Extreme Birth

Midwife Cara Muhlhahn with Sabine and Ronnie Schwarz on the roof of their apartment building. Their baby was born less than an hour after this photo was taken.Photo: Liz Rubincam

On a dreary morning not long ago, Cara Muhlhahn is tooling through Brooklyn in her dented Prius, which she calls her “Mobile On-Call Unit.” Since Muhlhahn is a home-birth midwife, appointments both prenatal and postnatal—and, of course, the big show itself—take place within clients’ homes, and she spends a great deal of her time speeding between boroughs and racking up two grand a year in parking tickets. When a woman goes into labor, “they’re always like, ‘How did you get here so fast?’ ” she says. “Mobile On-Call Unit!”

This morning’s first appointment—or “mommy,” as Muhlhahn refers to her patients—is Kristy Bloom, a 30-year-old preschool teacher who lives in Carroll Gardens. Bloom is a first-time mother, a “primip” in obstetrical parlance, in her 38th week of pregnancy. While Kristy’s husband, Doug, lugs the birthing tub from Muhlhahn’s car up the stairs, Kristy tells me how hiring Muhlhahn was literally a dream realized. In her first weeks of pregnancy, she’d watched the 2008 Ricki Lake–produced low-budget documentary The Business of Being Born. “I cried through the whole movie,” she says. “And then I was in the bathtub and I had this whole vision of the birth and Cara was there. And I came out of the bath and said, ‘Babe, that woman’s going to be our midwife.’ ”

Since participating in The Business of Being Born—or BOBB, as it’s known to the initiated—Muhlhahn has become the most visible proselytizer of the home-birth movement. She just released a memoir called Labor of Love, in which she headily describes her work: “Day after day, I deliver babies, save lives, facilitate and witness near miracles.” She calls her duties as a mouthpiece for the movement her “Moses responsibility.” And she’s hoping to grow her home-birth service to handle the increasing demand in New York, where the numbers are already overburdening the nine home-birth midwives in practice here.

You couldn’t ask for a better home-birth sales pitch than BOBB. The film presents a horrifically plausible portrayal of a hospital childbirth system gone insane, of labor turned into a medical pathology: the continuous fetal heart-rate monitoring that makes it difficult for a mother to get off her back and into a position that actually encourages birth; the fear of lawsuits that compels doctors to perform C-sections on babies experiencing even normal distress during labor; the “failure to progress”—medicalese for laboring in a rentable hospital bed too long—that causes doctors to initiate a chain of “unnecessary interventions” like the artificial-induction hormone pitocin paired with epidural anesthesia, which seem to manufacture their own fetal distress, which in turn produces more C sections. Even obstetricians admit that the shocking rise in C-sections—in 2006, 31 percent of all babies were born this way, up 50 percent from a decade before—has done nothing to improve infant- or maternal-mortality statistics.

BOBB didn’t really break news, but it did introduce the natural-birth argument to a new mainstream audience. “Nobody in Manhattan other than the real crunchy, hair-underneath-the-arm granola types knew anything about home birth,” says Jacques Moritz, a pro-midwifery obstetrician at St. Luke’s-Roosevelt who was featured in the film. “The movie changed everything. I hate to say these things go into fashion, but they do.” More than anything else, BOBB de-radicalized home birth, conflating it with garden-variety natural childbirth and allowing Muhlhahn, largely unchallenged, to argue for its safety. There are only two options when it comes to childbirth, the film seems to say, comparing shots of ecstatic mothers hoisting their babies at home with shots of women under bad hospital light screaming for rescue.

Muhlhahn is offered up as the eminently reasonable alternative to the medical mess, shown in her East Village apartment in the predawn hours, tucking her instruments into a doctor’s bag, looking like the medical pro she is, a dean’s-list graduate from Columbia’s School of Nursing. (She says she had the grades for med school, but revels in her decision to skip eight years of “character-warping educational methods.”) She looks nothing like the hippie-midwife stereotype. “Downright sexy” is how Ricki Lake has described Muhlhahn, a youthful 51-year-old with low-rise jeans and a husky Debra Winger laugh.

She also doesn’t practice like a typical midwife. Personal experience has led her to dismiss many of what she calls the “myths” that are still taught in school as the bedrock of safe practice. The big babies—ten-pounders and more—that most obstetricians are loath to deliver vaginally, because of the risk that their shoulders will get stuck in the birth canal, are nothing more than “fit challenges” to Muhlhahn, necessitating only patience. She regularly does vaginal births after C-section at home, and has even home-delivered the riskiest births, breeches and twins. “She’ll put herself on the line way more than most people, like taking on a birth that’s a little more high risk that most midwives wouldn’t take,” says Abby Epstein, BOBB’s director. “It’s not that she’s a cowboy. It’s because she wants to serve these couples that say, ‘I trust my body. I believe in this process.’ She puts her ass on the line in a huge way every time she kind of steps out of bounds to help somebody. That’s just who she is.”

