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The History of Child Birthing Practices and
How the Apgar Score Aided in Post-birth Infant Survival
VICTORIA MEDINA-VISCEGLIO
Image One: Photo courtesy of Birth Injury Help Center
Image Two: American pioneer birth scene, Gustave Joseph Witkowski, 1887. From Histoire des accouchements chez tous les peuples Photo courtesy of: Changes in Childbirth in the United States
Before the APGAR Score: The History of Midwives
Up until the medicalization of birthing practices in the late-nineteenth century, labor had been primarily assisted by midwives for centuries. For quick reference of its history, the practice of midwives and childbirth stretches as far back as the earliest recordings of birth in the Bible, to the first Colonial infants birthed by Bridget Lee Fuller aboard the Mayflower in 1620, and for the next two centuries succeeding the travelers to the New World, midwives were an integral part of childbirth throughout history.(1) That is until the emergence of medicalized birth in the late 1800s that brought doctors, forceps, pain relief, surgical practices, and eventually antibiotics, hospital births, and the Apgar score to become new common methods of birthing used in the United States. The creation of the Apgar score in 1952 by Virginia Apgar was a revolutionary one in terms of decreasing the rates of death among infants shortly after birth. Since its conception, the practice of the Apgar score has become a vital part of infant survival post-birth.
From the beginning of midwifery to Colonial American times, midwife skills had been passed down from experienced midwives to novices interested in the profession.(2) Even when a formal training institute was established in 1765 in Philadelphia, the majority could not afford such training and continued to apprentice under experienced midwives.(3) The typical work setting for a midwife was typically the home of the laboring patient along with normally female relatives and neighbors around the bedside to encourage and support the woman in labor.(4) Skilled midwives in the 18th century were highly valued and sought after considering they had more successful and practical experience delivering children, making many women in the profession typically older in age and most times widows who needed to support themselves.(5) Communities in need of skilled midwives would attract them with salaries or rent-free housing.(6) However, even with skill and experience, there was no way of preventing an unexpected death of a mother - usually from exhaustion, dehydration, infection, or excessive bleeding - as well as death of an infant from complications in childbirth.(7)(8) With one in eight births resulting in a mothers death and birth control consisting of vulcanized rubber in this period, women often times referred to childbirth as “the greatest of earthly miseries” and dreaded their potentially impending death.(9)(10) In this period, the typical mother gave birth to approximately five to eight children in her lifetime, increasing her chances of dying in childbirth henceforth explaining the feelings of dread in regards to falling pregnant - rather than becoming pregnant.(11) In this heavily Christian culture, it was expected of a woman to endure the pains of childbirth for it was Eve who bit into the forbidden fruit and provoked God to punish all future humans on Earth.(12) While women anticipated childbirth with dread, they knew this was their duty as Christian women and took on the pain valiantly. As for infants, even in the healthiest of environments one in ten children died before the age of five, and in less healthy environments three in ten died.(13)
One late 18th century midwife from Maine kept a diary filled with descriptive tellings of her experiences as a midwife including fording rivers in the winter, assisting laboring patients for hours and days at a time, and sometimes preparing deceased patients for burial. Martha Ballard’s track record was an incredible one for out of 996 deliveries, she experienced only four deaths.(14) Vigilant, skilled, and attentive midwives saw childbirth as a natural process and assisted it as so. The medicalization of childbirth took a more technical approach and saw it as something to treat with medicine and surgical procedures in hopes of reducing mortality rates in mothers and infants. By the late 18th century, doctors in England had influenced American doctors to take a larger part in child birthing and soon began the switch of child birthing from homes to hospitals.(15) Urban areas like Philadelphia, Boston, and New York were among the first to take part in physician-assisted childbirth and these “man-midwives” brought along medications and forceps with them.(16) Around 1790, midwives had begun to lose their popularity against doctor-assisted deliveries, however, they were still useful among laboring women in areas lacking access to doctors or resources to be able to afford a physician’s care.(17)
Early 19th century midwives still assisted births in the home and the average American woman was giving birth to six children, although some of them were miscarriages and stillbirths.(18) At this time, the culture of midwifery was slightly different compared to 18th century midwifery; only women midwives assisted women during childbirth, typically men were not in the room yet, and midwives were normally local women with kids of their own who learned midwifery skills through apprenticeships like other 19th century physicians did.(19) Midwives were not to interfere with the normal process of labor and birth, and instead comforted women while they waited for the body to naturally birth a child.(20) At this time, midwives received decent compensation but could also be paid with household goods or even a chicken.(21) Although midwife popularity was trending downwards, it was still common in the 19th century, especially in the southern regions of the United States; plantations were notorious for using slaves to act as midwives and assist the births of both black and white mothers.(22) This created the prevalence of black midwives in history as the trade was passed down.(23) In the northern regions of America, more white midwives could be seen serving both the upper and lower classes.(24) The transition of medicalized birth began towards the end of the 19th century and for reasons that even with all of the training and experience midwives had been prepared with, they were not technologically advanced or equipped enough to avoid the prevalence of infant or maternal mortality rates.
