21 , 23 , 25 – 27 ) revealed that newborn with birth weight 2500 gram delivered at public health facilities in Ethiopia. The pooled effects of two studies ( 21 , 25 ) determined that induced/augmented labor were 3.21 times (AOR:3.21, 95%CI:2.27–4.15) more likely to have low 5th minute Apgar score as compared to newborn delivered with normal labor at public health facilities in Ethiopia. The pooled effects of five studies ( 17 , 18 , 21 , 23 , 25 ) confirms that meconium-stained liquor were5.36 times (AOR: 5.36,95%CI: 3.45–7.27) more likely to have low 5th minute Apgar score as compared to not meconium-stained liquor newborn delivered at public health facilities in Ethiopia. The pooled effects of three studies ( 23 – 25 ) showed that uterine Presentation of fetus non vertex was 3.15 times (AOR:3.15,95% CI:1.31–5.01) more likely to have low 5th minute Apgar score as compared to vertex presentation newborn delivered at public health facilities in Ethiopia. Similarly the pooled effects of two studies( 24 , 26 ) new born delivered from mothers who had no ANC follow up were 11.46 times(AOR:11.46,95%CI: 3.94–18.97) more likely to have low 5th minute Apgar score as compared to new born delivered from mothers who had ANC follow up in Ethiopia. The pooled effects of two studies( 17 , 18 ) revealed that new born delivery by cesarean section were15.96 times (AOR:15.98,95%CI:14.76–17.22) more likely to have low 5th minute Apgar score as compared to new born delivered by normal vaginal delivery at public health facilities in Ethiopia. Similarly, these two studies ( 17 , 18 ) showed that newborn delivered from mothers who had APH/PPH were 8.92 times (AOR:8.92,95%CI: 7.87–9.98) more likely to have low 5th minute Apgar score as compared to new born delivered from mothers who had no APH/PPH. The pooled effects of two studies( 25 , 27 )confirms that Prolonged labor duration > 24 hours were13.29 times(AOR:13.92,95%CI:10.95–16.88) more likely to have low 5th minute Apgar score as compared to new born delivered normal labor duration in Ethiopia(Table 4 ). Table 4 Factors associated with low 5th minute Apgar score among newborns delivered at health facilities in Ethiopia Variables No. studies Pooled AOR (95%CI) P-value Reference Skin incision time > 3minute 2 4.76 (1.28–8.25) 0.007 Skin incision time < 3minute Gestational Hypertension 5 5.71(0.89–10.53) 0.02 No Hypertension Birth weight 2500 gram Induced/augmented labor 2 3.21(2.27–4.15) 0.000 Not induced/ augmented labor Meconium-stained liquor 5 5.36(3.45–7.27) 0.000 Not stained meconium Presentation non vertex 3 3.15(1.31–5.01) 0.001 Vertex presentation No ANC follow up 2 11.46(3.94–18.97) 0.003 ANC Mode of delivery Cesarean section 2 15.98(14.76–17.22) 0.000 Vaginal delivery APH/PPH 2 8.92(7.87–9.98) 0.000 No APH/PPH Prolonged labor duration > 24 hours 2 13.92(10.95–16.88) 0.000 Normal labor duration (< 24 hours) Discussion This systematic review and metanalysis examined the pooled magnitude and determinant factors associated with low 5-minute Apgar score among newborns in Ethiopia. In this meta-analysis the pooled magnitude of low 5-minute Apgar score among newborns were determined using Random effect restricted maximum likelihood model. The estimated pooled magnitude of low 5-minute Apgar score was 23%(95%CI:16–30). This implies that approximately 3 in 10 newborns delivered in Ethiopia had low 5-minute Apgar score. Furthermore, this is contributing significant cause of high neonatal mortality rate in Ethiopia. This finding are significantly higher than 0.3%- 2.4% report on reviews done in 23 countries of Europe( 31 ).The discrepancy might be due to different standards of medical care and overall socioeconomic development in high income countries might contribute to this observable difference. This implies that there is significant gap in low-income countries like Ethiopia on prevention of contributing factors newborn death. The results of meta-analysis of 7 studies evidenced that birth weight 2500 gram among newborns in Ethiopia. This is in lined with meta-analysis reported that low birth weight had low Apgar score ( 32 ).This might be due to the fact that low birth weight occurs as a result of maternal complications before conception or antepartum period. This review showed that meconium-stained amniotic fluid were significantly associated with low 5-minute Apgar score. These findings were similar to systematic review done on effects of meconium-stained amniotic fluid and low birth weight on birth asphyxia ( 32 , 33 ).The possible reason might meconium-stained amniotic fluid had major impact on mode of delivery and newborn outcome. In this review the pooled effects of 5 studies revealed that new born delivered from gestational hypertension mother had higher odds of low 5-minute Apgar score as compared to new born delivered from non-hypertension mothers. The possible reason might be gestational hypertension leads to both maternal and newborn complication that had great impact on mode of delivery( 34 ) . This meta-analysis showed that new born delivered by cesarean section were more likely to have low 5-minute Apgar score as compared to normal vaginal delivery. This findings was similar to study done in Australia( 35 ).This might be due to cesarean section delivery increase risk of respiratory distress and other complications like hypoglycemia. This meta-analysis also found that pregnancy complication like Antepartum and postpartum hemorrhage had significantly associated with low 5-minute Apgar score. The possible reason might be Antepartum hemorrhage is linked to high rates of preterm deliveries, low birth weight, anemia, postpartum hemorrhage, intrauterine fetal death, and perinatal mortality( 36 ). The meta-analysis showed that prolonged duration of labor (> 24 hours) had significantly associated with low 5-minute Apgar score. This findings were similar to study done in Sweeden and Brazil ( 37 , 38 ).The implication might be prolonged duration of labor are causes of dystocia increase risk of neonatal hypoxia. Strength and limitation of the study These systematic review and meta-analysis had several strengths and limitations 1st strength: The employment of a predetermined search method that reduces the reviewer’s bias 2nd strength: The study’s quality evaluation and data extraction were carried out by independent reviewers, which further reduced reviewer bias. 3rd strength: the use of sensitivity analysis and subgroup analysis to find the source of heterogeneity. 1st limitations. Contrarily, the heterogeneity in the study that could skew the results’ interpretation is what gives birth to its limitations. 2nd limitations. is that the validity of the estimate may be reduced by the subgroup analysis using only a small number of studies. Conclusion This review showed that approximately 3 in10 newborns delivered at health facilities of Ethiopia had low 5th minute Apgar score. Factors associated with low Apgar score were Skin incision time > 3 minutes for cesarean section delivery, gestational hypertension, birth weight 24hours. Therefore, Comprehensive intervention including enhancing ANC follow up, early identification danger sign and complication of pregnancy and nutritional coursing were recommended for healthcare workers and concerned stakeholders working on maternal, newborn, and child healthcare. Declarations Ethical clearance : Not applicable Consent for publication : Not applicable Availability of data : All data generated and analyzed during this review were included in the published article as supporting file Competing of interest : all authors have no competing of interest Funding : No fund for this review Authors’ contribution : All authors made a significant contribution to the work reported, whether that is in the conception, data extraction, quality control, analysis and interpretation of results and preparation of the manuscript. Critically reviewing the manuscript; gave final approval of the version to be published, have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work Acknowledgement : We acknowledge all authors who contributed for the success of this review References Apgar V, James LJAjoDoC. Further observations on the newborn scoring system. 