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An Illegitimate Birth

Kim and Steven McCarty put their baby in the hands of an unlicensed midwife.

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"Are you a labor puker?" Cassandra* asked Kimberly Krick. Cassandra, Kim, and Kim's fiance, Steven McCarty, were sitting in Cassandra's living room talking while quiet new age music seeped from the stereo. It was an unseasonably warm day in April 2002, and Cassandra was wearing a black sundress that revealed the tattoos on her arm and calf. At 11 weeks pregnant, this was Kim's first prenatal appointment, and Cassandra needed to take her history.

"Little-known medical fact," Cassandra added for Steve's benefit: "Unmedicated women vomit during labor." She's full of "little known" facts about the nature of women's bodies, and she shares them with clients in the same matter-of-fact tone she uses to scold children, discipline pets, and direct apprentices. The body instinctively knows to empty itself during labor, she told Kim and Steve during that first appointment. Most unmedicated women don't need to be told when to push. Laboring women tend to find the smallest, darkest spot in the house to give birth.

The two 22-year-olds on Cassandra's couch listened attentively. They were not her typical clients. She tends to work with affluent women with advanced degrees or, Cassandra says, "women more like myself: middle-class debutante princesses who decided that they wanted to be hippies." Recent clients included a molecular biologist, a psychologist, and a biochemical engineer. Kim, on the other hand, was a part-time student and doula, providing labor and postpartum support for new mothers; Steve sold radio advertising. The son of an orthopedic surgeon, he grew up believing "the hospital way was the only way" and was nervous at the idea of having a baby at home. Home birth "sounded fine for somebody else," he says. "I wanted physicians standing over making sure that everything was OK for my child."

Kim had already had that experience, with the birth of her three-year-old son, Jacob, and it was one of the reasons she was searching for an alternative. She'd given birth at Northwestern's Prentice Women's Hospital two months after an old boyfriend decided he wasn't ready to have a family. At what she thought would be a routine doctor's appointment, she'd been told she was dilated three centimeters and having contractions. "They strapped me up to everything you could possibly imagine," she says. "I had an IV, the fetal monitoring. I couldn't get up and move around. I was just lying there. After five or six hours, they broke my bag of water and things really started picking up. And then they gave me Pitocin, which makes it so much worse."

Pitocin is a synthetic hormone frequently used in hospitals to induce or speed up labor. The contractions it causes are sudden and intense, lacking the slow buildup of normal contractions, and women tend to feel more pain when it is administered so they're often given anesthesia along with it. Hungry and tired from laboring, Kim thought a sandwich would boost her energy but was told that she could only suck on ice chips. When she tried to get up and move around--a natural way of speeding labor and a more comfortable way to deal with contractions--the nurses scolded her. To get them to let her stand, she repeatedly told them she had to go to the bathroom.

There were so many medical personnel entering and exiting her hospital room that Kim doesn't remember who actually delivered Jacob. He was immediately whisked to the other side of the room, and Kim watched from afar as the nurses cleaned him. She'd told three different nurses that she wanted to breast-feed, but when they finally let her hold Jacob there was a bottle in his mouth.

As she left the hospital with her son, Kim says, "I remember getting off the elevator feeling so depressed, so crushed, because I was scared to take him outside. I was scared to walk out of the hospital with him because it was like, 'This is real.' I'm taking him, and there's bus fumes, and there's all these things I was thinking about that I didn't want him breathing in. I think if I would've had somebody in the hospital to talk to me more about what I was going to be feeling, I would have been more prepared for it. That's why with this pregnancy I had no hesitations about finding a midwife and doing this at home." This time she wanted to be the first to hold her child, and she hired Cassandra to help make that happen.

Kim and Steve were thinking about having a water birth, a method Cassandra advocates: "When we put women in water, it relaxes them," plus it tends to ease their pain. When a baby is born in warm water, she says, the switch from maternal to independent circulation is much more gradual and easier on the baby. She also likes the fact that, in a water birth, she is less able to interfere in a process she thinks should be primarily between mother and baby. "I have to be hands-off, let go of control," she says. "Part of the reason I do water birth is that my moms reach down and catch their own babies."

