Jennifer Block | March 2020 | 32 minutes (8,025 words)

Elizabeth Catlin had just stepped out of the shower when she heard banging on the door. It was around 10 a.m. on a chilly November Wednesday in Penn Yan, New York, about an hour southeast of Rochester. She asked her youngest child, Keziah, age 9, to answer while she threw on jeans and a sweatshirt. “There’s a man at the door,” Keziah told her mom.

“He said, ‘I’d like to question you,” Caitlin tells me. A woman also stood near the steps leading up to her front door; neither were in uniform. “I said, ‘About what?’” The man flashed a badge, but she wasn’t sure who he was. “He said, ‘About you pretending to be a midwife.’”

Catlin, a home-birth midwife, was open about her increasingly busy practice. She’d send birth announcements for her Mennonite clientele to the local paper. When she was pulled over for speeding, she’d tell the cop she was on her way to a birth. “I’ve babysat half of the state troopers,” she says.

It was 30 degrees. Catlin, 53, was barefoot. Her hair was wet. “Can I get my coat?” she asked. No. Boots? She wasn’t allowed to go back inside. Her older daughter shoved an old pair of boots, two sizes too big, through the doorway; Catlin stepped into them and followed the officer and woman to the car. At the state trooper barracks, she sat on a bench with one arm chained to the wall. There were fingerprints, mug shots, a state-issue uniform, lock-up. At 7:30 p.m. she was finally arraigned in a hearing room next to the jail, her wrists and ankles in chains, on the charge of practicing midwifery without a license. Local news quoted a joint investigation by state police and the Office of Professional Discipline that Catlin had been “posing as a midwife” and “exploiting pregnant women within the Mennonite community, in and around the Penn Yan area.”

Catlin’s apparent connection with a local OB-GYN practice, through which she had opened a lab account, would prompt a second arrest in December, the Friday before Christmas, and more felony charges: identity theft, falsifying business records, and second-degree criminal possession of a forged instrument. That time, she spent the night in jail watching the Hallmark Channel. When she walked into the hearing room at 8:00 a.m., again in chains, she was met by dozens of women in grey-and-blue dresses and white bonnets. The judge set bail at $15,000 (the state had asked for $30,000). Her supporters had it: Word of her arrest had quickly passed through the tech-free community, and in 12 hours they had collected nearly $8,000 for bail; Catlin’s mother made up the difference. She was free to go, but not free to be a midwife.

Several years back, a respected senior midwife faced felony charges in Indiana, and the county prosecutor allowed that although a baby she’d recently delivered had not survived, she had done nothing medically wrong — but she needed state approval for her work. The case, the New York Times wrote, “was not unlike one against a trucker caught driving without a license.” As prosecutor R. Kent Apsley told the paper, “He may be doing an awfully fine job of driving his truck. But the state requires him to go through training, have his license and be subject to review.”

But what if the state won’t recognize the training or grant a license?

Catlin is a skilled, respected, credentialed midwife. She serves a rural, underserved, uninsured population. She’s everything the state would want in a care provider. But owing to a decades-old political fight over who can be licensed as a midwife, she’s breaking the law.

* * *

Catlin has layered, shoulder-length gray hair, big eyes, and an air of calm openness; when I reached her home in May of last year, she greeted me at the top of her stairs. She hesitated at first when I asked her to recall the arrests and what precipitated them, not sure what she should discuss. “I don’t know how to be a criminal, Jennifer,” she told me.

Penn Yan is quaint, surrounded by rolling farmland, about an hour west of the tonier resort towns of the Finger Lakes. Catlin grew up north of there; for years she and her husband ran a feed mill on farmland that had been in his family for two generations. Then they ran a bulk food store. She was called to midwifery by her own birth experiences and began assisting a nurse-midwife who served the surrounding Mennonite community. She began formal studies with a distance midwifery program, which led to an apprenticeship and eventually to the certified professional midwife (CPM) credential, which she’s held since 2015.

I don’t know how to be a criminal, Jennifer.

