APGAR score

In 1953, Dr. Virginia Apgar, then the director of the department of anesthesiology at New York-Presbyterian Medical Center, invented a scoring system that allowed physicians to quickly identify signs of physical health or distress in newborns and immediately give them the care they needed. The APGAR score—which is both its inventor’s name and an acronym—measures an infant’s appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration one minute and five minutes after birth. Each component is assigned a score of 0, 1, or 2, adding up to a maximum score of 10. If an infant’s score is below 7, they will be re-tested four times or until they score 7 or more twice in a row.

Today, an updated version of the APGAR score is used in nearly every hospital in the world to evaluate the health of newborn babies. It’s easy to learn, cheap to implement, and highly effective. Let’s hear its birth story.

17.7%: World neonatal mortality rate in 2017

3.6%: US neonatal mortality rate in 2017

1 million: Babies who die within their first day of life every year globally

7,000: Newborns who die every day globally

~20,000: Babies Dr. Apgar delivered

4: Babies Dr. Apgar delivered in a single birth at Sloane Hospital for Women in 1944. The quadruplets were three girls and one boy.

$0: Profit Apgar made from the test

After World War II, infant mortality declined precipitously in the US, thanks to advances in medicine. In 1941, close to 5% of all infants died in the first month of life; by 1950 that mortality rate dropped below 3%.

Virginia Apgar noticed that while overall outcomes were improving, the rates of neonatal mortality, meaning newborns dying within 28 days of birth, remained stubbornly high. All roads seemed to lead back to the first 24 hours of life, when infants were either being sent home with undiagnosed health conditions and dying shortly after, or, if they had trouble breathing, were often being labeled as stillborn and left to die.

In evaluating her method, Apgar found that infants who got a score between 0 and 2 had a neonatal death rate of 14%; those scoring between 3 and 7 had a death rate of 1.1%; and those scoring between 8 and 10 had a death rate of 0.13%.

Born in 1909, Apgar was one of four women accepted into the College of Physicians and Surgeons of Columbia University in 1929.

Apgar wanted to become a surgeon, but the chair of surgery at Columbia encouraged her to enter anesthesiology instead. At the age of 28, she became head of the division of anesthesiology at Columbia Presbyterian and the first female physician to hold a full professorship at the College of Physicians and Surgeons. During a sabbatical from Columbia, she earned a master’s degree in public health. Apgar joined what is now the March of Dimes Foundation to lead fundraising, research, and public education efforts about congenital defects.

Apgar also built her own musical instruments (a viola and a cello), performed with musical ensembles like the symphony in Teaneck, New Jersey, and “learned to fly a single-engine plane in her 50s,” according to a tribute to her career published by New York Presbyterian.

“It’s just that I haven’t found a man who can cook.”

—Virginia Apgar, explaining why she never got married

1953: Apgar presents the APGAR score in “A proposal for a new method of evaluation of the newborn infant,” published in the medical journal Anesthesia & Analgesia.

1958: After years of testing on over 15,000 infants, Apgar publishes an updated version of the APGAR score in “Evaluation of the newborn infant: second report.”

1972: Apgar helps to convene the first Committee on Perinatal Health with all the major US medical bodies to work on improving maternal-fetal health and reducing infant mortality.

1974: Apgar dies.

1976: The Committee on Perinatal Health publishes a landmark study, “Toward Improving the Outcome of Pregnancy,” that changes the regional development of perinatal health services in the US.

2015: The American College of Obstetricians and Gynecologists’ (ACOG) Committee on Obstetric Practice states that the APGAR score “provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed.”

In a 2015 opinion statement, ACOG writes that the APGAR score has three main problems: It “is an expression of the infant’s physiologic condition at one point in time, which includes subjective components. There are numerous factors that can influence the Apgar score, including maternal sedation or anesthesia, congenital malformations, gestational age, trauma, and interobserver variability. In addition, the biochemical disturbance must be significant before the score is affected.”

As Melaina Juntti writes in Fatherly, “The point of this practice is to tell doctors how well the newborn is transitioning to life outside the womb and the level of immediate care needed—that’s it. A high Apgar score is not, as some proud parents want to believe, the first indicator that their child is destined for greatness. Nor is a low score a sign the baby will have health problems down the road.”

Most babies get a 0 or 1 for appearance, as it’s normal to be born with bluish hands and feet, or acrocyanosis.

Today, most newborn deaths happen in low- and middle-income countries. According to the World Health Organization, “a child born in sub-Saharan Africa or in Southern Asia is 10 times more likely to die in the first month than a child born in a high-income country.”

In 2015, almost every country in the world committed to a set of Sustainable Development Goals, one of which was to “reduce neonatal mortality to at least as low as 12 per 1,000 live births” by 2030. But they’re falling behind on that goal, according to the WHO, which recently predicted that “more than 60 countries” will miss the target, and that “about half of them” will not even meet the target by 2050. These same countries, the WHO pointed out, accounted for “80% of the burden of neonatal deaths in 2016.”