Cassandra moved to Chicago in 1999, fresh out of a five-year apprenticeship and with a lot fewer births under her belt than most Illinois midwives. Nevertheless she has established a busy home-birth practice with a fairly visible presence.

Cassandra is a direct-entry midwife, not a nurse-midwife, the kind you're likely to find in a hospital. Certified nurse-midwives (CNMs) are registered nurses who have completed an accredited course of study and passed the profession's national certifying exam. CNMs work with physicians who back them up when situations arise that are beyond the CNM's scope of practice--for example, when a cesarean section is necessary. Of more than 300 CNMs in Illinois, fewer than 10 percent attend home births. Cassandra, on the other hand, learned her job through self-study and an apprenticeship with a senior direct-entry midwife. She spends her work hours driving across the city and suburbs to check on newborns and assist births, sometimes with family members in the same room as the mother. She's the kind of midwife the Illinois Department of Professional Regulation wants to put out of business. In 1997 the IDPR served four DEMs with cease-and-desist orders on the grounds that they were practicing without a license. Over the next three years it served half a dozen more. Thus far Cassandra has managed to avoid the wrath of the IDPR. But many DEMs have left the practice--or the state.

Though midwives had been attending births for ages before nurses as we recognize them today came into existence, the state of Illinois considers the two professions to be synonymous. According to the state's Nursing and Advanced Practice Nursing Act, actions like "assessing the health-care needs of the mother and baby" and "attempting to promote, maintain, and restore the baby's health" can be construed as nursing practice and are prohibited without a license. Direct-entry midwives and their allies argue that the practice of midwifery is distinctly different from the practice of nursing and medicine. As an alternative to the medical model they hold up the Midwives Model of Care, a standard of practice drawn up by four midwifery-advocate groups in 1996. Based on the belief that giving birth is a natural physiological process, not a medical condition, it promotes an approach to pregnancy and birthing in which the mother's wishes are respected, use of technology is minimized, and emotional health is monitored as closely as physical well-being.

Some medical professionals think that midwives of Cassandra's ilk are dangerous. Dr. John Schneider, president of the Illinois State Medical Society, the largest and most powerful opponent of those advocating legal status for home-birth midwives, argues that direct-entry midwives are dangerous because they are not properly trained to deal with the life-threatening complications that may arise at birth. "I have no objection to a physician working with an advanced-practice nurse midwife," he says, but he vows that the organization will never recognize the legitimacy of direct-entry midwives: "This is not a third-world country." The American Public Health Association and the World Health Organization, on the other hand, have both endorsed births attended by midwives in out-of-hospital settings as a safe--and in the case of the WHO, the preferred--alternative.

"It's very hard for people trained in that mainstream medical way of thinking to believe that this could possibly be safe," says Valerie Runes, who has received two cease-and-desist orders from the IDPR and no longer practices midwifery. "Their whole training is based on saving women from pathology, saving women from danger. In most areas of medicine that's probably a good description. If you have somebody come into the ER with crushing substernal chest pain and shortness of breath, you want a highly trained doctor. But when you're talking about a normal physiological process, they have a hard time making that jump from being pathologically oriented to oriented toward a model of a healthy childbearing woman."

The World Health Organization believes that it's dangerous for ob-gyns to treat every birth as if it's a disaster waiting to happen. In "Care in Normal Birth," a 1997 working paper, it warns that such an attitude toward birth "interferes with the freedom of women to experience the birth of their children in their own way, in the place of their own choice," and "leads to unnecessary interventions." C-sections, for example, may deprive babies of the contraction-induced stimulation to their nervous system that helps to prepare them for life outside the womb. In hospital births there is a greater incidence of low birth weights, premature births, and respiratory distress. Some midwives use Pitocin to deliver the placenta, but when the hormone is used to induce labor, patients are usually required to undergo continuous fetal monitoring because of the increased likelihood of fetal distress. Being hooked up to the monitor and unable to move decreases a woman's ability to handle the pain, which makes her more likely to ask for anesthesia, inviting even more potential complications.

The WHO asserts that ob-gyns are so often preoccupied with emergency situations that they don't have time to give normally laboring women the attention they deserve. They identify midwives as the most appropriate and cost-effective birth practitioners for healthy women and recognize both the direct-entry and nursing models as valid routes of training. "More important than the type of preparation for practice offered by any government is the midwife's competence and ability to act decisively and independently," states "Care in Normal Birth."