In Canada, England, and most other industrialized countries, a “registered midwife” or “licensed midwife” serves as a primary maternity care provider and may attend births in hospital, birth center, or home settings. In the United States, things are more compartmentalized. CPMs attend “community births,” in homes and nonhospital settings, and CNMs (certified nurse midwives) attend women in conventional hospital labor and delivery wards (though some also work in homes and birth centers).

Catlin’s preceptor had encouraged her to go for the CPM rather than the CNM. “She was encouraging me to get my license,” said Catlin, and they sat down one day to look at the options: CPM, CNM, and to make the decision more complicated, a third credential, limited to New York, New Jersey, Missouri, Delaware, Rhode Island, and Maine, the Certified Midwife (CM). “She said as a CNM, she had 20 [hospital] births under her belt when they sent her out,” Caitlin said. The CM is also oriented toward hospital-based care, and there are only two training programs in the country, neither of which offered a distance program at the time, a dealbreaker for Catlin. But the CPM requires the student to attend at least 55 births in a community setting. “She just thought, compared to what I’d get as a CNM, that the CPM was far superior for home birth.”

CNM training is entirely health care facility-based, particularly hospitals; the training fits around the routines of institutional care and focuses on the midwife’s “piece of the pie,” as one put it to me. CNMs work alongside nurses, who help monitor labor, and pediatricians, who attend to the baby. CNMs learn how to dose Pitocin, the drug that speeds up contractions; how to read a continuous fetal monitor strip; and how to work with epidurals.

At home or in freestanding birth centers, there is no Pitocin, no epidural, and no machines that go beep — midwives use handheld doppler monitors to listen to fetal heart tones. The midwife oversees the entire event, from contractions to infant care. Birth in the community context happens in various positions (rarely do women choose to labor or push while on their backs), so any midwife who trains or works outside the conventional model also develops a nimble spatial awareness. The CPM also tends to be more accessible. In order to become a CNM, one must first become a registered nurse then enter a master’s program leading to certification. CPM programs require fewer credit hours and lead directly to certification. For people who, say, have a family and are rooted in a community, a distance program with a local apprenticeship has the necessary flexibility.

Before Catlin enrolled in 2012, New York CPMs could take the same exam nurse-midwives take to obtain a CM, which allowed licensing, and she and her advisors still believed that to be the case. In reality, that option was disappearing, because in 2011 the American College of Nurse-Midwives began requiring anyone sitting for its exam to have a master’s-level education at an approved program. (Catlin says the impact wasn’t immediately clear to her, and in any case New York seemed to look the other way when it came to the Amish communities). This shift also meant that credentialed midwives from outside the United States couldn’t qualify for licensure. “You could have a master’s degree from England and have delivered the royal baby and you wouldn’t be able to get reciprocity in New York,” said Susan Rannestad, a licensed midwife in the Hudson Valley.

* * *

The story of the outlaw midwife begins much, much earlier. It begins with patriarchy and the church and colonialism; in the United States it begins in the 1800s, when the white, male profession of medicine claimed authority over what today we call health care, and midwives were an obstacle. They were also an easy target — the majority were immigrant, Indigenous, and black women. At first states outlawed abortion partly as a means of limiting midwives’ practice. Then state after state erected statutory barriers for midwives, first by licensing and supervising existing midwives and later by denying licenses in all but a handful of states, so that by the 1960s hardly any midwives existed in North America. “The question was not whether midwives should disappear but how rapidly,” wrote historians Dorothy and Richard Wertz.

Doctors swiftly transformed childbirth from something women did in upright positions with social, skilled support to something doctors did to them with medical technology, though what happened was far from what today we would call evidence-based medicine. By the 1920s, the majority of laboring women were isolated in hospital wards and given morphine and scopolamine, an amnesiac. This produced what was called twilight sleep; the women were awake but wouldn’t form any memories of the experience. Cesareans were not yet common, but women were routinely shaved to their labias, flushed with an enema, strapped flat on their backs in stirrups with ankles and wrists in leather restraints, and given a liberal episiotomy — a cut to the vagina and perineum, which might tear further, especially if forceps were employed, which they often were. These mothers were not allowed to touch or breastfeed their babies and might not see them for hours or days.