Image One: McClure's Magazine, Painless Childbirth, June 1914
Image Two: Maternity Ward at Station Hospital, Camp Mackall, 1942
Photos courtesy of: Changes in Childbirth in the United States
Leading up to the APGAR Score: IMR and the Medicalization of Birth
In the late 1800s, Europe and North America had determined that child health and wellbeing were of critical political importance.(25) They began a pursuit towards reducing the number of infant deaths as the IMR (Infant Mortality Rate) was considered a sensitive index of child and communal health.(26) The United States took the approach of reducing IMR in immigrant and poor communities as they held the highest rates of infant mortality in the country.(27) Thus, the Progressive Era was born and large-scale efforts were made to aid in children’s health and began the uprise of the people’s faith in the medical community and science to solve problems.(28) This era also introduced methods of pain-relief for child birth such as chloroform. Kate Chopin, a mother in the late-nineteenth century, wrote a sentiment regarding her first experience with child birth on May 22, 1871:
“I can remember yet that hot southern day on Magazine Street in New Orleans. The noises of the street coming through the open windows, that heaviness with which I dragged myself about; my husband’s and mother’s solicitude; old Alexandrine the quadroon nurse with her high bandana tignon, her hoop-earrings and placid smile; old Dr. Faget; the smell of chloroform, and then waking at 6 in the evening from out of a stupor to see in my mother’s arms a little piece of humanity all dressed in white; which they told me was my little son! The sensation with which I touched my lips and my fingertips to his soft flesh only comes once to a mother. It must be the pure animal sensation: nothing spiritual could be so real – so poignant.”(29)
Technological advancements in medicine gave steam for male-midwives and physicians to wedge their way into obstetrics. Forceps were an eighteenth century invention and were used to help move infants through the birthing canal when stuck.(30) Since women were not allowed to use forceps at this point in time, male midwives and doctors considered themselves superior to female midwives.(31) The trend of using physician-assisted birthing practices began with wealthy upper class women whilst the majority of mothers were still using midwives.(32) The continuation of medical developments didn’t stop there and advancements continued to make pregnancy, labor and childbirth safer. From the late nineteenth century to early twentieth, Europe and North America were working, progressing, and popularizing the germ theory which played a great role in saving the lives of mothers and infants.(33) Before germ theory and antiseptics entered the child birthing world, doctors had a much worse track record compared to midwives as they caused more deaths from lack of washing hands between procedures and spreading tons of infections between the ill to mothers and infants.(34) Anesthetics were progressing around the mid to late-nineteenth century and doctors were learning how to effectively use chemicals in order to numb pain on injured patients and during surgeries.(35) Chemicals like chloroform were used on mothers giving birth, like Queen Victoria!(36) Although anesthetic-use was becoming increasingly popular in the medical community, the previously mentioned notion that the Christian community frowned upon pain relief during pregnancy and childbirth was unfortunately still prevalent in this time.(37) Another advancement was the discovery of pathogens that happened in this time as well; That’s when antiseptics and hygienic practices entered the medical community and procedures became much safer, in turn dramatically preventing unnecessary deaths.(38) When this practice came into play, cesarean sections or c-sections began to rise in popularity because the new hygienic practices and antiseptic methods prevented inevitable death by infection.(39) North American advancements in medicine were a catalyst for the definitive move from home births with midwives to hospital births with physicians.(40) In 1924, the first US president to be born in a hospital was Jimmy Carter in 1924, and by the 1950s approximately 88% of births were physician-assisted in hospitals.(41) The 1950s, specifically 1952, also introduced a new post-birthing practice that would eventually become an accepted and widely used method after all births that continues to help prevent asphyxia in infants.