But the WHO also defines a midwife as someone who is licensed and recognized by her government--which is not the case for direct-entry midwives in Illinois. Even those DEMs who, by examination, have been certified as professional midwives by the North American Registry of Midwives are unable to be licensed in Illinois. When asked why the Illinois State Medical Society considers direct-entry midwives unqualified to serve as primary birth practitioners, Schneider points to the example of Yvonne Cryns, a direct-entry midwife who in 2000 was indicted on two counts--involuntary manslaughter and involuntary manslaughter of an unborn child--after she attended a home birth in Round Lake Beach at which the baby was stillborn. On February 21, 2003, ruling on the Yvonne Cryns case, the Supreme Court of Illinois upheld the IDPR's argument that practicing direct-entry midwifery is the same thing as practicing nursing.

If the death of a child were all it required to discredit an entire profession, however, obstetricians--with their comparatively higher infant mortality rates--would be out of a job. The overwhelming majority of laboring women in the U.S. continue to be cared for by doctors in hospital settings, and in spite of all of the obstetrical technology, the U.S. infant mortality rate was 28th in the world in 1998 (the most recent year statistically available) according to the Maternal and Child Health Bureau of the Department of Health and Human Services. In developed countries where midwives act as primary birth practitioners, mortality and cesarean rates are much lower. Schneider attributes the U.S.'s high figures to complications during birth and lack of decent prenatal care.

Cassandra was born on a Friday the 13th in 1969, while her mother was in "twilight sleep," probably from an anesthetic cocktail of morphine and scopolamine that blocks women in childbirth from remembering it afterward. She was raised in Louisville, Kentucky, by her mother and stepfather, whom she describes as "the kind of Christians that believe God loves you and wants you to have a lot of money so you can put the fish on the back of your Lexus or Mercedes." She grew up as a southern princess, showing dogs and participating in cotillions and debutante balls. Her rebellious nature didn't really hit its stride until she was at the University of Kentucky, where she became known by her dormmates for her willingness to accompany them to the abortion clinic. She wrote poetry and partied like she thought all great poets did, and when she was 22, the unmarried, green-haired princess came home pregnant.

The stories people told her about all the medical procedures involved in a hospital birth disturbed Cassandra. She'd seen dogs give birth to 12, 13, 14 puppies at a time without any assistance. Was she incapable of giving birth to one baby? She sought the help of a midwife, but the only one she found refused to take her on as a client: she was already five months pregnant, and she didn't have the money to pay the full fee before her baby was born. Instead she found an aging family practitioner known for being more hands-off than most physicians. Although Cassandra toured the hospital with her personal birth plan in hand and made it clear--in "the nicest possible way"--that she wanted a natural birth, she still thinks it was mostly luck that she actually had one.

"I was stuck at nine centimeters, basically stuck in transition--which is supposed to take a half hour to forty-five minutes--for nine hours," she says. Transition is the part of labor experienced just before it's time to push. "It's that last little bit of dilation. It's the part of labor where women freak out and go, 'Oh my God, I can't do this.' It's where they become totally overwhelmed by their labor."

After nine hours she felt like she was hitting her head against a brick wall. The contractions weren't producing any forward motion, and she was in incredible pain. She finally let the doctors break her amniotic sac. All of the fluid came rushing out, and she felt her child sink into her pelvis. Nothing happened for about 45 minutes; then she had three strong contractions and started to push. Eighteen minutes later she pushed a baby girl into the world. "I still remember her shoulders sliding out from under my pubic bone," she says. "It was the most painful and sublime feeling ever." The labor had been difficult, but Cassandra was proud to say that no doctor or drug had managed it for her. When she tried to talk about the experience, however, people couldn't get past the fact that she'd had a drug-free birth. "Forget about all that other stuff," they would say. "You didn't have drugs?"

"That's when I realized it was just even more screwed up than I thought," Cassandra says. "If people couldn't even hear you tell a story about how great childbirth was even though it hurt a lot, then there was something really screwy going on."