1962;104(4):419-28. Fetus AAoPCo, Newborn, Obstetricians ACo, Practice GCoO, Watterberg KL, Aucott S, et al. The apgar score. 2015;136(4):819-22. Torday JS, Nielsen HC. The Molecular Apgar Score: A Key to Unlocking Evolutionary Principles. Frontiers in pediatrics. 2017;5:45. Torday JS, Nielsen HCJFip. The molecular Apgar score: a key to unlocking evolutionary principles. 2017;5:45. Jeganathan R, Karalasingam SD, Hussein J, Allotey P, Reidpath DDJBp, childbirth. Factors associated with recovery from 1 minute Apgar score< 4 in live, singleton, term births: an analysis of Malaysian National Obstetrics Registry data 2010–2012. 2017;17:1-12. Iliodromiti S, Mackay DF, Smith GC, Pell JP, Nelson SMJTL. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. 2014;384(9956):1749-55. Li F, Wu T, Lei X, Zhang H, Mao M, Zhang JJPo. The Apgar score and infant mortality. 2013;8(7):e69072. Cnattingius S, Norman M, Granath F, Petersson G, Stephansson O, Frisell TJP, et al. Apgar score components at 5 minutes: risks and prediction of neonatal mortality. 2017;31(4):328-37. Gutbir Y, Wainstock T, Sheiner E, Segal I, Sergienko R, Landau D, et al. Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18 years of follow-up. 2020;179:959-71. Wainstock T, Sheiner EJJocm. Low five-minute apgar score and neurological morbidities: does prematurity modify the association? 2022;11(7):1922. Li J, Cnattingus S, Gissler M, Vestergaard M, Obel C, Ahrensberg J, et al. The 5-minute Apgar score as a predictor of childhood cancer: a population-based cohort study in five million children. 2012;2(4):e001095. Nassr AA, Abdelmagied AM, Shazly SAJJopm. Fetal cerebro-placental ratio and adverse perinatal outcome: systematic review and meta-analysis of the association and diagnostic performance. 2016;44(2):249-56. Bunnag AJIJoSS, Humanity. Sustainable economic development in Thailand. 2013;3(1):39. ICF. EPHIEEa. .Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. 2019. Organization WH. Newborn mortality fact sheets. 2022. WHO. World health statistics 2022: monitoring health for the SDGs, sustainable development goals. 2022. Ajibo BD, Wolka E, Aseffa A, Nugusu MA, Adem AO, Mamo M, et al. Determinants of low fifth minute Apgar score among newborns delivered by cesarean section at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia: an unmatched case control study. BMC Pregnancy and Childbirth. 2022;22(1):665. Gebremedhin MM, Gebremichael MW, Gebremichael BG, Hailu TA, Gebremeskel GA, Tlaye KG, et al. Determinants of low APGAR score in newborns delivered at Lemlem Karl general hospital, Northern Ethiopia, 2018: a case control study. 2020. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru CJJEI. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. 2015;13(3):147-53. Institute. JB. Critical Appraisal Tools Australia: The University of Adelaide; 2018. http:// joannabriggs.org/research/criticalappraisal-tools.html. . 2018. Obsa MS, Shanka GM, Menchamo MW, Fite RO, Awol MAJJop. Factors associated with Apgar score among newborns delivered by Cesarean sections at Gandhi Memorial Hospital, Addis Ababa. 2020;2020. Mersha A, Shibiru S, Bante AJJoP, Care N. Meconium-stained liquor and low birth weight increases the odds of low fifth-minute apgar scores in public health facilities of arba minch town, southern Ethiopia: a cross-sectional study. 2020;10(3):86-90. Zewude SB, Ajebe TM, Gessesse SS, Wassie THJIJoANS. Proportion and predictive factors of low apgar score at five minute among singleton term neonates delivered in Debre Tabor specialized hospital, northwest Ethiopia: A cross-sectional study. 2021;15:100322. Abebe M, Tebeje TM, Gugsa T, Kebede D, Temesgen T, Figa Z, et al. Factors associated with low fifth minute Apgar score among newborns delivered at public health facilities of Dilla town, Southern Ethiopia, 2022. 2024;20:100656. Gudayu TWJAhs. Proportion and factors associated with low fifth minute Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia. 2017;17(1):1-6. Yeshaneh A, Kassa A, Kassa ZY, Adane D, Fikadu Y, Wassie ST, et al. The determinants of 5th minute low Apgar score among newborns who delivered at public hospitals in Hawassa City, South Ethiopia. 2021;21(1):266. Getachew B, Etefa T, Asefa A, Terefe B, Dereje DJIjop. Determinants of low fifth minute Apgar score among newborn delivered in Jimma University medical center, Southwest Ethiopia. 2020;2020. Sterne JA, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. Journal of clinical epidemiology. 2001;54(10):1046-55. Chandler J, Cumpston M, Li T. Cochrane Handbook for Systematic Reviews of Interventions. Lin L, Chu HJB. Quantifying publication bias in meta‐analysis. 2018;74(3):785-94. Siddiqui A, Cuttini M, Wood R, Velebil P, Delnord M, Zile I, et al. Can the Apgar score be used for international comparisons of newborn health? 2017;31(4):338-45. Widiyaningrum AN, Pamungkasari EP, Murti BJJoM, Health C. Meta-Analysis: Amniotic Meconium and Low Birth Weight as Predictors of Asphyxia in Newborns. 2020;5(5):590-600. Mohammad N, Jamal T, Sohaila A, Ali SR. Meconium stained liquor and its neonatal outcome. Pakistan journal of medical sciences. 2018;34(6):1392-6. Mersha AG, Abegaz TM, Seid MAJBp, childbirth. Maternal and perinatal outcomes of hypertensive disorders of pregnancy in Ethiopia: systematic review and meta-analysis. 2019;19:1-12. Thavarajah H, Flatley C, Kumar S. The relationship between the five minute Apgar score, mode of birth and neonatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2018;31(10):1335-41. Fantahun Y, Mesfin EJEJoRH. Perinatal and Maternal Outcome of Antepartum Hemorrhage in Addis Ababa University. 2020;12(3):8-. Altman M, Sandström A, Petersson G, Frisell T, Cnattingius S, Stephansson OJEjoe. Prolonged second stage of labor is associated with low Apgar score. 2015;30:1209-15. Salustiano EMA, Campos JADB, Ibidi SM, Ruano R, Zugaib MJRdAMB. Low Apgar scores at 5 minutes in a low risk population: maternal and obstetrical factors and postnatal outcome. 2012;58:587-93. Additional Declarations No competing interests reported. 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Five factors are used to evaluate the baby’s condition and each factor is scored on a scale of 0 to 2, with 2 being the best score for each: the scoring system is an accepted tool for assessing the vitality of newborn infants. The score is based on measures of heart rate, respiratory effort, skin color, muscle tone, and reflex irritability (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).Scores obtainable are between 0 and 10, with 10 is the highest possible score. A total score of 7–10 is considered “normal,” and a lower Apgar score indicates depressed vitality (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eInitially, the Apgar score at 1-min is used to assess the need for immediate resuscitation. The 5-minute Apgar score indicates the capacity to recover and the potential need for ongoing management (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Low Apgar score was predictors of neonatal mortality and morbidity(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). low Apgar score at 5 minute are predictors of neonatal survival(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and In recognition of low Apgar score at 5 minute score of \u0026lt; 7, are associated with an increased risk of neonatal respiratory distress, need for mechanical ventilation and admission to neonatal intensive care unit(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) a higher risk of childhood cancers(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) and high risk of cerebral palsy(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInfant and child mortality rates are basic indicators of a country’s socio-economic situation and quality of life (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In recent years there is a continuous decline in infant and under 5-mortality but neonatal mortality remains stable especially in a country like Ethiopia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the first 20 days of life, 2.3\u0026nbsp;million children worldwide perished in 2022. Roughly 6500 neonatal fatalities occur each day, making up 47% of all child deaths under the age of five. Since 1990, there has been a significant global improvement in child survival. Neonatal deaths decreased from 5.0\u0026nbsp;million in 1990 to 2.3\u0026nbsp;million in 2022 on a global scale. However, compared to post-neonatal under-5 mortality, the drop in neonatal death from 1990 to 2022 has been slower.