A prenatal visit at the office of her client Nicole Tucker.Photo: Liz Rubincam

When my wife, Robin, found out she was pregnant, she insisted I queue BOBB on Netflix. I’d never even heard of it, but Robin had read about it in Vogue, and all our pregnant friends had seen it. My friend Michael from Park Slope said it’s always popping up in that what-your-neighbors-are-watching feature on Netflix.

Robin and I happened to be in the midst of a maddening search for the perfect doctor. Several years ago she’d been diagnosed with lupus, a disease that makes it more difficult to carry babies to term. She was, in obstetrical terms, “high risk,” a label that automatically excludes women from most offices, except the enormous and impersonal hospital practices that can afford the monstrously expensive high-risk malpractice insurance. So we found ourselves, unhappily, in a large high-risk practice at NYU. The waits were excruciating, the offices sterile, and it became obvious at each visit that without our chart the doctor wouldn’t have known whether we were there to have a baby or take her lunch order.

Muhlhahn was different. One hot day last August, we went to her home office on 11th Street between Avenues B and C. A female assistant brought us into a waiting room decorated like a Moroccan souk. I was touched by her interest and impressed by the amount of time she was willing to devote to our case. But I was concerned by her lack of experience with lupus, and mystified by her reaction when Robin brought up the idea of delivering with a highly recommended midwife who delivers the babies of high-risk patients at St. Vincent’s. Muhlhahn rolled her eyes. “You might as well go with an obstetrician,” she scoffed.

I could tell that Robin was lapping up the home-birth pitch: no drugs to cloud baby’s or mother’s mind, no separation from baby, no cutting, and the promise of an unparalleled sense of accomplishment and an indescribable hormonal rush. Like many women, Robin recognized her opportunity to experience—to feel—one of the few truly primal experiences life still offers. “You will go into an altered state of consciousness,” says medical anthropologist Robbie Davis-Floyd in BOBB. “And you cannot have the bliss without the pain.”

The goal is, in Muhlhahn’s words, to render the experience “more poetic than clinical.” To that end, Lake and Epstein will soon put out a book, Your Best Birth, that approaches birth the way a wedding guide might, with chapters like “The Guest List” and “Loving Your Labor.” During the birth of her first son, Lake was crestfallen to be transferred from the birthing center at St. Luke’s-Roosevelt to the labor and delivery ward after her labor stalled. “I wanted it a certain way,” Lake tells me. “I’m like a type A, a Virgo, and I had mapped out this birth plan and I wanted a certain song playing and the whole thing.” Epstein, upon seeing a room at the Roosevelt birthing center, said it reminded her of a “cheesy hot-tub suite in a slightly run-down Las Vegas hotel.” Why settle for this when you can have prosecco in bed followed by a delicious homemade pasta Bolognese, as the writer Daphne Beal chronicled in a piece about her idyllic home birth in Vogue?

But even more essential than promised nirvana or perfect aesthetics is the implication that messing with the birthing process can affect the bonding between mother and child. In BOBB, French obstetrician and natural-birth pioneer Michel Odent contends that a “complex cocktail of love hormones … create a state of dependency, addiction” between mother and child. Interrupting that natural flow with drugs or a Cesarean, he posits, invites dire consequences. “It’s simple,” he says. “If monkeys give birth by Cesarean section, the mother is not interested in her baby … So you wonder, what about … the future of humanity?”

When you ask Muhlhahn’s many happy customers to recount their birth stories, they struggle a bit; you suspect they feel the way an astronaut might attempting to describe space travel to someone who’s never flown in a plane. “When you get through that transition, and you experience the birth of your child, you get the endorphins, the best bonding experience, I mean, I can’t even explain how meaningful and important and life-changing an event it was,” says Jeannie Gaffigan, who delivered her second child with Muhlhahn. (Her husband, comedian Jim Gaffigan, recounted their experience onstage: “[Home birth] means you take the hundreds of years of medical knowledge and just throw that away. And you wing it! Hey, I can’t program a VCR. I’m here to help. Where would you like me to stand terrified?”) Joking aside, women turn to Muhlhahn because she inspires confidence in them—confidence in her clinical skills and knowledge of the birth process but also confidence that their bodies are fully capable of the arduous task. Her admirers say that she’s gifted at intuiting when a laboring mother needs cheerleading and hand-holding and when she needs her to step back and leave her to labor in peace. “You really do develop a relationship and a friendship with her,” says Leigh Pennebaker, a sculptor who delivered with Muhlhahn in 2007. “You don’t feel like a number, or a random patient, and you never feel that clock ticking. What she offers is just so remarkable.”