In early May, Kim started experiencing cramps that reminded her of pains she'd had during a previous miscarriage. When they intensified to the point where she was curled in a ball on her bed crying, she and Steve decided it was time to call the midwife. Cassandra used a handheld ultrasound device to listen to the baby's heartbeat, which was nice and strong. She couldn't determine the source of Kim's pain, but she taught Kim and Steve some relaxation techniques and recommended some herbal remedies--catnip tea, lobelia, and motherwort--to ease it and bring her blood pressure down. The herbs seemed to work, but a week later she started cramping again. She felt like her muscles were being pulled apart. The pain increased through the evening until she could hardly walk. This time she decided to go to Swedish Covenant Hospital.

A triage nurse wanted to know who Kim's obstetrician was. She told her she had a midwife. The nurse asked for her midwife's name, but Kim, wanting to protect Cassandra, said she'd rather keep it anonymous. The nurse must have assumed that Kim was lying, because she marked on her chart that she wasn't receiving any prenatal care.

The doctor arrived 20 or 30 minutes later, did a vaginal exam, and said that everything looked fine but that he wanted to do an ultrasound just in case. He asked for the name of her ob-gyn. Kim repeated that she wanted to keep her midwife's name anonymous. The doctor told her that she was too far along in her pregnancy not to be receiving prenatal care. Kim decided not to waste her energy arguing.

The nurses wanted to fill her with a catheter to make sure her bladder was full enough for the ultrasound, but Kim refused. She'd visited the same hospital when she'd had her miscarriage, and the insertion of a catheter had been an experience she didn't want to repeat, so she let her bladder fill the old-fashioned way. It was 11:30 PM, and the ultrasound technician was supposed to be in by midnight. Kim knew she could hold it for 30 minutes. By 12:40, however, the technician still hadn't arrived. Kim was crying from the pain. Whenever Steve tried to ask what was going on, the nurses would respond to Kim, as if to suggest that it was none of his business.

It was 1:15 by the time the ultrasound technician arrived, at which point Kim's bladder had been full for nearly two hours. Steve was excited about the ultrasound--the fetus was swimming and flipping inside its mother--but Kim was in too much pain to look at the screen. The doctor wasn't sure what was causing her trouble, but as far he could tell the baby was fine. It was the same answer Cassandra had given them in the comfort of their own home. The doctor wrote a prescription for Tylenol 3 with codeine that Kim opted not to fill.

"Why give a pregnant woman codeine?" Cassandra asked after listening to Kim and Steve recount their experience in the ER. "You can't shit on codeine. As if pregnant women don't have a hard enough time." It was a Friday night in May, the 13th week of Kim's pregnancy. Cassandra and her two apprentices lounged on the floor in Kim and Steve's living room in socks and bare feet. Cassandra says she'd never tell clients not to go to the emergency room. "I may say, 'In my opinion it really seems to me like everything's OK. But I can really understand if you might need to get this checked out.'" Under some circumstances she might encourage them to go. The most important thing, she says, is for parents to do what they feel they need to feel safe.

Cassandra repeated her herbal remedy for Kim's cramps as her apprentices scribbled in their notebooks. Kim mentioned that she especially liked the motherwort. "It really calms me down so much. After I take it, there are things that I'd usually say to Steve that I just don't." The women in the room laughed. Cassandra also wanted Kim to double up on her prenatal vitamins and take calcium and magnesium to lower her blood pressure.

They moved on to the topic of food, and Kim admitted that she wouldn't be getting enough protein if it weren't for MET-Rx bars. Cassandra had lent Kim some books on meal planning and taught her how to interpret her own urinalysis results, which she casually refers to as "the pee stick." Kim read hers with the apprentices looking over her shoulder, asking questions about ketones and glucose, pH, and ascorbic acid. Cassandra answered with ease, and one of them joked that she only kept them around to make herself feel smart. "That's what apprentices are for," Cassandra parried: "To scrub poo stains off the carpet and raise my ego."

"Before you decide you're going to be a midwife," Cassandra says, "you have the birth junkie phase, where you will do anything for anybody to get to go to their birth. Anybody. You'll accost people in grocery stores." After her daughter was born, "I wanted to go see other births, because mine changed my life." She managed to get herself invited to witness five or six hospital births, starting with family members and moving on to a roommate and friends of friends.

