Supplementary Material 4: Dataset.

Background
Birth asphyxia is a consistent key contributor to neonatal morbidity and mortality, notably in sub-Saharan Africa. The APGAR score, though a globally used diagnostic tool for birth asphyxia, remains largely understudied especially in resource-poor settings.
Objective
This study determined how effectively the APGAR score is used to diagnose birth asphyxia in comparison to the gold standard (umbilical cord blood pH <7 with neurologic involvement) at Moi Teaching and Referral Hospital (MTRH), and identified healthcare provider factors that affect ineffective use of the score.
Methods
Using a quantitative cross-sectional hospital-based design, term babies born in MTRH who weighed ≥2500g were randomly and systematically sampled; and healthcare providers who assign APGAR scores were enrolled via a census. Umbilical cord blood was drawn at birth and at 5minutes for pH analysis. APGAR scores assigned by healthcare providers were recorded. Effective use of the APGAR score was determined by sensitivity, specificity, positive and negative predictive values. At a significance level of 0.05, multiple logistic regression analysis identified the independent provider-associated factors affecting ineffective use of the APGAR score.
Results
We enrolled 102 babies, and 50 (49%) were females. Among the 64 healthcare providers recruited, 40 (63%) were female and the median age was 34.5years [IQR: 31.0, 37.0]. Assigned APGAR scores had a sensitivity of 71% and specificity of 89%, with positive and negative predictive values of 62% and 92% respectively. Healthcare provider factors associated with ineffective APGAR score use included: instrumental delivery (OR: 8.83 [95% CI: 0.79, 199]), lack of access to APGAR scoring charts (OR: 56.0 [95% CI: 12.9, 322.3]), and neonatal resuscitation (OR: 23.83 [95% CI: 6.72, 101.99]).
Conclusion
Assigned APGAR scores had low sensitivity and positive predictive values. Healthcare provider factors independently associated with ineffective APGAR scoring include; instrumental delivery, lack of access to APGAR scoring charts, and neonatal resuscitation.