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Background  To examine the association between the Apgar score and neonatal mortality over gestational age in China and to explore whether this association changed when Apgar scores were combined at 1 and 5 min.    Methods  Data for all singleton live births collected from 438 hospitals between 2012 and 2016 were used in this study. Poisson regression with a robust variance estimator adjusted for a complete set of confounders was used to describe the strength of the association between the Apgar score and neonatal mortality.    Results  The relative risks of neonatal death-associated intermediate Apgar score at 5 min peaked at 39–40 weeks of gestation and subsequently decreased if the gestational age increased to 42 weeks or above, in contrast to the low Apgar score. Among both preterm and term new-borns with Apgar scores at 5 min, new-borns that were not small for gestational age had a lower mortality rate than those that were small for gestational age. The association between Apgar score and the neonatal mortality was even stronger when scores at 1 and 5 min were combined.    Conclusions  Apgar score is not only meaningful for preterm new-borns but also useful for term new-borns, especially term new-borns that are not small for gestational age. Once the baby’s Apgar score worsens, timely intervention is needed. There is still a gap between China and high-income countries in terms of sustained treatment of new-borns with low Apgar scores.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12884-020-03533-3.

Apgar score and neonatal mortality in China: an observational study from a national surveillance system