She saw doctors perform procedures she'd managed to avoid. "They were practicing legal medicine," says Cassandra. "Not health care, but 'What do we have to do to make sure that we don't get sued?'" At one birth the doctors opted to pull a baby down the birth canal with a vacuum extractor--a plastic suction cup applied to an infant's scalp. The instrument is usually used in combination with pain medication, but in this case time was of the essence. "They stuck a vacuum extractor inside of the woman without an epidural," says Cassandra. "She was pulling so hard on the bed her forearms were shaking." All Cassandra could do to help was hold her down. "That's the only time I've been at a birth where I saw blood hit the wall."

Cassandra started meeting people in the alternative birth community, people she could talk to about what she was seeing. After she made an offhand comment about being able to handle a birth better than doctors she'd seen in action, a birth educator suggested that she become a midwife. The more Cassandra thought about it, the more the idea appealed to her.

As in Illinois, direct-entry midwives can't get licenses in Kentucky; the state stopped issuing them in the early 70s, arguing that nurse midwives would fill the role DEMs once had. By the mid-90s, however, there were only a few nurse midwives practicing in the state and even fewer attending out-of-hospital births. (In states where lay midwifery is licensed--including Oregon, California, Florida, and Minnesota--aspiring practitioners can enroll in formal training programs and workshops.) Cassandra opted to combine independent study with apprenticeships under the supervision of a senior midwife, or preceptor. After a brief stint with the woman who'd rejected her as a client, she met Mary Ann Watson, a midwife who's been practicing since the 70s. Cassandra liked both Watson's take-charge, no-nonsense attitude and her trusting, hands-off approach.

"We used to say that we wanted to prove that midwives didn't have green hair and horns, but when I first met Cassandra she had green hair," Watson says. It was the tail end of 1994, and Cassandra was busy raising her daughter, taking classes, and doing birth-advocacy work. Watson was willing to overlook appearances, but she required a lot of self-motivation and dedication from her apprentices. She expected them to come when they were called--whether the call came in the middle of sex, during a child's birthday party, or at a family member's funeral. "I didn't know if [Cassandra] was going to make a good apprentice or not," says Watson. "She had her hand in a lot of things."

Watson had a busy practice. She accepted clients who lived up to 100 miles away from her home, covering Lexington and Louisville as well as towns across state lines. Because she was often on the go, she expected her apprentices to supplement contact hours with self-study. She held classes on controlling blood loss, examining placentas, completing newborn exams, handling hospital transfers, risk signs to look for in screening prospective clients out for care, and how to trust their instincts. These discussions were just as likely to take place on the go, according to Watson. "The best way to learn from me is to ride with me, and I'll train you in the car."

When they accompanied her to births, apprentices stayed up so that Watson could be rested for the most crucial parts of labor. They cleaned instruments and filled out charts. After a new apprentice had been to a few births and understood how labor progressed, it became her job to arrive first and start setting up. As her knowledge and experience grew, so did her responsibilities.

"If you're coming at this from a spiritual perspective, the first catch you make will be the one that God gives you when you're ready to have it," says Cassandra. She delivered her first baby after she'd been to around 30 births, 15 of them as Watson's apprentice. Watson still hadn't arrived, and the mother, who'd given birth to four previous children, was laboring quickly. When it became evident that she was going to have to do the delivery, Cassandra made sure everything she needed was within reach and called on her observations from previous births to help the mother. When the baby began to crown she put her hands in position the way she'd seen Watson do it. "When the head came out it was this tremendous energy coming at me, like somebody throwing a bucket of water. I pulled my hands back and said, 'Wow!' And then I remembered that I was supposed to be the midwife and got my hands back down there. The baby just flew out. It was just as pink as could be." Cassandra was high for days. "When you're a midwife you've got one foot in one world and one foot in another. Another human being, a whole other person is present in the world, and you're there helping them make that transition through. You can just feel it. It makes the hairs on your neck stand up."