The Creation of the APGAR Score: The Mid-20th Century
The Apgar Score was developed by anesthesiologist Dr. Virginia Apgar at Columbia University in 1952.(42) Not only is the Apgar Score named after its creator, it is also used as a mnemonic to describe the score’s components: appearance, pulse, grimace, activity and respiration.(43) It is used to rapidly evaluate newborn children immediately after birth and reevaluated a few minutes after birth in response to resuscitation if needed.(44) The Apgar scoring is endorsed by the American College of Obstetricians and Gynecologists (ACOG) as well as the American Academy of Pediatrics (AAP).(45) When using the scoring system, the main objectives are to: identify physiological criteria for calculating the Apgar score, describe clinical relevance of the score, outline its limitations, and foster the best possible care to newborns and families by coordinated collaboration and effective communication within the interprofessional team members involved in evaluating and managing the newborns.(46) The NIH National Library of Medicine published an article on the Apgar Scoring. Here is their in-depth explanation as well as the limitations of the scoring system that is done at 1 minute and 5 minutes post-birth:
“Elements of the Apgar score include color, heart rate, reflexes, muscle tone, and respiration. Apgar scoring is designed to assess for signs of hemodynamic compromise such as cyanosis, hypoperfusion, bradycardia, hypotonia, respiratory depression, or apnea. Each element is scored 0 (zero), 1, or 2. The score is recorded at 1 minute and 5 minutes in all infants with expanded recording at 5-minute intervals for infants who score seven or less at 5 minutes, and in those requiring resuscitation as a method for monitoring response. Scores of 7 to 10 are considered reassuring.
Apgar scores may vary with gestational age, birth weight, maternal medications, drug use or anesthesia, and congenital anomalies. Several components of the score are also subjective and prone to inter-rater variability. Thus, the Apgar score is limited in that it provides somewhat subjective information about an infant’s physiology at a point in time. It is useful in gauging the response to resuscitation but should not be used to extrapolate outcomes, particularly at 1 minute as this does not hold any long-term clinical significance. Apgar score alone should not be interpreted as evidence of asphyxia and its significance in outcome studies while widely reported is often inappropriate. Resuscitation should always take precedence over calculating a clinical score.”(47)
Other sources speak to the importance of the Apgar score in much higher regard than the former. The NewYork-Presbyterian health care delivery system wrote an article on Dr. Virgina Apgar and the Apgar Score refers to it as, “the post-birth assessment that's saved countless newborn lives.”(48) A quote from Dr. Richard Smiley, a Professor of Anesthesiology at Columbia University Medical Center and chief of obstetric anesthesia at NewYork-Presbyterian/Columbia University Medical Center, regarding the Apgar Score:
“‘The score gave physicians and nurses a requirement to look at the newborn in an organized method, and it’s helped prevent the death of countless babies. Once physicians and nurses had to assign a score, it created an imperative to act to improve the score… ‘It was essentially the birth of clinical neonatology,’”(49)
Before the Apgar score, many infants were mislabeled as stillborns because they had trouble breathing or were small and blue; Since there was no protocol to encourage resuscitation or medical intervention in newborns, many babies were left to die.(50) Dr. Richard Smiley claimed that, “Before, you took the baby out, cleaned it, and hoped it lived. A large number of neonates could have survived if they had simply been given oxygen or warmed up.”(51)
Current Trends in Birthing Practices