This shift did not make birth safer. Until the advent of antibiotics, the rates of maternal death and infant death in hospitals actually increased. The midcentury was a dark time for reproductive health all around: Abortion was illegal and dangerous, contraception was physician-controlled and required the female recipient have a ring on her finger, and maternity care was barbaric. It wasn’t until the antiestablishment and feminist movements collided in the 1960s that pregnant women began rejecting the hospital, forcing a resurgence of physiologic (what used to be called “natural”) birth.

The women who were called to attend these births — who at first did not even know to call themselves midwives — were relearning a lost body of knowledge, restoring autonomy and humanity to childbirth, resurrecting a female domain from a patriarchal and paternalistic one. They may have been radical, but they were not anti-learning or anti-technology. As historian Wendy Kline makes clear in Coming Home: How Midwives Changed Birth, in each locale where home birth rerooted, the lay midwives collaborated with supportive physicians who provided mentorship, supplies, and emergency backup. Within a decade they started establishing schools, national standards, and the foundations for a national credential, the CPM.

Catlin is far from the first midwife to face criminal charges — there have been hundreds in the U.S., though nobody has done an official count in more than a decade. Usually what precipitates an arrest is a poor outcome, most often an infant death. In 2017, a veteran Utah midwife began serving a 180-day jail sentence (the prosecution had asked for the maximum, 15 years) after a jury found her guilty of manslaughter in the death of a twin born premature during a snowstorm. In 2014, an unlicensed midwife in North Carolina spent nearly 300 days in jail awaiting trial. In July 2019, an unlicensed midwife in Nebraska was charged with negligent child abuse. In Georgia, a CPM is suing the state board of nursing after receiving a cease-and-desist letter threatening a $500 fine for every instance in which she had identified herself as a “midwife.”

‘You could have a master’s degree from England and have delivered the royal baby and you wouldn’t be able to get reciprocity in New York,’ said Susan Rannestad, a licensed midwife in the Hudson Valley.

A recent review of home birth studies from several countries including the United States, published in the Lancet, concluded that planned home birth with a trained attendant does not increase risk to the baby. Other studies (this one out of Canada, and this one that included CPMs in the U.S., among others) attest to the benefits for the mother, like less physical injury, less chance of surgery, and more success breastfeeding. The Cochrane Library, which conducts reviews across medicine to inform evidence-based practice, concludes that “studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up.” That there are mechanisms in place to seamlessly transfer care if necessary is a caveat that appears throughout the literature, and it challenges the public health priorities of restrictive states like New York. Another recent study found that the more integrated U.S. midwives are into the system — based on criteria like licensing and insurance coverage — the better a state’s birth outcomes are.

The low risk notwithstanding, some babies just don’t survive birth. Even Sweden, the country at the top of the list of such public health measures, loses 2 infants per 1,000 births. There’s an absolute risk to new life, which means that unfortunate outcomes will be part of every OB or midwife’s career.

The case that prompted Catlin’s arrest, according to news reports and other clinicians familiar with the event (she’s unable to talk about it while the case is ongoing), was that of a mother whose labor stalled at 9 centimeters. They transported her to a hospital about 35 minutes away, and the baby was born with assistance of a vacuum extractor about an hour and a half later. The baby appeared healthy at first, but within the first hour his condition worsened and he was transported to a neonatal intensive care unit at another hospital. He died several hours after birth of disseminated intravascular coagulation, a blood clotting syndrome, possibly due to infection. Midwives who conducted a peer review found that Catlin transported appropriately and could not have caused the death.

That hospital, F.F. Thompson, is affiliated with Strong Memorial in Rochester, which is party to a signed “transport agreement” initiated by the New York State Association of Licensed Midwives to discourage retaliation. Eva Pressman, MD, director of OB-GYN at Strong, explained that this was to “make sure that when home birth attendants come with patients they were able to transfer the care in a receptive and organized way.” Pressman told me that she has interacted with a handful of unlicensed midwives over the years and has never found cause to report any to the state. “Most of the time we appreciate the care that they’ve been giving the patients outside of the hospital,” she said. “We appreciate the information that they’re able to give us when they transfer to us, and we appreciate the support they’re able to give to the patients and families when they’re here.”