Watson believes an apprentice is ready to begin taking on her own clients after she's attended 50 births, at which point her own role changes from that of teacher and trainer to that of helping her apprentices through difficult moments. Cassandra's first clients were mostly parents who'd worked with a midwife once or twice before, knew Watson's reputation, and were willing to give one of her trainees a try. She and other apprentices of Watson's formed an unofficial collective of midwives who often worked together at births. Cassandra had married in 1997; by 1999, when her husband got a job offer in Chicago, she'd spent nearly five years with Watson. Though Cassandra was still looking over her shoulder for her preceptor's advice, Watson thought she'd be fine on her own if she kept in touch and partnered with other midwives on a couple of births before stepping out on her own in the new town. "It was a little earlier than I would have necessarily let her go," Watson says, "but she had a great deal of knowledge."

Despite Watson's blessing, a torn ligament in her knee and a crumbling marriage kept Cassandra from practicing when she first moved to Chicago. She didn't think she could offer physical or emotional care to expectant mothers when she was struggling just to care for herself. She worked temp jobs for over a year, taking time to introduce herself to people in Chicago's alternative birth community and easing her way back into practice by attending a few births with other midwives. Direct-entry midwives were difficult to find at first because so many were practicing underground. When she did finally get in touch with them, she wasn't happy about what she found.

"The second saddest thing next to us being illegal is that we're our own worst enemies," Cassandra says. She laments what she perceives as a hostility toward new ideas and a general unwillingness to connect with the medical community. "There's still a lot of resistance from midwives who are no longer practicing and who feel like they've really gotten burned by the 'establishment,' or burned by people in more mainstream practices, who want absolutely no interface whatsoever--or very, very careful interface--with other mainstream entities."

In light of the IDPR's pursuit of direct-entry midwives, Cassandra understands the hesitancy of her peers to network with those outside their circle. However, she thinks their hesitancy too often manifests itself as paranoia, which prevents them from forming alliances with individuals who are making an effort to understand what DEMS are all about. The proposed Certified Professional Midwife Licensure Act (Illinois House Bill 577, which would license and regulate direct-entry midwives who've completed the requirements for certification by the North American Registry of Midwives) fizzled this winter without even making it out of committee hearings. But the passage of such legislation--primarily advocated by the Illinois Council of Certified Professional Midwives--may depend on the willingness of DEMs and other home-birth advocates to cultivate relationships with other birth practitioners, including nurse midwives. "If we want to get this bill passed we need them to jump on board," she says. "I don't care what kind of midwives they are, as long as they're happy midwives."

To that end she's been connecting with nurse midwives both professionally and politically. She has partnered with two nurse midwives at home births, and she belongs to a group consisting of members of the American College of Nurse Midwives, direct-entry midwives, women who have worked under both titles, and home-birth advocates that meets monthly at University of Illinois-Chicago's nursing school. Though no official declarations of support have been made, nurse midwives in the group have made suggestions on how to revise the wording of the bill and whom to meet with in order to increase the possibility of its success. The bridge meetings are not without moments of tension; Cassandra sometimes feels that other members of the group have misconceptions about her clients and her skills. But she's grateful for the opportunity to change those perceptions.

"Cassandra has courage," says Michelle Breen, executive director of Chicago Community Midwives and executive secretary of the national group Citizens for Midwifery. "It's hard for a practitioner not recognized by the state to be active in the broader birth community." A lot of nurse midwives, says Breen, have never met a direct-entry midwife and have no idea what their practice entails. "There's so much time spent defining who's who and how we're different from each other that there's not enough energy spent on educating the community and increasing access to midwives."

But even if HB 577 had passed, Cassandra wouldn't have been able to practice legally: the proposed legislation would license only direct-entry midwives with NARM certification, and thus far Cassandra has not taken the exam. She's not sure she wants to. "People that have sat the exam can get very high on their horse," she says. She's heard other midwives say that those who don't are afraid of challenging themselves and that no one will respect them if they fail. "That is co-opting the argument of the establishment, when doctors have said, 'You have no certification. You're not legitimate.' I think the whole process of becoming certified as a certified professional midwife is hypocritical and antithetical to a self-regulating profession which trains through an apprenticeship model. I think right now the only reason why people wanna be a CPM is to prove to other health-care providers that they know what they're talking about."

