It’s time to remove skin color from the Apgar Score for newborns

In medicine, inertia can be a strangely powerful force, but Virginia Apgar never succumbed to it. She brought incredible energy to her work in anesthesia, neonatology, and dysmorphology (the study of birth defects) and questioned the status quo when she thought it might save lives.

With gratitude for her tireless work, we have reevaluated the eponymous health assessment Apgar developed more than 70 years ago and concluded that one of its components — skin color — should be abandoned. It’s a step Apgar herself might have encouraged; she knew this part of her evaluation method was weaker than the others. We have a chance now to correct that bias.

Apgar developed her scoring system in the early 1950s to help identify newborns who might need immediate medical attention after birth. The Apgar Score, performed one minute and five minutes after a baby is born, called for a consistent, rapid evaluation of five categories associated with a newborn’s health: heart rate, respiration, muscle tone or activity, reflex response to stimulation, and skin color. Her method worked, reducing infant mortality (although the original articles do not say by how much), and is still used today.

Apgar’s system also was flawed — and she knew it. In her original paper presenting the scoring method, she wrote that color “is by far the most unsatisfactory sign” of newborn health because it did not work on darker skin.

The Apgar Score offers four limited choices for the skin color score: completely pink, acrocyanotic (bluish discoloration from a lack of oxygen), pale, and blue. Put simply, children of color cannot turn “completely pink” and may not seem to turn bluish due to a lack of oxygen as others might.

The skin color component’s utility is also limited by perception. Apgar meant to introduce objective measures to assess newborns, but color perception is subjective. People from different cultures, of different genders, and who have different visual abilities perceive color differently.

Apgar’s perspective was rooted in her own education and experience. The first part of her medical work was in anesthesiology, where she learned to identify how well oxygenated a patient was based on the patient’s skin color. At the time, it was a standard way to evaluate patients.

We conducted a study that reviewed a comprehensive, reliable national database to see which newborns received perfect Apgar Scores. Not surprisingly, white newborns had a significantly higher chance of receiving a “perfect” or “optimal” score of 10. We found that the harm is that more healthy babies of color may end up in the neonatal intensive care unit with more unnecessary interventions.

We also found studies that report unreliability and high variability in how medical observers perceive color. Perhaps most important, many medical professionals say the color score contributes little to the Apgar Score’s value, and there are regions of the world where those evaluating newborns ignore this part of the assessment. Hopefully, that’s where we’re headed, too.

To be clear, the Apgar Score has saved countless newborns, and Apgar was not racist.

However, today we have an opportunity — and a responsibility — to uncover and eliminate racial bias wherever it exists. Using skin color to evaluate and score newborns does not advance health equity or promote better outcomes for patients. It advances racial bias, systemically, from a child’s first minute.

It is time to part ways with this component of Apgar’s method, and the score would be out of eight, not 10.

The comprehensive adoption of the Apgar Score has led it to be said that every newborn is seen through the “eyes” of Virginia Apgar. That vision was not racist, but it did introduce a racial element to the assessment of newborn health for babies of color, one that is both subjective and not clinically useful. If we keep using it out of a sense of medical tradition, we are giving in to inertia, something Apgar never did.

Throughout her career, Apgar pushed herself and pushed boundaries. She established a new department of anesthesia soon after she graduated from medical school, attended more than 17,000 births, drew attention to newborn health and birth defects, and carried around a resuscitation kit because she didn’t want anyone dying on her watch. She never retired.

In keeping with her boundless energy and passion for progress in medicine and education, we must see what Apgar herself had noted: Skin color is the least useful way to evaluate a newborn.

Amos Grünebaum, M.D., is associate director of obstetrics and gynecology at Northwell Health. Monique De Four Jones M.D., M.B.A., is associate chief of labor and delivery at Long Island Jewish Medical. Dawnette Lewis, M.D., M.P.H., is director of Northwell Health’s Center for Maternal Health. Frank A. Chervenak is the chair of obstetrics and gynecology at Lenox Hill.