Monitoring Leigh Pennebaker during labor.Photo: Liz Rubincam

But labor is an unpredictable thing, and sometimes the experience is more nightmarish than poetic. Muhlhahn’s patient Sandra Garcia was one week overdue when her water finally broke on a Sunday night in early November. She labored that night and through the next day assisted by her husband, Jeff Wise, and her doula, a former NYU postpartum nurse who was now working for Muhlhahn. (Muhlhahn, busy with another labor, appeared only sporadically.)

Monday night, Garcia was approaching 24 hours of labor. Most hospitals insist that a baby be delivered no more than 24 hours after membrane rupture because of the risk of infection, but Muhlhahn isn’t a big clock-watcher. Instead, she takes precautions to avoid infections: “After rupture,” she says, “no routine exams, no baths, no sex.” By 10 p.m., the doula decided that Garcia was about to deliver. So, with candles lit, Garcia got in the birthing tub, which, because of the risk of infection, represents the endgame, the mother’s pushing venue. Except it wasn’t time to push. At Garcia’s insistence, Muhlhahn performed an exam at around 3:30 a.m. and discovered she was only a half-inch dilated. The doula had somehow misjudged her progression. Still, Muhlhahn wasn’t concerned. “There’s no such thing as stalled labor,” they remember her assuring them. “Labor just takes a long time.” With that, she left to deliver another baby.

Late Wednesday afternoon, nearly 72 hours into his wife’s labor, Wise started to freak out. The doula had gone home to rest. It was getting dark. They had no instrument to check the baby’s heart rate. His wife’s face was pallid, her knees and elbows raw from supporting her weight during the contractions. The apartment reeked of vomit and urine from her catheter.

“How long is too long for a woman to be in labor?” Wise demanded to know when Muhlhahn finally returned to the apartment that night. “Never,” Muhlhahn replied flatly. Her philosophy was simple: Trust the wisdom of the body to send the baby out when it’s ready. But she agreed to examine Garcia again. If she hadn’t progressed significantly, they’d go to St. Vincent’s. The results were startling: two centimeters. She had hardly progressed at all.

Garcia crouched on all fours in the back seat of Muhlhahn’s Prius as they drove to the hospital. When they arrived, Garcia was surprised by her reaction to the place she’d been avoiding. “It was a feeling of, ‘Oh my God. Here are people in their white lab coats who know what they’re doing, and there’s equipment and medicine here.’ Then I looked over at Cara with her crazy hair and ragtag clothes and I said to myself, ‘What was I thinking?’ ” They learned that the baby was facing Garcia’s belly and that this “back labor” was likely why she had felt so much pain and progressed so little.

The next morning, Garcia woke with a 103-degree fever, a sign of infection. An exam showed that after 84 hours of labor, she was still less than five centimeters dilated. The baby had to come out by C-section. Remment Garcia Wise weighed in at eight pounds, eleven ounces, about two pounds more than Muhlhahn had estimated. Rem was whisked away to the Neonatal Intensive Care Unit, where he stayed for five days. It was far worse than any scenario Garcia had sought to avoid with a home birth.

“How do you feel about having a C-section?” Muhlhahn asked the couple at a follow-up appointment to discuss what had happened. It was the first they’d spoken to her since she’d dropped them off at the hospital. Garcia felt the question was barbed with the implication that if she’d only had more patience—tried harder—she could have had a vaginal birth. “I had a plan the whole time,” Muhlhahn told them, “and you just didn’t trust me.”

Muhlhahn calls St. Vincent’s her “backup hospital.” About 10 percent of her patients end up transferring there during labor. But her relationship with the hospital is not exactly formal. “St. Vincent’s is her dump,” says one former obstetrics resident who’s treated Muhlhahn’s transfers. “She could say any hospital is her backup, because no hospital is ever going to deny a woman care. She’d bring her patients in, holding their hands, find out we were going to have to do a section, and then she’s out the door. To me, that’s a dump.” Other doctors on the floor have referred to her transferred patients as “train wrecks.”