CPMs are not protected under the law in Illinois. IDPR's pursuit of Runes, who was certified, is evidence of that. But if Cassandra became a CPM and a bill passed licensing certified direct-entry midwives, at least clients like Kim and Steve wouldn't have to worry about revealing her name to doctors. Cassandra would be able to make referrals to other health-care providers and sign her name to them. She could fill out birth certificates without any hassles. Insurance companies might be more willing to reimburse her clients. She'd be able to practice with the kind of confidence that, she admits, fear of prosecution makes difficult for many midwives to sustain. Still, Cassandra cherishes the sense of responsibility that comes with being an unregulated midwife. "Doctors don't have to give you stats about how many babies they've caught, how many transports they've had, what kinds of situations they've handled and what they haven't," she says. "I have to provide an informed-consent form. I have to provide references. I can't lie about those things. If you have a malpractice suit or you have a lawsuit and you can fall back on the fact that you have that CPM credential, that's garbage. Nobody should be responsible for you and your actions as a midwife except for you."

Not all of her allies agree with Cassandra. Breen, also from Kentucky, has known Cassandra since 1994. She chose Watson--who was granted NARM certification through a "grandmothering" process--to deliver her baby. But she thinks it's in the best interest of the movement for DEMs to get certified. "Cassandra is very dedicated to traditional midwifery, and I know why she honors that and loves that," says Breen. "But...traditional midwives don't carry a lot of respect from the general public. If somebody reads in the newspaper, 'The state won't recognize traditional midwives,' the general public thinks that's a good thing." People respond differently, she says, when they hear that certified professional midwives are not legally recognized by the state of Illinois. Organizations that promote home birth and recognize the validity of the apprenticeship learning model--like Illinois Families for Midwifery and Citizens for Midwifery--have taken public stances specifically promoting NARM-certified midwives even when their members and supporters have used the services of noncertified midwives. Even Watson admits that having the CPM behind her name makes her more credible in some eyes.

Cognizant of arguments like Breen and Watson's, Cassandra wavers about taking the exam. Sometimes, she says, she knows that she can only stand on her principles for so long before it begins to harm "the movement." Sometimes she says she has to put the health and safety of her clients before any movement. "I don't know what the right answer is right now," she admitted recently. "All I know is I've got a lot of pregnant women to help."

"Tell me about this baby," Cassandra said to Kim, as she had at almost every prenatal. It was a Thursday night in mid-October, 39 weeks into Kim's pregnancy. Scented candles cast shadows in Cassandra's living room. In August the prenatals had increased from once to twice a month. Now they were weekly. Cassandra had attended Kim and Steve's wedding in July; the apprentices had been invited to the baby shower. When they gathered now, they were just as comfortable joking about the joys of postpregnancy sex as they were debating the latest birth-related medical studies.

Kim read her pee stick, and Cassandra quizzed her about her diet. After her blood pressure was recorded, Kim lay on the couch and lifted her shirt. The stretch marks on her stomach looked like golden, elongated fingerprints against the rosy surface of her skin.

The preferred and most common position of a baby inside a mother's womb is the occiput anterior position (the baby facing the mother's back). During the 28th week Cassandra had discovered Kim's baby was presenting in the occiput posterior position (baby facing mother's front). If a baby presents posterior at the onset of labor, the mother is in for a slow, painful experience referred to as "back labor." In hospital settings this can lead to any number of interventions, from anesthesia or Pitocin to a C-section. Fortunately for Kim, earlier in the day she'd felt the baby flip nearly 180 degrees. The sensation had been so strong she joked that maybe she was carrying an alien.

Cassandra allowed her apprentices to try to judge the baby's new position and listen for the heartbeat and placenta with a fetoscope before doing it herself. Steve, eager to see his child, wondered about the gender. Cassandra swung a crystal over Tracy's stomach for fun but came to no conclusions. Everyone seemed to be on the same emotional wavelength: a little silly with baby fever.

Two weeks later, early on the first Monday in November, Kim and Steve's apartment was filled with the sounds of a woman in labor. Steam rose off the surface of the water in the birthing pool in Kim and Steve's bedroom. Kim sat naked and floating; Steve, in trunks, was her labor support. Her mother and her 16-year-old sister stood by to make sure she was fed, hydrated, and cool. Kim was reaching the end stages of transition, and her head rolled side to side with the deep moans that accompanied each contraction. If Steve was nervous, it didn't show.