Today, the Apgar Score is used in hospitals all over the world and can be performed by a physician, midwife, or nurse.(52) It is encouraged for the same person to calculate all initial and ongoing Apgar scores for consistency and to reduce inter-rater variability because some components are subjective and can impact the scoring and health of a neonate.(53) While the Apgar scoring system has dramatically improved the chances of survival in newborns, medical developments are increasingly advancing at rapid rates, and the sum of money spent on maternity care is tremendous, the US still holds one of the highest mortality rates for women and infants compared to other wealthy and advanced countries.(54) Women are currently lacking the proper care during pregnancy due to a shortage of hospitals and ob-gyns, most especially in rural areas of the US.(55) While the World Health Organization (WHO) states that the ideal rate of cesarean section procedures to be at 10%, the rate in the US is a whopping 32%, and within that rate, “13 percent of women report feeling pressured by their providers to have the procedure.”(56) Other developed countries like the United Kingdom, France, and Australia use midwives just as much as obstetric care.(57) The Scientific American considers a widespread adoption of midwife-assisted deliveries could aid in decreasing the rates of mortality in women and infants as well as providing more accessible care in rural areas of the US. With that being said, here is what the Scientific American has to say about midwife training in the US:
“In the U.S., certified midwives and nurse-midwives must hold a graduate degree from an institution accredited by the American College of Nurse-Midwives, and certified professional midwives must undergo at least two years of intensive training. This is designed to make midwives experts in normal physiological pregnancy and birth. Thus, for women with low-risk pregnancies who wish to deliver vaginally, it often makes sense to employ a midwife rather than a more costly surgeon. Yet only about 8 percent of U.S. births are attended by midwives.”(58)
While the 1960s marked the desertion of midwife practices in the US, current trends are slightly making their way back to the use of midwifery across the country with 8% of births being assisted by midwives.(59) Scientific American states, “[Midwifery] has made a comeback since then, with practitioners just as well trained as doctors to supervise uncomplicated deliveries. Studies show that midwife-attended births are as safe as physician-attended ones, and they are associated with lower rates of C-sections and other interventions that can be costly, risky and disruptive to the labor process. But midwifery still remains on the margins of maternity care in the U.S.” There have been cases of midwife-assisted births taking place in hospital rooms with doctors just a shout away if medical intervention is needed.(60)
By examining the history of the child birthing practices in the US, the Apgar Score, and current trends regarding child birth and mortality rates, we have gotten a better sense of how the first few minutes of life throughout American history has drastically changed for the better. Regardless of the unfortunately increasing mortality rates in the US, it cannot be denied that we have advanced incredibly from a time before antiseptics or natural child birthing pains being pressured upon when anesthetics were available to women due to Christian influences and the sins of Eve. With the future of medical care in the hands of the next generation of up-and-coming doctors, physicians, nurses, midwives, and other medical personnel, there is an enormous amount of potential to fix the unnecessarily high rates of mortality in women and infants and to provide the best possible and essential care to pregnant women everywhere.
Footnotes
(1) Elaine Marie Cooper, “Childbirth in Colonial America,” Heroes, Heroines, and History, last modified August 29, 2019, https://www.hhhistory.com/2019/08/childbirth-in-colonial-america.html, 1.
(2) Cooper, “Childbirth”, 1.
(3) Cooper, “Childbirth”, 1.
(4) Paul, Paula, Alexis, Rodentraiser, Tammy Bradford, and Jenn. “19th Century Midwives.” History of American Women, May 29, 2020. https://www.womenhistoryblog.com/2014/06/19th-century-midwives.html, 1.
(5) Paul et al., “19th Century Midwives”, 1.
(6) Ibid, 1.
(7) Ibid, 1.
(8) Cooper, “Childbirth”, 1.
(9) Ibid, 1.
(10) Women's Health, Embry. “History of Contraception & Its Evolution in America.” Embry Women's Health, November 27, 2019. https://embrywomenshealth.com/history-of-contraception-its-evolution-in-america/#:~:text=In%20colonial%20America%2C%20vulcanized%20rubber,cervix%20to%20prevent%20sperm%20entry, 1.
(11) Paul et al., “19th Century Midwives”, 1.
