ABSTRACT
Background: Maternal anaemia a major risk factor for adverse pregnancy outcomes. This increases the risk of low birth weight and preterm delivery. Hence such newborns may have low APGAR score at both 1 minute and 5 minutes of life.
Aim: To find out association between maternal haemoglobin levels and APGAR score.
Materials and Methods: A cross-sectional study was designed comparing the impact of maternal anemia on APGAR score of the newborn with that of non-anemic mothers for a period of one year. Sample size was 200, divided into two groups of 100 subjects each. Group-1 included 100 anemic pregnant women and Group-2 included 100 non-anemic pregnant women. Hemoglobin was estimated on automated hematology analyzer and APGAR score was calculated by a single person to avoid subjective variability at one and five minutes of life. A baby who scored 7 or above was considered in good health and a score of less than 7 was considered low. Statistical analysis was done using software Statistical Package for Social Science (SPSS) version 16. Data was compared using t-test at a confidence level of 95%. 
Results: The number of anemic mothers who showed a lower APGAR score of their neonates , were more at both one minute (32%) and five minutes (24%) as compared to the non anemic group (08% and 06% respectively), with a statistically significant difference of these two variables between the two groups.
Conclusion: There is linear association between maternal anemia and a greater probability of having lower APGAR score in a neonate at both one and five minutes of life.
Key words : Maternal anemia, APGAR, Neonate.

Introduction
In 1952, Virginia APGAR proposed the APGAR score for evaluating newborns shortly after delivery. Five characteristics - heart rate, muscle tone, respiratory effort, reflex irritability, and color - are assessed at birth and values are assigned from 0 to 2. The score is the total sum of all the five components of which a score of 7 or above indicates that the baby’s condition is good to excellent. The APGAR score is determined at one minute and five minutes following the delivery and is a rapid way for evaluation of the physical condition of newborn.(Table 1) The five-minute APGAR score has been regarded as the better predictor of survival in infancy. [1]
Table 1: APGAR score [2]

Maternal anemia is one of the major risk factors for adverse pregnancy outcomes. There is significant increase in fetal mortality and morbidity with maternal anemia. This increases the risk of low birth weight and preterm delivery. Hence such newborns may have low APGAR score at both 1 minute and 5 minutes of life. Although some studies showed association between lower APGAR scores and maternal anemia, yet it is unclear to what extent the maternal anemia affects neonatal and maternal health due to variation in the data from different studies. [3]
About fifty percent of the Indian pregnant women are found to be anemic and about one fifth of maternal mortality is directly or indirectly related to maternal anemia. [4,5] Apart from  maternal morbidity and mortality anemia also affects the perinatal outcome. It can cause maternal infections, post partum hemorrhage and pre-eclampsia. The risk of low birth weight and preterm delivery increases with maternal anemia. Thus such newborns are compromised and may have low APGAR score both at 1 minute and 5 minutes of life after the delivery. Thus the aim of our study is to find out if there is an association between maternal anemia and low APGAR score.
Materials and Methods
A cross-sectional study was designed to compare the impact of maternal anaemia on APGAR score of the newborn with that of non-anemic mothers at medical college hospital, Tumkur for a period of one year. Institutional ethical committee approved the study. Through convenient sampling, Sample size was 200 divided into two groups of 100 subjects each. Group-1 included 100 anaemic (haemoglobin <11.0 g/dl) pregnant women and Group-2 included 100 non-anaemic (haemoglobin >11.0 g/dl) pregnant women. Inclusion criteria was all pregnant women 18 years and older and a singleton pregnancy. Women with obstetrical complications, history of previous preterm delivery, or any other medical illness, except anaemia, were excluded to decrease the confounding factors. Haemoglobin was estimated on automated haematology analyzer and APGAR score was calculated according to standard format by a single person to avoid subjective variability at one and five minutes of life (Table 1). A neonate was considered to be in good health if the score was 7 or above and with a score of less than 7 was considered to be low.
STATISTICAL ANALYSIS
Statistical analysis was done using software Statistical Package for Social Science (SPSS) version 16. Frequencies were calculated for categorical data and compared using chi-square test, a p value of <0.05 was considered statistically significant.
RESULTS
Difference between the two groups, anemic and the non anemic mothers was found to be statistically significant (p<0.003), as 32 out of 100 (32%) neonates delivered to mothers in the anemic group showed a low APGAR score at one minute as against 08 out of 100 (08%) in the neonates delivered to the mothers in the non anemic group (table 2).
Table 2: Comparison of low APGAR score at 1 minute of the newborn with the mothers in the non anaemic groups and anaemic group.