\u003c/p\u003e \u003cp\u003eWhere a child is born still affects their odds of surviving; sub-Saharan Africa and southern and central Asia account for the majority of newborn mortality. With 27 deaths per 1000 live births in 2022, Sub-Saharan Africa had the highest rate of newborn mortality, followed by central and southern Asia with 21 deaths per 1000 live births(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the key focuses of the Sustainable Development Goals (SDG) is newborn health, with nations aiming to meet the target of lowering neonatal mortality to 12 deaths per 1,000 live births by 2030. In order to fulfill the SDG objective (SDG 3.2.1) for under-five mortality by 2030, 54 countries—three quarters of which are in the WHO African Region must drastically lower their under-five mortality rates (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNeonatal mortality rates in sub-Saharan African nations were notable, despite the fact that a lot of work has been done. The Apgar score is one of the first instruments used to evaluate a newborn's health. The early prevention of morbidity and mortality in neonates thus depends critically on recognizing the factors that contribute to a low Apgar score. In Ethiopia there is no comprehensive evidence on magnitude and determinants of low Apgar score. Therefore, this systematic review and metanalysis aimed to assess the estimated pooled magnitude and determinant factors associated with low fifth minute Apgar score among newborn delivered at health facilities in Ethiopia. This study findings provide evidence for health care professionals, policy makers and concerned stakeholders working on maternal, newborn and child health care for development of appropriate intervention measure.\u003c/p\u003e "},{"header":"Method","content":"\u003ch2\u003eResearch question\u003c/h2\u003e\n\u003cp\u003eWhat are the determinants factors of low fifth minute Apgar score among newborns delivered at public health facilities in Ethiopia?\u003c/p\u003e\n\u003ch3\u003eSearch strategies\u003c/h3\u003e\n\u003cp\u003eThis systematic review and meta-analysis were conducted to estimate the pooled magnitude of low APGAR score at 5th minutes among newborn delivered at health facilities in Ethiopia and to summarize associated factors with low APGAR score at 5th minutes. Preferred reporting items of systematic review and meta-analysis (PRISMA)(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e) flow diagram standards (Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e) and a PRISMA checklist were used during the review process.\u003c/p\u003e\n\u003cp\u003eElectronic databases such as PubMed, EMBASE, Midline, Scopus, Web of Science, Google Scholar, and Science Direct were used to retrieve studies reported in the English language with publication years from inception to date. The search was conducted from February 20 to 30, 2024.\u003c/p\u003e\n\u003cp\u003eThe search strategies were conducted by combining keywords using AND/OR Boolean terms. \u0026ldquo;Low APGAR score at 5th minutes, \u0026quot; APGAR score\u0026rdquo;, \u0026ldquo;APGAR score at 5th minutes\u0026rdquo;, AND newborn/neonate/ \u0026lsquo;AND/OR \u0026quot;determinant/associated/risk factors \u0026ldquo;are both in the medical subject heading and free text terms. To prevent further duplication, we have looked up published or current projects relating to the topic in the PROSPERO database (\u003cspan\u003e\u003cspan\u003ehttp://www.library.ucsf.edu\u003c/span\u003e\u003c/span\u003e). As a result, the conclusion showed that there were neither ongoing nor published articles on this review. Therefore, the protocol for this systematic review and meta-analysis is registered in the International Prospective Register of Systematic Reviews (PROSPERO)(Ongoing).\u003c/p\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e\n \u003cp\u003eA cross-sectional study, a cohort study, quasi experimental studies, experimental and a case study that reports APGAR score at 5th minutes among newborn delivered at health facilities of Ethiopia are included. Publication year from inception to date, English language and study area are in Ethiopia are other inclusion criteria.\u003c/p\u003e\n \u003cp\u003eExclusion criteria were language other than English, duplicated articles, and not measuring the outcome variable. Two authors (TFA and ETF) independently searched and screened the studies based on the title and abstract at the initial steps. In the next step, both authors select the full text based on the eligibility criteria independently. In cases of disagreement, the third author (EKB they were resolved by making decision.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eStudy quality Assessment\u003c/h2\u003e\n \u003cp\u003eThe quality of the studies included in this systematic review and meta-analysis was done using the Joanna Briggs institute (\u003cspan\u003e19\u003c/span\u003e) checklist for analytical cross-sectional studies(\u003cspan\u003e20\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe JBI critical appraisal cheek list had eight parameters with the options of Yes, No, unclear and not applicable.\u003c/p\u003e\n \u003cp\u003eThe quality checklist parameters include the following questions:(\u003cspan\u003e1\u003c/span\u003e) Were the criteria for inclusion in the sample clearly defined?, (\u003cspan\u003e2\u003c/span\u003e) Were the study subjects and the setting described in detail?,(\u003cspan\u003e3\u003c/span\u003e) Was the exposure measured in a valid and reliable way?,(\u003cspan\u003e4\u003c/span\u003e) Were objective, standard criteria used for measurement of the condition?,(\u003cspan\u003e5\u003c/span\u003e) Were confounding factors identified?,(\u003cspan\u003e6\u003c/span\u003e) Were strategies to deal with confounding factors stated?,(\u003cspan\u003e7\u003c/span\u003e) Were the outcomes measured in a valid and reliable way?, and (\u003cspan\u003e8\u003c/span\u003e) Was an appropriate statistical analysis used? Studies were considered low risk if there was a score of 50% and above of the quality assessment indicators and included in the final analysis(\u003cspan\u003e19\u003c/span\u003e) (Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eQuality assessment of included studies in this systematic review and meta-analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAuthors name\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCriteria for inclusion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy subject and setting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMeasure of exposure\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIdentify of confounding factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStrategy to deal with confounding\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMeasure of outcome\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eObjective for measurement of the condition\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003estatistical analysis used\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003epercent (100%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLevel of quality\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObsa. MS\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e21\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMersha.A\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e22\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZewude.SB et al(\u003cspan\u003e23\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbebe. M,\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e24\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGudayu. TW,\u003c/p\u003e\n \u003cp\u003eet al\u003c/p\u003e\n \u003cp\u003e(\u003cspan\u003e25\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYeshaneh. A, et al\u003c/p\u003e\n \u003cp\u003e(\u003cspan\u003e26\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGetachew. B et al(\u003cspan\u003e27\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGebremedhin.MM et al(\u003cspan\u003e18\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAjibo.BD.