(12) “The History of Childbirth,” Birth Injury Help Center (Birth Injury Help Center), accessed May 6, 2023, https://www.birthinjuryhelpcenter.org/childbirth-history.html, 1.
(13) Paul et al., “19th Century Midwives”, 1.
(14) Cooper, “Childbirth”, 1.
(15) Ibid, 1.
(16) Ibid, 1.
(17) Ibid, 1.
(18) Paul et al., “19th Century Midwives”, 1.
(19) Ibid, 1.
(20) Ibid, 1.
(21) Ibid, 1.
(22) Ibid, 1.
(23) Ibid, 1.
(24) Ibid, 1.
(25) Jeffrey P Brosco, MD, “The Early History of the Infant Mortality Rate in America: ‘A Reflection Upon the Past and a Prophecy of the Future’1,” Publications.aap.org, February 1, 1999, https://publications.aap.org/pediatrics/article/103/2/478/62105/The-Early-History-of-the-Infant-Mortality-Rate-in?autologonchecked=redirected, 2.
(26) Brosco, “Infant Mortality Rate”, 2.
(27) Ibid, 2.
(28) Ibid, 2.
(29) Paul et al., “19th Century Midwives”, 2.
(30) Birth Injury Help Center, “Childbirth”, 2.
(31) Ibid, 2.
(32) Ibid, 2.
(33) Harvard Library, “Germ Theory,” Contagion - CURIOSity Digital Collections, March 26, 2020, https://curiosity.lib.harvard.edu/contagion/feature/germ-theory#:~:text=Germ%20theory%20states%20that%20specific,between%20about%201850%20and%201920, 2.
(34) Birth Injury Help Center, “Childbirth”, 2.
(35) Ibid, 2.
(36) Ibid, 2.
(37) Ibid, 2.
(38) Ibid, 2.
(39) Ibid, 2.
(40) Ibid, 2.
(41) Ibid, 2.
(42). Leslie V. Simon, Muhammad F. Hashmi, and Bradley N. Bragg, “Apgar Score - Statpearls - NCBI Bookshelf ,” Apgar Score (StatPearls Publishing LLC, February 19, 2023), https://www.ncbi.nlm.nih.gov/books/NBK470569/, 3.
(43) Ibid, 3.
(44) Ibid, 3.
(45) Ibid, 3.
(46) Ibid, 3.
(47) Ibid, 3.
(48) Leigh Flayton, “The History behind the Apgar Score,” NewYork-Presbyterian, March 10, 2023, https://healthmatters.nyp.org/apgar-score/, 3.
(49) Flayton, “History Behind Apgar”, 3.
(50) Ibid, 3.
(51) Ibid, 3.
(52) Simon et al., “Apgar Score”, 4.
(53) Ibid, 4.
(54) The Editors, “The U.S. Needs More Midwives for Better Maternity Care,” Scientific American (Scientific American, February 1, 2019), https://www.scientificamerican.com/article/the-u-s-needs-more-midwives-for-better-maternity-care/#:~:text=Yet%20only%20about%208%20percent,and%20discomfort%20associated%20with%20childbirth, 4.
(55) The Editors, “Better Maternity Care”, 4.
(56) Ibid, 4.
(57) Ibid, 4.
(58) Ibid, 4.
(59) Ibid, 4.
(60) Cooper, “Childbirth”, 4.
About The Author
Victoria Medina-Visceglio is currently a sophomore majoring in Psychology and minoring in History at Boston University. She is apart of BU's Alpha Delta Pi sorority, ADPi's Diversity, Equity, and Inclusion committee, BU Women's Club Ice Hockey, as well as BU's Brazilian Association. Before BU, she attended Johnson & Wales University in Providence, Rhode Island for her freshman year of college and played NCAA Women's Ice Hockey. She is from Sandwich, Massachusetts, more commonly known as the oldest town in Cape Cod, MA. When she is not playing hockey or at the beach, she is most likely working at the Falmouth Raw Bar, trying out new seafood and hibachi restaurants, or driving off-Cape to visit friends.
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