Difference between the two groups anemic and the non anemic mothers was found to be statistically significant (p<0.012) in our study as 24 out of 100 (24%) neonates delivered to mothers in the anemic group showed a lower APGAR at five minutes as against 06 out of 100(6%) in the neonates delivered to the mothers in the non anemic group. The number of anemic mothers who showed a lower APGAR score of their neonates were more at both one minute (32%) and five minutes (24%) as compared to that of non anaemic group (08% and 06% respectively), with a statistically highly significant difference of these two variables (p<0.003 and p<0.01 respectively) between the two groups (Table 3).
Table 3: Comparison of the low APGAR score at 5 minutes of newborn with the mothers in the non anaemic groups and anaemic group.

Table 4: Comparison of low APGAR score at 1 minute of the newborn with the mothers in the non anaemic groups and anaemic group.

Table5: Comparison of low APGAR score at 5 minute of the newborn with the mothers in the non anaemic groups and anaemic group.

Discussion
Anemia of pregnancy can have short-term and long term effects on the newborn[6]. The pregnancy outcomes vary depending upon the type of the anemia. Many studies have shown differences in outcomes between the physiological anemia of pregnancy and nutritional anemia secondary to iron deficiency[7].  Maternal anemia has an impact on perinatal outcomes such as preterm delivery, increased risk of death during perinatal period,  low birth weight.[8] The maternal hemoglobin values during the  pregnancy are associated with birth weight and preterm births in a U shaped relationship with a higher rates of neonates who are small at low and high concentrations of maternal haemoglobin.  However, this association may be a result from using ‘lowest haemoglobin’ rather than a haemoglobin value controlled for the stage of pregnancy. Similar to this a U-shaped association is likely to be seen between maternal haemoglobin and the perinatal mortality, but the data is insufficient to establish such association[9]. The major proportion of neonates of the anemic mothers group had an APGAR score of <5 at one minute in our study, with a highly significant difference from the non anemic group (p - 0.003). Our study results are similar to the findings of Lone et al who found that the maternal anemia is associated with a 2.1 times increased risk (95% CI = 1.2-3.7) of APGAR score of <5 at one minute of life, in an univariate analysis of their study population[10]. Similarly our study results were also consistent with recent study which was conducted in El Sahel Teaching Hospital, Cairo, Egypt, in which the study subjects were divided into non-anemic, mildly anemic and severely anemic categories and the comparisons between pregnancy outcomes on gestational age, birth weight, birth length and Apgar score showed a statistically significant difference.[11]

Limitation
Our study was limited to the singleton pregnancy without any comorbidities except anemia, hence the results cannot be generalised.
Conclusion
Our study found a linear association between maternal anemia with a greater probability of having a lower APGAR score in a neonate at both one minute and five minutes of life. This strengthens the necessity in treating maternal anemia at an early period to prevent fetal and neonatal morbidity. Proper antenatal care and counseling can reduce the occurrence of anemia in pregnancy and thereby improve the neonatal outcome.
Acknowledgment
I would like to thank Department of Obstetrics and Gynecology for timely cooperation and data collection. I thank all the participants of the study for their cooperation. 
Financial support and sponsorship: nil
Conflict of interest: nil
References

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Corresponding author : Dr. G V Kumar, Professor of Paediatrics, Sri Siddhartha Medical College, Sri Siddhartha Academy of Higher Education, Tumakuru, Karnataka, India PIN- 572107 E-mail: kumargowripura@gmail.com