There is, of course, a long-standing animosity between doctors and midwives, particularly those who take births out of hospitals. In a 2008 policy statement, the American College of Obstetricians and Gynecologists reiterated its position against home birth: “Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.” But St. Vincent’s seems to have bridged the divide better than most hospitals. George Mussalli, the chairman of obstetrics and gynecology since 2006, has fostered much goodwill within the midwifery community. Joan Bryson, a veteran home-birth midwife out of Park Slope, and Karen Jefferson and Martine Jean-Baptiste, the home-birth duo that goes by JJB Midwifery, actually have hospital privileges there.

Filling out medical charts after a 45-hour labor.Photo: Liz Rubincam

Muhlhahn claims that she could have privileges at St. Vincent’s as well, but she prefers not to be encumbered by the hospital’s restrictions. “I actually like legitimacy. I don’t enjoy being an outlaw,” she says. But there are ways in which she has made herself an outlaw of sorts—by not carrying malpractice insurance, for instance. “I think she’s dangerous,” says a member of the obstetrics staff at St. Vincent’s. “You need to be accountable. Something bad is going to happen with her approach to management. Bad things happen to all of us.”

Though it is required by law for every midwife in New York to have one, Muhlhahn also doesn’t have a signed practice agreement with a physician, a document that outlines the parameters of a midwife’s care and the protocols under which a mother would automatically “risk out” of home birth. According to most practice agreements, vaginal births after Cesareans, diabetics, breech babies, twins, and many overdue and oversize babies merit hospital births. Muhlhahn’s website touts studies showing home births to be just as safe as hospital births, but when these kinds of high-risk births are included in statistics, the home-birth perinatal mortality rate jumps to fourteen per thousand versus five per thousand in the hospital, according to a University of Arizona study.

“How long is too long for a woman to be in labor?” the father-to-be asked. “Never,” Muhlhahn replied.

Obstetrician Jacques Moritz is no partisan in any doctor-versus-midwife battle. To the jeers of many of his M.D. colleagues, he hosted a screening of BOBB at St. Luke’s-Roosevelt. His own mother was a midwife, and he has signed practice agreements with twelve midwives who work at the Roosevelt birthing center. He wouldn’t, however, do the same for Muhlhahn. “I like her, but there’s some protocols that she has that I just can’t sign off on,” he says. Like the breech babies and vaginal births after Cesarean (VBACs) she says she’s performed at home? “That’s like bragging,” he says. “There’s a lot of stuff I’ve done, too, and said afterward, ‘Wow, I didn’t know I could do that.’ But I wouldn’t want to do it again.”

“I’m not that comfortable with VBACs at home,” says Muhlhahn, “but I know most can have them fine. Most VBAC mommies know they have less of a chance of giving birth vaginally in a hospital.”

For all her home-birth successes—she has delivered more than 700 babies—Muhlhahn has also had some tragedies. In 2003, she and her former birthing center settled a $950,000 malpractice suit brought by the parents of a child who was injured during delivery. As the baby’s head was crowning, he suffered a shoulder dystocia, when a baby’s shoulders get stuck behind the mother’s pelvis. It was imperative to get the baby out quickly, because he couldn’t breathe in that position. “Cara was crying and saying that she thought she was going to lose the baby,” Yvette Garcia, the boy’s mother, said in a deposition. The child survived, but the cervical nerves in his neck were damaged, rendering his right arm paralyzed, a condition called Erb’s Palsy. According to Garcia’s deposition, when she first brought the boy to the family pediatrician, the doctor took one look at the lame appendage and “knew that the baby was yanked out.” Garcia’s complaint argued that Muhlhahn should have known that the baby would be too large for a vaginal delivery.

In her memoir, Muhlhahn tells the worst story of all: In the summer of 2007, a woman named Lisa was at the end of a particularly long labor. As the head crowned, Muhlhahn noticed the baby’s heartbeat decelerate. She kicked once from inside her mother, and then was still. Muhlhahn got the baby out and began CPR, but couldn’t revive her. “Why had everything I had counted on that had worked for the last twenty years failed?” she writes. “We all had to ask ourselves if this baby would have been alive if indeed she had been born in the hospital.” Moritz says Muhlhahn should go easy on herself; if a clinician hasn’t lost a baby, she just hasn’t done enough births. “The problem is that we’re talking about the possibility the outcome would be different,” he says. “No one who loses a baby in a hospital says, ‘Oh, I wonder if this would have been better if I’d done it at home?’ ”

My wife and I decided not to go with a home birth, not least because Robin’s rheumatologist threatened to drop her as a patient if she chose that route. In Robin’s 39th week, during a routine test at our doctor’s office, the baby’s heartbeat decelerated precipitously. The doctor sent her to NYU to be monitored for a couple of hours, and while she was there, her water broke. The decelerations continued, corresponding to Robin’s contractions; every time she clenched up, you could see the heart rate plunge from 130 beats per minute down to 60 on the monitor, then right back up again. They made V shapes on the tape.