\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e17\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eSelection of the study\u003c/h2\u003e\n \u003cp\u003eThe articles were initially found based on the study\u0026apos;s objectives and screened based on their titles and abstracts. In the second step, the article that did not meet the inclusion requirements was eliminated. After this, the eligible articles were further screened by reading the full texts, and those that did not meet the inclusion criteria were excluded. Finally, the eligible full-text articles that fulfilled the inclusion criteria were included in the review.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eData extraction\u003c/h2\u003e\n \u003cp\u003eData were extracted on a Microsoft Excel spreadsheet from the included studies. Information was extracted based on the study\u0026apos;s characteristics: name of the first author, publication year, study settings, study design, sample size, sampling technique, data collection technique, Magnitude of low APGAR score at 5 minute and determinant factors associated with low APGAR score at 5 minutes were extracted.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eOutcome measurement\u003c/h2\u003e\n \u003cp\u003eThe main outcome is the magnitude of low Apgar score at fifth minute among newborns delivered in health facilities of Ethiopia. The Apgar scores computed by using five components.\u003c/p\u003e\n \u003cp\u003e1. Appearance: two points for pink, 1 point for bluish extremities, 0 points for blue.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e2. Pulse rate: 2 points for \u0026ge;\u0026thinsp;100 beats/minute, 1 point for \u0026lt;\u0026thinsp;100, and 0 points for none.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e3. Grimace: 2 points for crying, 1 point for whimpering, and 0 points for silence.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e4. Activity: two points for active, 1 point for moderate, and 0 points for limp.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e5. Respiration: 2 points for regular breathing, 1 point for irregular and \u0026lt;\u0026thinsp;30 breath/ minute, and 0 points for none.\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eLow fifth-minute Apgar scores were determined as a score of \u0026lt;\u0026thinsp;seven at the fifth minute after summing the scores (Reference). The authors used adjusted odds ratio to determine associated factors of low 5-minute Apgar score.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eStatistical analysis and Publication bias\u003c/h2\u003e\n \u003cp\u003eData analysis was conducted using STATA version 17 (Sta-ta Corp., College Station, TX, USA). A random effect model meta-analysis was employed to estimate the pooled magnitude of low APGAR score at 5 minutes on neonates of mothers who gave birth at health facilities in Ethiopia. The heterogeneity among effect sizes of the included studies was evaluated using the Q test results with a significance difference of P\u0026thinsp;\u0026lt;\u0026thinsp;0.1 and a ꓲ\u003csup\u003e2\u003c/sup\u003e static value\u0026thinsp;\u0026gt;\u0026thinsp;75%(\u003cspan\u003e28\u003c/span\u003e) and Potential publication bias was assessed by using a funnel plot. The factors associated with low APGAR score at 5 minutes were summarized using qualitative thematic analysis. The risk of publication bias for this systematic reviews and meta-analyses was tested using an subjective judgment funnel plot symmetry ,and objectively by Egger\u0026rsquo;s test(\u003cspan\u003e29\u003c/span\u003e, \u003cspan\u003e30\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Result","content":"\u003ch3\u003eSearch outcomes\u003c/h3\u003e\n\u003cp\u003eIn all, 1982 articles were obtained from the selected databases and registrations. After 996 items were eliminated for being duplicates, 986 articles were screened using title and abstract and exclude 889. Finally, 97 articles were screened by full text and 88 articles were excluded using inclusion and exclusion criteria. Ultimately, 9 articles with a total of 3508 participants were included in the qualitative and quantitative synthesis (Fig.\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eCharacteristics of included studies\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e presents a summary of the study characteristics, major quantitative and overall findings of the studies included in the review. Nine articles were included in this review fulfilled the inclusion and exclusion criteria and measure the magnitude of low 5th minute APGAR score of newborns delivered at public health facilities in Ethiopia.\u003c/p\u003e\n\u003cp\u003eFrom total of nine articles 3508 newborns delivered at public health facilities of Ethiopia were included. The study design used for the included study were 4 articles unmatched case control(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e24\u003c/span\u003e, \u003cspan\u003e26\u003c/span\u003e) ,4 cross sectional study design(\u003cspan\u003e22\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e, \u003cspan\u003e25\u003c/span\u003e, \u003cspan\u003e27\u003c/span\u003e) and 1 article cohort study(\u003cspan\u003e21\u003c/span\u003e).Six studies used systematic random sampling technique(\u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e\u0026ndash;\u003cspan\u003e25\u003c/span\u003e) ,while three use simple random sampling technique(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e26\u003c/span\u003e, \u003cspan\u003e27\u003c/span\u003e).The included studies was done six regions of Ethiopia 2 in each regions of Amhar(\u003cspan\u003e23\u003c/span\u003e, \u003cspan\u003e25\u003c/span\u003e), Sidama (\u003cspan\u003e24\u003c/span\u003e, \u003cspan\u003e26\u003c/span\u003e) and Southern nation nationality(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e22\u003c/span\u003e) and 1each region of Tigray(\u003cspan\u003e18\u003c/span\u003e), Oromia(\u003cspan\u003e27\u003c/span\u003e) and Addis Ababa(\u003cspan\u003e21\u003c/span\u003e).The sample size ranges from lowest 261(\u003cspan\u003e25\u003c/span\u003e) study done in Gonder and Highest 662(\u003cspan\u003e18\u003c/span\u003e) in Lemlem Karl hospital Tigray region. Most 77.7% (7/9) of the studies published in the last 4 years and the rest 2 published since 2017 this suggesting recent increase interest of subject area in Ethiopia. All the studies use the same measurement criteria of APGAR score of newborns delivered immediately at 5 minutes.