"Bowling ball or watermelon?" Cassandra asked.

"What?" Kim asked.

"Bowling ball or watermelon?"

"Both."

The question is a way of determining how low in the birth canal the baby has descended: which does it feel like between the expectant mother's legs? Cassandra doesn't like to do vaginal exams unless there isn't time to communicate with the mother. She preferred to ask questions about the sensations Kim was feeling and note changes in the kinds of noises she was making.

"The CD's skipping!" Kim said in the middle of a contraction.

"You're such a mom," Cassandra teased, as one of her apprentices fixed the CD player. "You can push out a baby and figure out the CD's skipping."

Kim had experienced so much false labor that she was pushing before she was convinced that the baby was coming. Cassandra explained that on their second or third pregnancy, women tend to experience a lot of false contractions, followed by only a few hours of hard labor. "These women will take a week or two weeks of laboring every night. They do a little at a time." Though it can be frustrating for expectant mothers, she doesn't think there's any need to induce labor in such situations. "Our bodies know what we need. These women can't afford to be in labor for 24 hours because they have so many obligations. You give birth the way you live life." Kim had started having contractions around three in the afternoon; it was 5:30 the next morning before Steve--over Kim's protests--had asked Cassandra to come over. Kim was already hitting transition when Cassandra arrived with apprentices and daughter in tow (Kim had invited the 11-year-old to the birth). The apprentices set up all the necessary tools: gloves, gauze pads, herbs in case of hemorrhaging, Pitocin, the ultrasound, a stethoscope, an oxygen tank, and the most essential tool for water births: a flashlight.

Cassandra encouraged Kim to do some flipping in the pool so that she could work through contractions in different positions. For the most part, however, she appeared to be handling the labor well on her own, and Cassandra felt comfortable splitting her attention between the birth and the cup of coffee she kept mislaying. This was part of her commitment to being as hands-off as possible: when a cup of coffee could become a point of focus in the middle of labor, it showed the parents and people in attendance that birth was a normal process. Usually, she says, she'd give the parents more time alone, but because Kim was so far along when she arrived she stayed in the room with them.

Once Kim reached the pushing stage, Cassandra suggested that she kneel through some contractions. Kim got on her knees in the water and leaned over the edge of the tub away from Steve. "Go ahead and put your fingers inside if you want and tell me if you feel your baby," Cassandra said. "When you stick your finger in, your baby's head is gonna be about that far." She demonstrated with her fingers in the air. In Cassandra's experience, when a mother can feel her baby's head in the birth canal, it often gives her the extra impetus needed to push. Kim reached in and felt her baby's head, and then Steve did the same. When Kim's water broke, shortly afterward, bits of membrane and blood floated into the pool, fetched out with green fishnets by the apprentices.

Minutes later the baby started to crown, and everyone in the apartment gathered around the pool. Cassandra's daughter, Kim and Steve's roommate, and Kim's 13-year-old brother came in from the living room. Two-year-old Jacob, as if sensing the importance of the moment, went directly to his mother and took her hand. Cassandra pointed her flashlight into the water between Kim's legs and let the beam rest on the small head covered in brown hair. She could tell by the color of the scalp that the baby was getting enough oxygen. For a moment between pushes, Kim and Steve caressed the top of their baby's head. Then Steve took a hand mirror and positioned it in front of them at an angle that allowed Kim to see the crowning scalp. After the next push, the tiny head came out entirely, but Cassandra didn't see the baby turn toward Kim's right thigh to maneuver its shoulders out, as most newborns do instinctively. Cassandra eased a few fingers inside and rotated the baby's shoulder, allowing the new person to come swimming into the world. On the final push Kim arched her back, then leaned on Steve in fatigue. Cassandra used her hands as a blockade to prevent the baby from floating underneath Kim's leg, but she wouldn't bring it out of the water.

"Kim," she said calmly over everyone's exclamations, "reach down and catch your baby."

* a pseudonym

Art accompanying story in printed newspaper (not available in this archive): photos/Lloyd DeGrane.

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