Monthly Archives: March 2010

The mother of the Apgar score

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Virginia Apgar MD devised the simple observational test that bears her name after watching doctors swiftly give up on struggling newborn babies, leaving them to die, Atul Gawande writes in his book, Better. At the time, a few years after World War II, one in 30 births in the United States ended in the infant’s death.

Virginia Apgar

Dr. Virginia Apgar

The Apgar score, introduced in 1953, is a 10-point scale for assessing how a newborn baby is doing — first with the birth process, and then with adjusting to the world. It is given in hospitals one minute after birth, and again at five minutes. A robust baby might garner 10 points, but a baby with an Apgar score of four or less draws serious concern and, likely, vigorous intervention.

Dr. Apgar’s scoring system transformed delivery, Gawande writes. “Even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered,” he writes.

The daughter of a Westfield, N.J., insurance executive, Dr. Apgar graduated from Mount Holyoke College in 1929, and began medical school at Columbia University’s College of Physicians and Surgeons, where eight of her classmates were women and 81 were men. She began a surgical residency but, in the depths of the Great Depression, decided it might be difficult, especially as a woman, to make a living as a surgeon.

Dr. Apgar enrolled first in a course for nurse-anesthetists and then in Dr. Ralph Waters’ seminal residency program in anesthesiology at the University of Wisconsin in Madison, followed by a stint with Emery Rovenstine at Bellevue Hospital in New York — strong training for the day.

She founded the anesthesiology program at Columbia’s College of Physicians and Surgeons. However, when the program became a department, Dr. Apgar was passed over for the job as chairman, in favor of a man. She did become a full professor, though — in itself an accomplishment at the time — and was a pioneer in obstetrical anesthesiology.

Dr. Apgar saw a number of birth defects during the thousands of births she attended, and in 1958 she went back to school in public health at Johns Hopkins’ medical school in Baltimore. In 1959, Dr. Apgar joined the March of Dimes in its campaign to eliminate birth defects.

Dr. Apgar never married. Her entire life, she was famous for intelligence, energy, empathy and a great sense of humor. She was still working on behalf of the most vulnerable babies when she died in 1974, at the age of 65, of liver failure.

Gawande’s chapter about Dr. Apgar, “The Score,” also ran in the New Yorker.

Mothers & babies can use the luck of the Irish

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Green River

The Chicago River, ready for the parade

From Chicago on St. Patrick's Day, here is our famous green river, dyed last Saturday for the big downtown parade, captured by my friend Bill Linden.

What does this have to do with the birth story? Well, nothing, but we of Irish descent just get the one day to celebrate, you know? Or, counting parade day and the festivities on the South Side on Sunday, three days, tops.

And Ireland does have the lowest maternal mortality rate in the world at last tally, with just one mother dying per 100,000 births in 2005.

That certainly is something to celebrate, and to remark upon.

Happy St. Patrick's Day!

Photo courtesty of Bill Linden

The Frontier Nursing Service

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Mary Breckinridge, a daughter of a prominent Kentucky family that included John C. Breckinridge, James Buchanan’s vice president, suffered the loss of both her children before they reached the age of 5. Instead of allowing these tragedies to ruin her life, she channeled her energy into a passionate campaign to improve the health of the children of Appalachia.

Mary Breckinridge

Mary Breckinridge at work

To Breckinridge, a healthy child required a safe birth, a living mother and a healthy family. Making childbirth safe was a primary goal when, in 1925, she founded the Frontier Nursing Service in Leslie County, Ky. The previous year, Breckinridge, 43 and already a nurse, had traveled to England to learn midwifery because she could find no adequate course in the United States. She continued to send FNS nurses to England until the outbreak of World War II.

The FNS deployed the first nurse-midwives to practice in the United States. Breckinridge had encountered nurse-midwives in Europe, and thought that the model was well suited not only for delivering babies but also for providing prenatal care and for assessing and helping to plan for the health needs of the whole family and, indeed, the whole community.

FNS nurses traveled by horseback to attend home births; high-risk patients went to the FNS hospital in Hyden, Ky. Clinics in the community served an average of 250 families. The FNS maternal mortality rate for its first 30 years was about one quarter of the rate for the United States as a whole.

Breckinridge died in 1965. The Frontier Nursing Service, based in Wendover, Ky., is still active, as its midwifery school, which was added in 1939.

A Midwife’s Tale

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Only one American midwife of the Revolutionary War era left a diary that has been recovered, Martha Ballard of Hallowell, Maine. It is a fairly basic document. Some entries are just a few words. Still, between 1785 and 1812, a time of incredible change in New England, Martha tended her diary regularly.

A Midwife's Tale

A Midwife's Tale

In 1990, the historian Laurel Thatcher Ulrich used her own considerable knowledge of the period to connect the dots in Ballard's diary. The result was A Midwife's Tale, which won the Pulitzer Prize and other awards. It is a terrific book, and it was made into a film for PBS's "American Experience."

One of the best things about A Midwife's Tale is the fact that Ulrich has given us a fully fleshed-out picture of Martha Ballard, and has at the same time retained her distinctive voice. Ballard was a religious, hard-working wife and mother who trained her daughters and other young women to assist her, understood the medicinal uses of the plants she grew in her kitchen garden, and in her prime delivered two-thirds of the children in Hallowell.

The town had more than one doctor, but in 816 births over the course of 27 years, Martha called a doctor in to help her with a birth just twice. In all those years, Martha saw 19 babies and five mothers die just before, during or just after birth.

While childbirth rested on a community of women when Ballard began her career, one of the tensions of the book comes out of the inroads male doctors were already making into midwifery by the time Martha died in 1812.

The death of an uncommon woman

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Mary Wollstonecraft, the earliest feminist writer in English, died in childbirth in London in 1797. At a time when women were bound to the home and dependent on the men in their lives, Wollstonecraft was a professional writer who had already had one child out of wedlock, and had only recently married her lover, the writer William Godwin.

Mary Wollstonecraft

Mary Wollstonecraft

The birth began with a midwife of Mary’s choosing, but when the placenta would not come out, a male physician was called in and removed it surgically.  Wollstonecraft died 11 days later, at the age of 38, of puerperal fever, a wound infection.

At the beginning of the 19th century, women found their public voice.  Wollstonecraft didn’t have an easy life, but the speed with which others followed in her footsteps reflects seismic changes.  Jane Austen’s first novel, Sense and Sensibilty, was published in 1811; born in 1775, Austen was a well educated woman.

Mary Wollstonecraft not only supported herself with her writing, but she started women on the path to speaking for themselves. On the day she died, Godwin wrote, “There does not exist her equal in the world.”

The daughter Wollstonecraft bore that day grew up to marry the poet Percy Bysshe Shelley, and to write a seminal Gothic novel, Frankenstein, as Mary Shelley.