\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCharacteristics of included studies in the review\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAuthor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eyear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy area\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSampling technique\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMagnitude of low APGAR score at 5th minutes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObsa. MS\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e21\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMersha.A\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e22\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArba Minch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSNNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZewude.SB et al(\u003cspan\u003e23\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDebre Tabor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbebe. M,\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e24\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDilla\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSidama\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGudayu. TW,\u003c/p\u003e\n \u003cp\u003eet al\u003c/p\u003e\n \u003cp\u003e(\u003cspan\u003e25\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGondar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYeshaneh. A, et al\u003c/p\u003e\n \u003cp\u003e(\u003cspan\u003e26\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHawassa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSidama\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGetachew. B et al(\u003cspan\u003e27\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJimma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGebremedhin.MM et al(\u003cspan\u003e18\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLemlem Karle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAjibo.BD.\u003c/p\u003e\n \u003cp\u003eet al(\u003cspan\u003e17\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWolaita Sodo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSNNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCase control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e329\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003cspan type=\"Underline\" name=\"Emphasis\"\u003eNote\u003c/span\u003e: SNNP: Southern nation nationalities of people, SRS: systematic random sampling, srs: simple random sampling\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eMeta analysis results\u003c/p\u003e\n\u003ch2\u003ePooled magnitude of low 5th minute APGAR score\u003c/h2\u003e\n\u003cp\u003eIn this review, the pooled magnitude of low 5th minute Apgar score using random effect model restricted maximum likelihood model was found 23% (95% CI 16\u0026ndash;30) (Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eHeterogeneity of Result\u003c/h2\u003e\n\u003cp\u003eThe hetrogeniety between the studies included in the review was high(I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;95.82%,t\u0026thinsp;=\u0026thinsp;6.88) and it was significant (P\u0026thinsp;=\u0026thinsp;0.00) with 95% CI(Fig.\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e).The sources of high hetrogenity is not identified.However an increase hetrogenity is expected in the meta analysisof the magnitude of low 5th minute Apgar score of newborn delivered at health facilities in different regions and study design and the results could be interpreted sequentially and with caution.\u003c/p\u003e\n\u003cp\u003eMoreover, the study tested a wide prediction interval, which was a direct and easily interpretable indicator compared to the CI, suggesting high heterogeneity.\u003c/p\u003e\n\u003ch2\u003ePublication bias and sensitivity analysis\u003c/h2\u003e\n\u003cp\u003eThe publication bias was assessed using Begg\u0026rsquo;s test(P\u0026thinsp;=\u0026thinsp;00.3481) and Egger\u0026rsquo;s regression test(P\u0026thinsp;=\u0026thinsp;0.1664) non-significant, both of which shows there is publication bias. The review also revealed asymmetry in the funnel plot (Fig.\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTo identify the source of heterogeneity that affects the pooled magnitude of low 5th minute Apgar score among newborns delivered at health facilities of Ethiopia, we conducted a sensitivity analysis. According to the findings of the sensitivity analysis, the pooled magnitude of low 5th minute Apgar score among newborns obtained when every study was excluded from the analysis was within the 95% CI of the pooled magnitude of low 5th minute Apgar score when all studies fitted together. Furthermore, the sensitivity analysis result showed that the pooled magnitude of low 5th minute Apgar score ranges from 21.76%(95%CI,14.92\u0026ndash;28.60) and 24.50(95%CI,17.811\u0026ndash;31.18) when each study was left out of the sensitivity analysis (Fig.\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eSubgroup analysis\u003c/h2\u003e\n\u003cp\u003eSince there is substantial heterogeneity among the pooled magnitude of low 5th minutes of Apgar score, subgroup analysis was done based on publication year, study region, sample size\u0026thinsp;\u0026lt;\u0026thinsp;350 and \u0026gt;\u0026thinsp;350, study design and sampling technique.\u003c/p\u003e\n\u003cp\u003eSubgroup analysis based on publication year shows that there is high magnitude of low 5th minutes of Apgar score publication year from 2021\u0026ndash;2024 with 29.55% (95%CI, 22.069\u0026ndash;37.03).\u003c/p\u003e\n\u003cp\u003eSub group analysis using sample size revealed that there was high magnitude of low 5th minutes of Apgar score with sample size\u0026thinsp;\u0026gt;\u0026thinsp;350 with 24.87% (95%CI, 14.685\u0026ndash;35.067) and subgroup analysis using study design shows that unmatched case control was high 33.369% (95%CI, 33.322\u0026ndash;22.416) and low using Cohort study design 12.8% (95%CI, 12.765\u0026ndash;12.835) (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSubgroup analysis-based on publication year, region, sample size, study design and sampling technique on low 5th minute Apgar score in Ethiopia\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eSubgroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eNo. studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eEstimates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeterogeneity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMagnitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePublication year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2017\u0026ndash;2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.974\u0026ndash;25.738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2021\u0026ndash;2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.069\u0026ndash;37.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAddis Ababa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.765\u0026ndash;12.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.736\u0026ndash;20.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSNNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.312\u0026ndash;40.888\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSidama\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.251\u0026ndash;33.447\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.467\u0026ndash;11.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.334\u0026ndash;33.416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.306\u0026ndash;29.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.876\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.685\u0026ndash;35.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.765\u0026ndash;12.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.161\u0026ndash;18.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnmatched case control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.322\u0026ndash;22.416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSampling technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSystematic random sampling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.019\u0026ndash;29.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSimple random sampling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.792\u0026ndash;40.