Nobody has taken public responsibility for reporting Catlin to authorities. It’s possible that the attending physician — new to the area — was unaware of the agreement or disagreed with it. In any case, a baby died, Caitlin was unlicensed, and somebody called the police, setting the wheels of criminal justice in motion.

* * *

CPMs are licensed providers in 33 states and counting, and New York could have been among them had a 1992 law been implemented differently.

In January of that year, midwife Hilary Schlinger sat in the waiting area of the Albany office of New York State Assembly member Dick Gottfried. The door was closed. Schlinger and another midwife were there to meet with a staffer about the final wording of the Professional Midwifery Practice Act, which was expected to pass and which Schlinger believed would allow her and other home birth midwives to obtain licensing.

There was reason to hope.

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At the time, nurse-midwives were allowed to attend births in hospitals as nurses with an extra nine months of training in midwifery, but they lacked autonomy from physicians and wanted a pathway to practice that didn’t require training in irrelevant disciplines like geriatrics or intensive care. They looked to countries in Europe and elsewhere, where midwives trained via a “direct-entry” pathway that leads to a credential without requiring a nursing degree.

Home birth midwives like Schlinger were already using the term “direct-entry,” but they were still unregulated and vulnerable to criminal prosecution. Others, even some nurse-midwifery leaders, called them “lay” midwives. Still, the home birth midwives joined the nurse-midwives in their yearslong effort to get a bill that would provide a “direct entry” pathway to midwifery. The nurse-midwives wanted “to get out from under nursing,” as one put it, as much as the home birth midwives wanted a licensed credential. In theory, this gave both groups common cause.

But many in the home birth community were nervous about collaborating with people who were already part of the medical hierarchy. If the underground midwives went public with a campaign, they would make themselves known and possibly more vulnerable to censure; collaborating on a bill risked compromising their autonomy. But if they didn’t, they risked being excluded from licensure entirely. Schlinger felt very strongly that they should have a seat at the table and led a delegation of sorts to the city to meet with nurse-midwife leaders.

“We were not greeted with open arms, to say the least,” Schlinger said. “We were trying to strategize, how do we get our voices heard, how do we not be dismissed within this process. Here are people who are licensed and feel that they had power, and we felt we were being swatted away.”

So the home birth midwives wrote their own dream bill, hired a lobbyist, and found a sponsor. The bill was never going to pass, but that was never the point: the New York State Assembly Committee on Higher Education told the competing groups to work out one piece of legislation amenable to both. “In essence, it put a hold on their bill when we introduced ours. So we pushed our way into the conversation,” Schlinger said.

For the next two legislative sessions, the home birth midwives lobbied for the nurse-midwives’ bill, with the understanding that they’d be involved in negotiating the particulars. It was clear that “the nurse-midwives would own the title midwife unless we did something,” Schlinger’s colleague Alice Sammon told interviewers. In Schlinger’s telling, the home birth midwives were promised two things: two seats on the incipient midwifery board, and consideration of their education for equivalency — and thus licensure. Schlinger actually held a license in New Mexico, where she had studied; other midwives had studied and were credentialed in other states or in Europe. And those who had begun attending births in the late ’60s and early ’70s — who were basically homeschooled in home birth and who were the ones developing training programs and writing midwifery textbooks and organizing nationally — believed they would be able to validate their knowledge and experience, even if it hadn’t come from a formal program, and obtain licenses.

What was at stake for the home birth midwives wasn’t only their ability to practice in New York or who could call themselves a midwife. It was about protecting a different understanding of the physiology of childbirth and how best to support it. “As these original lay midwives became more sophisticated in their understanding of the details of medical training and practice, they saw quite clearly that what they were seeing at home births often did not reflect what they were reading about and seeing in hospital birth.… They were developing a different knowledge system,” said Anne Frye, a CPM and textbook author. The danger was that the state would again be deputized to quash this movement just as it was finding its legs and emerging from the shadows.

