Low 5-Minute Apgar Score (<7) Among Inborn Neonates at Banadir Hospital, Mogadishu, Somalia: Prevalence and Associated Factors

Every newborn takes their first breaths in a fragile window of time, where the transition from the safety of the womb to the outside world can be smooth or suddenly difficult. In the minutes following birth, doctors and midwives use a simple, universal checklist to gauge how well a baby is adapting. This checklist, known as the Apgar score, rates a newborn on five basic signs: their heart rate, their breathing effort, their muscle tone, their reflexes, and the color of their skin. Each sign receives a score from zero to two, and the total is checked at one minute and again at five minutes after birth. A score below seven at the five-minute mark signals that the baby is struggling and needs immediate help to breathe and stabilize. While this tool does not diagnose a specific disease, it serves as a critical early warning system for a condition often called birth asphyxia, where a baby does not get enough oxygen during labor. In many parts of the world, especially where resources are scarce, understanding how often these struggles happen and what causes them is essential for saving lives and preventing long-term harm.

In a major hospital in Mogadishu, Somalia, researchers recently set out to measure exactly how often this struggle occurs among babies born inside the facility and to identify the specific circumstances that make it more likely. The team focused on Banadir Hospital, a primary referral center for mothers and infants in the capital. Between January and March of 2026, they observed 315 live births, carefully recording the details of the mother's health, the progress of the labor, and the condition of the baby. Their goal was not just to count the number of babies with low scores, but to find the patterns that link a difficult birth to specific factors like the length of labor, the size of the baby, or the condition of the amniotic fluid. By looking at these real-world events, the researchers hoped to provide a clear picture of the risks facing newborns in this setting, offering a roadmap for where medical teams can focus their attention to improve outcomes.

The study found that among the 315 babies born during the observation period, 26 had a five-minute Apgar score below seven. This translates to a prevalence of 8.3 percent, meaning that roughly one in every twelve babies born at the hospital required significant assistance or showed signs of distress at the five-minute mark. While this rate is lower than some estimates from neighboring countries, it represents a significant burden of preventable difficulty. The researchers discovered that this struggle was not random; it was strongly linked to three specific conditions. Babies who weighed less than 2,500 grams at birth were far more likely to have a low score than those of average weight. Similarly, when labor lasted longer than twelve hours, the odds of the baby struggling increased significantly. The third major factor was the appearance of the amniotic fluid; when the fluid was stained with meconium, a dark green substance passed by the fetus, the baby was much more likely to have a low score compared to cases where the fluid was clear.

Beyond these physical factors, the study also examined the mother's medical history, including her vaccination status. The data showed an unexpected link between the mother's tetanus vaccination and the baby's condition. Babies born to mothers who had received only a partial course of tetanus shots were more likely to have a low Apgar score than those born to fully vaccinated mothers. However, the researchers were careful to note that this finding is uncertain. There is no known biological reason why a tetanus shot would directly cause a baby to struggle with oxygen during birth. Instead, the team suggests that this pattern likely reflects a broader issue: mothers who received only partial care may have faced other unmeasured challenges, such as poorer overall health or less consistent medical supervision, which contributed to the difficult birth. The data did not show a similar risk for mothers who received no shots at all, which further suggests that the partial vaccination result might be a statistical coincidence rather than a direct cause.

The implications of these findings are practical and immediate for the hospital staff and the families they serve. The three main factors identified—low birth weight, prolonged labor, and meconium-stained fluid—are all things that medical teams can recognize before or during delivery. When a mother arrives with a baby who is small, or when labor drags on, or when the fluid is stained, these are clear signals that the team needs to be extra prepared. They should monitor the baby more closely and have resuscitation equipment ready to use the moment the baby is born. The study reinforces the importance of skilled attendance during birth, where a trained professional can spot these warning signs early and act quickly. While the link to tetanus vaccination remains a mystery that needs further investigation, the other three factors provide a solid foundation for improving care. By focusing on these specific risks, hospitals can better prepare for the moments when a newborn needs help, turning a potential tragedy into a manageable medical event.