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eDeterminant factors associated with low 5th minute Apgar score\u003c/h2\u003e\n\u003cp\u003eFrom the total retrieved articles included in this review, eight studies reported factors associated with low 5th minute Apgar score (\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e\u0026ndash;\u003cspan\u003e27\u003c/span\u003e).The pooled effects of two studies (\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e) demonstrate that newborn delivered by cesarean section with Skin incision time\u0026thinsp;\u0026gt;\u0026thinsp;3 minutes were 4.76 times(AOR:4.76,95%CI: 1.28\u0026ndash;8.25) more likely to have low 5th minute Apgar score as compared to skin incision time\u0026thinsp;\u0026lt;\u0026thinsp;3 minutes among newborn delivered at public health facilities in Ethiopia\u003c/p\u003e\n\u003cp\u003eThe pooled effects of five studies(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e, \u003cspan\u003e24\u003c/span\u003e) showed that newborns delivered from gestational hypertension mothers were 5.71times (AOR\u0026thinsp;=\u0026thinsp;5.71, 95%CI: 0.89\u0026ndash;10.53) more likely to have low 5th minute Apgar score as compared to no gestational hypertension. The pooled effects of seven studies(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e, \u003cspan\u003e25\u003c/span\u003e\u0026ndash;\u003cspan\u003e27\u003c/span\u003e) revealed that newborn with birth weight\u0026thinsp;\u0026lt;\u0026thinsp;2500 gram were 4.82 times (AOR:4.82,95%CI:3.72\u0026ndash;5.91) more likely to have low 5th minute Apgar score as compared to newborn with birthweight\u0026thinsp;\u0026gt;\u0026thinsp;2500 gram delivered at public health facilities in Ethiopia.\u003c/p\u003e\n\u003cp\u003eThe pooled effects of two studies (\u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e25\u003c/span\u003e) determined that induced/augmented labor were 3.21 times (AOR:3.21, 95%CI:2.27\u0026ndash;4.15) more likely to have low 5th minute Apgar score as compared to newborn delivered with normal labor at public health facilities in Ethiopia.\u003c/p\u003e\n\u003cp\u003eThe pooled effects of five studies (\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e, \u003cspan\u003e21\u003c/span\u003e, \u003cspan\u003e23\u003c/span\u003e, \u003cspan\u003e25\u003c/span\u003e) confirms that meconium-stained liquor were5.36 times (AOR: 5.36,95%CI: 3.45\u0026ndash;7.27) more likely to have low 5th minute Apgar score as compared to not meconium-stained liquor newborn delivered at public health facilities in Ethiopia.\u003c/p\u003e\n\u003cp\u003eThe pooled effects of three studies (\u003cspan\u003e23\u003c/span\u003e\u0026ndash;\u003cspan\u003e25\u003c/span\u003e) showed that uterine Presentation of fetus non vertex was 3.15 times (AOR:3.15,95% CI:1.31\u0026ndash;5.01) more likely to have low 5th minute Apgar score as compared to vertex presentation newborn delivered at public health facilities in Ethiopia. Similarly the pooled effects of two studies(\u003cspan\u003e24\u003c/span\u003e, \u003cspan\u003e26\u003c/span\u003e) new born delivered from mothers who had no ANC follow up were 11.46 times(AOR:11.46,95%CI: 3.94\u0026ndash;18.97) more likely to have low 5th minute Apgar score as compared to new born delivered from mothers who had ANC follow up in Ethiopia.\u003c/p\u003e\n\u003cp\u003eThe pooled effects of two studies(\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e) revealed that new born delivery by cesarean section were15.96 times (AOR:15.98,95%CI:14.76\u0026ndash;17.22) more likely to have low 5th minute Apgar score as compared to new born delivered by normal vaginal delivery at public health facilities in Ethiopia. Similarly, these two studies (\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e18\u003c/span\u003e) showed that newborn delivered from mothers who had APH/PPH were 8.92 times (AOR:8.92,95%CI: 7.87\u0026ndash;9.98) more likely to have low 5th minute Apgar score as compared to new born delivered from mothers who had no APH/PPH.\u003c/p\u003e\n\u003cp\u003eThe pooled effects of two studies(\u003cspan\u003e25\u003c/span\u003e, \u003cspan\u003e27\u003c/span\u003e)confirms that Prolonged labor duration\u0026thinsp;\u0026gt;\u0026thinsp;24 hours were13.29 times(AOR:13.92,95%CI:10.95\u0026ndash;16.88) more likely to have low 5th minute Apgar score as compared to new born delivered normal labor duration in Ethiopia(Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eFactors associated with low 5th minute Apgar score among newborns delivered at health facilities in Ethiopia\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. studies\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePooled AOR\u003c/p\u003e\n \u003cp\u003e(95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin incision time\u0026thinsp;\u0026gt;\u0026thinsp;3minute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.76 (1.28\u0026ndash;8.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSkin incision time\u0026thinsp;\u0026lt;\u0026thinsp;3minute\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGestational Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.71(0.89\u0026ndash;10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirth weight\u0026thinsp;\u0026lt;\u0026thinsp;2500 gram\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.82(3.72\u0026ndash;5.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBirth weight\u0026thinsp;\u0026gt;\u0026thinsp;2500 gram\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInduced/augmented labor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.21(2.27\u0026ndash;4.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot induced/ augmented labor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMeconium-stained liquor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.36(3.45\u0026ndash;7.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot stained meconium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresentation non vertex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.15(1.31\u0026ndash;5.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVertex presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo ANC follow up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.46(3.94\u0026ndash;18.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eANC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMode of delivery Cesarean section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.98(14.76\u0026ndash;17.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAPH/PPH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.92(7.87\u0026ndash;9.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo APH/PPH\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProlonged labor duration\u0026thinsp;\u0026gt;\u0026thinsp;24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.92(10.95\u0026ndash;16.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal labor duration (\u0026lt;\u0026thinsp;24 hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review and metanalysis examined the pooled magnitude and determinant factors associated with low 5-minute Apgar score among newborns in Ethiopia. In this meta-analysis the pooled magnitude of low 5-minute Apgar score among newborns were determined using Random effect restricted maximum likelihood model. The estimated pooled magnitude of low 5-minute Apgar score was 23%(95%CI:16\u0026ndash;30). This implies that approximately 3 in 10 newborns delivered in Ethiopia had low 5-minute Apgar score. Furthermore, this is contributing significant cause of high neonatal mortality rate in Ethiopia.\u003c/p\u003e \u003cp\u003eThis finding are significantly higher than 0.3%- 2.4% report on reviews done in 23 countries of Europe(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).The discrepancy might be due to different standards of medical care and overall socioeconomic development in high income countries might contribute to this observable difference. This implies that there is significant gap in low-income countries like Ethiopia on prevention of contributing factors newborn death.\u003c/p\u003e \u003cp\u003eThe results of meta-analysis of 7 studies evidenced that birth weight\u0026thinsp;\u0026lt;\u0026thinsp;2500 gram were 4.82 times (AOR:4.82,95%CI:3.72\u0026ndash;5.91) more likely to have low 5th minute Apgar score as compared to newborn with birthweight\u0026thinsp;\u0026gt;\u0026thinsp;2500 gram among newborns in Ethiopia. This is in lined with meta-analysis reported that low birth weight had low Apgar score (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).This might be due to the fact that low birth weight occurs as a result of maternal complications before conception or antepartum period.