Left: Weighing Kelly DiVico's baby shortly after birth. Right: Muhlhahn's patient Monica Eleazar with her son Liam.Photo: Liz Rubincam

Very quickly, our plot unfurled much like the nightmare scenarios in BOBB. Since Robin’s water had broken, the clock was ticking, so the nurse gave her pitocin to get things moving. Soon, the contractions were so intense that Robin was screaming for the anesthesiologist. The epidural brought instant pain relief, but the V shapes on the monitor continued with each contraction.

Some time later, a resident burst into the room. “We’re concerned about your baby,” he said. “He’s been recovering well from the decelerations up to this point, but we don’t know how long that will last. We want to get him out.” And then he gave us a meaningful look. “I know you didn’t want it to go this way,” he said, “but the good news is if you decide to have another baby, you’ll be a great candidate for a vaginal birth.” Just like that, we were handed a rain check for the birth we had hoped for.

Henry was born at 2:30 a.m., ten hours after Robin had gone into labor. In retrospect, I have no idea whether he was ever in real danger. Maybe she could have pushed him out. Maybe if we’d never seen those fetal-monitor strips, we would have assumed he was all right, and in all likelihood he would have been. But in Robin’s telling of the story, Henry was in real danger. There wasn’t even a question of what to do.

What I do know is that in the moment that resident hoisted the little boy over the curtain protecting me and Robin from the sight of her exposed viscera, everything changed about that place. The nursing staff was warm, competent, and quick to respond. Contrary to everything I’d heard, the hospital never tried to separate us from our baby. (One of the ways the influence of midwives has made hospital births a more humane experience.) Robin was in pain, but happier than I’d ever seen her. I began to wonder if “labor amnesia”—the idea that evolution has made sure mothers don’t remember much of the pain of childbirth—might apply to C-sections as well. When women meet their healthy babies, they are so overcome with joy that they forget about the horror and construct a memory of something far more beautiful.

The McNally Jackson bookstore in Soho can barely contain the crowd that comes out to celebrate the publication of Muhlhahn’s memoir, Labor of Love. There are not enough folding chairs to accommodate all the women who’ve shown up. Store owner Sarah McNally is lugging around Jasper, the 5-month-old product of a twelve-hour birth with Muhlhahn, and laughing about the doula who had tried to hydrate her with ginger ale. (“I don’t mean to be rude,” McNally had told her, “but I don’t drink high-fructose corn syrup.”) Novelist and The Believer editor Heidi Julavits arrives with 2-week-old Solomon tucked into a Moby wrap; she’d used Muhlhahn’s colleague Miriam Schwarzchild. There is much talk of empowering feats of strength and hormone highs. “I felt like a superhero,” says Daphne Beal, the author of the Vogue article about home birth. “I envisioned myself climbing up a building Spiderman style.”

“I had a birth this morning, so I’m sleep-deprived, as usual. I did seven births in eleven days!” Muhlhahn says, seemingly astounded by her own stamina. Thanks to BOBB, the last 24 months have been the busiest in the dozen years since she first set up a solo practice in the bedroom of her Stuy Town apartment. Recently, she has more than tripled the number of births she takes on, to ten a month.

Before signing books, Muhlhahn sits on a panel and answers questions. “Have you observed a difference in home-birth versus hospital babies?” asks one menopausal woman in a beret. “Are they calmer?” Muhlhahn responds that no scholarship on such a thing exists, but says, “The baby born this morning was just so calm … Even though that might not be measurable data, these outcomes are extremely important to the human race.” The woman nods, satisfied. “It’s a great place to start,” she enthuses.

The panel’s star, however, might be Jessica Robinson, who receives gasps from the impressed crowd for revealing a thumbnail of her experience: 76 hours of labor, which included a 30-block walk on her third day and an episode in which Muhlhahn had to coax her out of the bathroom of a Brooklyn acupuncturist’s office. The adventure eventually yielded a ten-pound, twelve-ounce boy, the heaviest baby Muhlhahn had ever delivered to a primip. “It just seemed,” Muhlhahn says, savoring the victory, “like a completely normal delivery.”

Extreme Birth