\u003c/p\u003e \u003cp\u003e This review showed that meconium-stained amniotic fluid were significantly associated with low 5-minute Apgar score. These findings were similar to systematic review done on effects of meconium-stained amniotic fluid and low birth weight on birth asphyxia (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).The possible reason might meconium-stained amniotic fluid had major impact on mode of delivery and newborn outcome.\u003c/p\u003e \u003cp\u003eIn this review the pooled effects of 5 studies revealed that new born delivered from gestational hypertension mother had higher odds of low 5-minute Apgar score as compared to new born delivered from non-hypertension mothers. The possible reason might be gestational hypertension leads to both maternal and newborn complication that had great impact on mode of delivery(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eThis meta-analysis showed that new born delivered by cesarean section were more likely to have low 5-minute Apgar score as compared to normal vaginal delivery. This findings was similar to study done in Australia(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).This might be due to cesarean section delivery increase risk of respiratory distress and other complications like hypoglycemia.\u003c/p\u003e \u003cp\u003eThis meta-analysis also found that pregnancy complication like Antepartum and postpartum hemorrhage had significantly associated with low 5-minute Apgar score. The possible reason might be Antepartum hemorrhage is linked to high rates of preterm deliveries, low birth weight, anemia, postpartum hemorrhage, intrauterine fetal death, and perinatal mortality(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe meta-analysis showed that prolonged duration of labor (\u0026gt;\u0026thinsp;24 hours) had significantly associated with low 5-minute Apgar score. This findings were similar to study done in Sweeden and Brazil (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).The implication might be prolonged duration of labor are causes of dystocia increase risk of neonatal hypoxia.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitation of the study\u003c/h2\u003e \u003cp\u003eThese systematic review and meta-analysis had several strengths and limitations\u003c/p\u003e \u003cp\u003e1st strength: The employment of a predetermined search method that reduces the reviewer\u0026rsquo;s bias\u003c/p\u003e \u003cp\u003e 2nd strength: The study\u0026rsquo;s quality evaluation and data extraction were carried out by independent reviewers, which further reduced reviewer bias.\u003c/p\u003e \u003cp\u003e3rd strength: the use of sensitivity analysis and subgroup analysis to find the source of heterogeneity.\u003c/p\u003e \u003cp\u003e1st limitations. Contrarily, the heterogeneity in the study that could skew the results\u0026rsquo; interpretation is what gives birth to its limitations.\u003c/p\u003e \u003cp\u003e2nd limitations. is that the validity of the estimate may be reduced by the subgroup analysis using only a small number of studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review showed that approximately 3 in10 newborns delivered at health facilities of Ethiopia had low 5th minute Apgar score. Factors associated with low Apgar score were Skin incision time \u0026gt; 3 minutes for cesarean section delivery, gestational hypertension, birth weight \u0026lt; 2500 gram, induced/augmented labor, meconium-stained liquor, Presentation of fetus non vertex no ANC follow up Cesarean section delivery APH/PPH and Prolonged labor duration \u0026gt; 24hours. Therefore, Comprehensive intervention including enhancing ANC follow up, early identification danger sign and complication of pregnancy and nutritional coursing were recommended for healthcare workers and concerned stakeholders working on maternal, newborn, and child healthcare.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical clearance\u003c/strong\u003e: Not applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e: All data generated and analyzed during this review were included in the published article as supporting file\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Competing of interest\u003c/strong\u003e: all authors have no competing of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No fund for this review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e:\u0026nbsp;All authors made a significant contribution to the work reported, whether that is in the conception, data extraction, quality control, analysis and interpretation of results and preparation of the manuscript. Critically reviewing the manuscript; gave final approval of the version to be published, have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgement\u003c/strong\u003e: We acknowledge all authors who contributed for the success of this review\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eApgar V, James LJAjoDoC. Further observations on the newborn scoring system. 1962;104(4):419-28.\u003c/li\u003e\n\u003cli\u003eFetus AAoPCo, Newborn, Obstetricians ACo, Practice GCoO, Watterberg KL, Aucott S, et al. The apgar score. 2015;136(4):819-22.\u003c/li\u003e\n\u003cli\u003eTorday JS, Nielsen HC. The Molecular Apgar Score: A Key to Unlocking Evolutionary Principles. Frontiers in pediatrics. 2017;5:45.\u003c/li\u003e\n\u003cli\u003eTorday JS, Nielsen HCJFip. The molecular Apgar score: a key to unlocking evolutionary principles. 2017;5:45.\u003c/li\u003e\n\u003cli\u003eJeganathan R, Karalasingam SD, Hussein J, Allotey P, Reidpath DDJBp, childbirth. Factors associated with recovery from 1 minute Apgar score\u0026lt; 4 in live, singleton, term births: an analysis of Malaysian National Obstetrics Registry data 2010\u0026ndash;2012. 2017;17:1-12.\u003c/li\u003e\n\u003cli\u003eIliodromiti S, Mackay DF, Smith GC, Pell JP, Nelson SMJTL. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. 2014;384(9956):1749-55.\u003c/li\u003e\n\u003cli\u003eLi F, Wu T, Lei X, Zhang H, Mao M, Zhang JJPo. The Apgar score and infant mortality. 2013;8(7):e69072.\u003c/li\u003e\n\u003cli\u003eCnattingius S, Norman M, Granath F, Petersson G, Stephansson O, Frisell TJP, et al. Apgar score components at 5 minutes: risks and prediction of neonatal mortality. 2017;31(4):328-37.\u003c/li\u003e\n\u003cli\u003eGutbir Y, Wainstock T, Sheiner E, Segal I, Sergienko R, Landau D, et al. Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18 years of follow-up. 2020;179:959-71.\u003c/li\u003e\n\u003cli\u003eWainstock T, Sheiner EJJocm. Low five-minute apgar score and neurological morbidities: does prematurity modify the association? 2022;11(7):1922.\u003c/li\u003e\n\u003cli\u003eLi J, Cnattingus S, Gissler M, Vestergaard M, Obel C, Ahrensberg J, et al. The 5-minute Apgar score as a predictor of childhood cancer: a population-based cohort study in five million children. 2012;2(4):e001095.\u003c/li\u003e\n\u003cli\u003eNassr AA, Abdelmagied AM, Shazly SAJJopm. Fetal cerebro-placental ratio and adverse perinatal outcome: systematic review and meta-analysis of the association and diagnostic performance. 2016;44(2):249-56.\u003c/li\u003e\n\u003cli\u003eBunnag AJIJoSS, Humanity. Sustainable economic development in Thailand. 2013;3(1):39.\u003c/li\u003e\n\u003cli\u003eICF. EPHIEEa. .Ethiopia Mini Demographic and Health Survey 2019: Final Report. Rockville, Maryland, USA: EPHI and ICF. 2019.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Newborn mortality fact sheets. 2022.\u003c/li\u003e\n\u003cli\u003eWHO. World health statistics 2022: monitoring health for the SDGs, sustainable development goals. 2022.\u003c/li\u003e\n\u003cli\u003eAjibo BD, Wolka E, Aseffa A, Nugusu MA, Adem AO, Mamo M, et al. Determinants of low fifth minute Apgar score among newborns delivered by cesarean section at Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia: an unmatched case control study. BMC Pregnancy and Childbirth. 2022;22(1):665.\u003c/li\u003e\n\u003cli\u003eGebremedhin MM, Gebremichael MW, Gebremichael BG, Hailu TA, Gebremeskel GA, Tlaye KG, et al. Determinants of low APGAR score in newborns delivered at Lemlem Karl general hospital, Northern Ethiopia, 2018: a case control study. 2020.\u003c/li\u003e\n\u003cli\u003eMunn Z, Moola S, Lisy K, Riitano D, Tufanaru CJJEI. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. 2015;13(3):147-53.\u003c/li\u003e\n\u003cli\u003eInstitute. JB. Critical Appraisal Tools Australia: The University of Adelaide; 2018. http:// joannabriggs.org/research/criticalappraisal-tools.html. . 2018.\u003c/li\u003e\n\u003cli\u003eObsa MS, Shanka GM, Menchamo MW, Fite RO, Awol MAJJop. Factors associated with Apgar score among newborns delivered by Cesarean sections at Gandhi Memorial Hospital, Addis Ababa. 2020;2020.\u003c/li\u003e\n\u003cli\u003eMersha A, Shibiru S, Bante AJJoP, Care N. Meconium-stained liquor and low birth weight increases the odds of low fifth-minute apgar scores in public health facilities of arba minch town, southern Ethiopia: a cross-sectional study. 2020;10(3):86-90.\u003c/li\u003e\n\u003cli\u003eZewude SB, Ajebe TM, Gessesse SS, Wassie THJIJoANS. Proportion and predictive factors of low apgar score at five minute among singleton term neonates delivered in Debre Tabor specialized hospital, northwest Ethiopia: A cross-sectional study. 2021;15:100322.\u003c/li\u003e\n\u003cli\u003eAbebe M, Tebeje TM, Gugsa T, Kebede D, Temesgen T, Figa Z, et al. Factors associated with low fifth minute Apgar score among newborns delivered at public health facilities of Dilla town, Southern Ethiopia, 2022. 2024;20:100656.\u003c/li\u003e\n\u003cli\u003eGudayu TWJAhs. Proportion and factors associated with low fifth minute Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia. 2017;17(1):1-6.\u003c/li\u003e\n\u003cli\u003eYeshaneh A, Kassa A, Kassa ZY, Adane D, Fikadu Y, Wassie ST, et al. The determinants of 5th minute low Apgar score among newborns who delivered at public hospitals in Hawassa City, South Ethiopia. 2021;21(1):266.\u003c/li\u003e\n\u003cli\u003eGetachew B, Etefa T, Asefa A, Terefe B, Dereje DJIjop. Determinants of low fifth minute Apgar score among newborn delivered in Jimma University medical center, Southwest Ethiopia. 2020;2020.\u003c/li\u003e\n\u003cli\u003eSterne JA, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. Journal of clinical epidemiology. 2001;54(10):1046-55.\u003c/li\u003e\n\u003cli\u003eChandler J, Cumpston M, Li T. Cochrane Handbook for Systematic Reviews of Interventions.\u003c/li\u003e\n\u003cli\u003eLin L, Chu HJB. Quantifying publication bias in meta‐analysis. 2018;74(3):785-94.\u003c/li\u003e\n\u003cli\u003eSiddiqui A, Cuttini M, Wood R, Velebil P, Delnord M, Zile I, et al. Can the Apgar score be used for international comparisons of newborn health? 2017;31(4):338-45.\u003c/li\u003e\n\u003cli\u003eWidiyaningrum AN, Pamungkasari EP, Murti BJJoM, Health C. Meta-Analysis: Amniotic Meconium and Low Birth Weight as Predictors of Asphyxia in Newborns. 2020;5(5):590-600.\u003c/li\u003e\n\u003cli\u003eMohammad N, Jamal T, Sohaila A, Ali SR. Meconium stained liquor and its neonatal outcome. Pakistan journal of medical sciences. 2018;34(6):1392-6.\u003c/li\u003e\n\u003cli\u003eMersha AG, Abegaz TM, Seid MAJBp, childbirth. Maternal and perinatal outcomes of hypertensive disorders of pregnancy in Ethiopia: systematic review and meta-analysis. 2019;19:1-12.\u003c/li\u003e\n\u003cli\u003eThavarajah H, Flatley C, Kumar S. The relationship between the five minute Apgar score, mode of birth and neonatal outcomes. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2018;31(10):1335-41.\u003c/li\u003e\n\u003cli\u003eFantahun Y, Mesfin EJEJoRH. Perinatal and Maternal Outcome of Antepartum Hemorrhage in Addis Ababa University. 2020;12(3):8-.\u003c/li\u003e\n\u003cli\u003eAltman M, Sandstr\u0026ouml;m A, Petersson G, Frisell T, Cnattingius S, Stephansson OJEjoe. Prolonged second stage of labor is associated with low Apgar score. 2015;30:1209-15.\u003c/li\u003e\n\u003cli\u003eSalustiano EMA, Campos JADB, Ibidi SM, Ruano R, Zugaib MJRdAMB. Low Apgar scores at 5 minutes in a low risk population: maternal and obstetrical factors and postnatal outcome. 2012;58:587-93.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Apgar score, newborn, 5th minute Apgar score, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4221694/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4221694/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eApgar score is the most consistently used measure of neonatal health and it provides an accepted and convenient method for reporting the status of newborn infants in the few minutes after birth. Apgar score at 5th minute are better predictor neonatal survival. There is no evidence on pooled magnitude and determinant factors associated with low 5th minute Apgar score among newborns delivered in Ethiopia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis review aimed to estimate the pooled magnitude and associated factors with low 5th minute Apgar score among newborns delivered at health facilities of Ethiopia\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e \u003cp\u003e Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist guideline was followed for this review and meta-analysis. Electronic data base (PubMed, EMBASE, Midline, Cochrane library, Web of science, Google scholar and Science direct) were used to retrieve studies. Data were extracted using Microsoft Excel and analyzed using STATA version 17. Publication bias was checked by funnel plot, Beggs and Egger\u0026rsquo;s regression test. Pooled analysis was conducted using a weighted inverse variance of random effect model. Subgroup and sensitivity analysis was done.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResult\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNine papers were included from the total of 1982 articles that were retrieved using various electronic databases in order to determine the aggregate magnitude of low five-minute APGAR scores. A total of 23% (95% CI 16\u0026ndash;30) of newborns delivered at Ethiopian health facilities had a low 5-minute APGAR score. Factors associated with low Apgar score were Skin incision time\u0026thinsp;\u0026gt;\u0026thinsp;3 minutes (AOR:4.76,95%CI:1.28\u0026ndash;8.25),gestational hypertension (AOR\u0026thinsp;=\u0026thinsp;5.71, 95%CI: 0.89\u0026ndash;10.53), birth weight\u0026thinsp;\u0026lt;\u0026thinsp;2500 gram (AOR:4.82,95%CI:3.72\u0026ndash;5.91) ,induced/augmented labor (AOR:3.21, 95%CI:2.27\u0026ndash;4.15),meconium-stained liquor (AOR: 5.36,95%CI: 3.45\u0026ndash;7.27), Presentation of fetus non vertex (AOR:3.15,95% CI:1.31\u0026ndash;5.01), no ANC follow up (AOR:11.46,95%CI: 3.94\u0026ndash;18.97), cesarean section delivery(AOR:15.98,95%CI:14.76\u0026ndash;17.22),APH/PPH (AOR:8.92,95%CI:7.87\u0026ndash;9.98),and Prolonged labor duration\u0026thinsp;\u0026gt;\u0026thinsp;24hours (AOR:13.92,95%CI:10.95-16).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis review revealed that approximately 3 in 10 newborns delivered at health facilities of Ethiopia had low 5th minute Apgar score. Therefore, Comprehensive intervention including enhancing ANC follow up, early identification danger sign and complication of pregnancy and nutritional coursing were recommended for healthcare workers and concerned stakeholders working on maternal, newborn, and child healthcare.\u003c/p\u003e","manuscriptTitle":"Determinants of Low Fifth Minute Apgar Score among Newborn Delivered at health facilities in Ethiopia,systematic review and meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 18:26:12","doi":"10.21203/rs.3.rs-4221694/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43b3d00e-beb4-40ca-8528-c31760374b8e","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T02:08:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-10 18:26:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4221694","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4221694","identity":"rs-4221694","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}