When the door opened to Gottfried’s office and Pat Burkhardt, one of the main nurse-midwife organizers, walked out with Shea Bergan, the staffer who’d taken the lead on the bill, Schlinger was stung. She remembers Bergan reassuring her: home birth midwives would have a voice on the board. But what happened next could be a plotline from Big Little Lies: infighting among women with varying degrees of social and political power, police work, secret meetings, charges of deception and betrayal, handcuffs. People whisper of dalliances and possibly an extramarital affair. Except there’s no murder victim — or maybe there is.

The New York State Professional Midwifery Practice Act passed in 1992. In 1994 the state established the Board of Midwifery, which would write the regulations and oversee education, practice, and discipline. The home birth midwives did not get any seats. Elaine Mielcarski, a Syracuse-based CNM who lobbied in Albany every week for a decade and remains a vocal skeptic of home birth midwives’ competence, became the board’s chair. Today, she is adamant that no promises were made to the “lay midwives” regarding board seats or licensing eligibility. “As a matter of fact, I did absolutely the opposite. I told them what the requirements would be,” she told me. “I said, ‘Look, I’m not sure how long it’s going to take to pass this legislation, but go now and enroll in community college. Take biology, take microbiology, take chemistry.’” She went on: “There was never, ever a discussion [of seats] — ever — because that law made it illegal for lay midwives to practice without a license.”

One of the board’s first actions was to adopt the same exam required to become a CNM for any prospective direct-entry midwife, which would grant every CNM immediate licensure under the new statute. It also satisfied last-minute wording of the bill — negotiated behind those closed doors to satisfy the powerful nursing lobby — that the new direct-entry midwives’ education would have “nursing equivalency.”

The board invited home birth midwives to apply for licenses in early 1995; around a dozen did, and 10 months later, all were denied. Shortly thereafter, several of those same midwives were sent cease-and-desist letters from the Office of Professional Discipline, while others were arrested, their clients investigated. Schlinger and other midwives started showing up to the board meetings to speak their minds, which prompted motions to move agenda items out of the gallery to closed-door sessions.

The tension came to a head on December 13, 1995, when New York State charged Roberta Devers-Scott, a popular Syracuse midwife, with the new felony-level crime of “practicing midwifery without a license.” Before the 1992 law, midwives like her risked misdemeanor charges. Now, the stakes were higher: The unlicensed practice of any profession codified by New York State law is a felony. Devers-Scott had been the target of a sting. Two agents from the New York State Office of Professional Discipline posed as a couple the week prior, and the purported dad came back with an officer to arrest her the next week while she was working her part-time gig as a family planning counselor at the county health department.

“They came to the office — the prosecutor, a male officer, and the undercover officer, all in suits,” she recalled. Just as Catlin had, she said, “Let me get my boots.” Police handcuffed her, led her out of the office, and pushed her into a cruiser.

After the arraignment, she went to the media — with bright blue eyes and jet-black hair and a cosmopolitan wardrobe and a voice she wasn’t afraid to use, she decided to go big. “I was full of piss and vinegar. I was angry about what was happening with midwifery,” she said over coffee in a hotel lobby last spring, still bright and animated and dressed in all black. “I was the top news story, I don’t know how many nights on the nightly news. They put ‘CRIMINAL’ with a question mark on the screen.” She used her platform to talk about CPMs and CNMs and being excluded from the Midwifery Practice Act. “There were always throngs of people at every hearing,” she said. In the end, Devers-Scott accepted a plea bargain and pled guilty to the lower-level crime of “attempted practice of midwifery without a license,” then moved to Vermont, where she organized for CPM licensure. It took one year.

The board invited home birth midwives to apply for licenses in early 1995; around a dozen did, and 10 months later, all were denied.

Pat Burkhardt founded the CNM program at NYU and sat on the inaugural midwifery board; today she holds a doctorate in public health and is mostly retired. She looks back regretfully at what she calls “the witch hunts” that followed the passage of the law and formation of the board. “What did we know about felonies and misdemeanors?” she told me. “I certainly was ignorant of it. Whether I was unique in that, I don’t know.” What Burkhardt did understand at the time — and agreed with — was that the Office of Professions was never going to validate the home birth midwives’ education as “equivalent.” “The bottom line for the negotiating at the time was [that the home birth midwives] had not accepted or imposed or even designed any standards for education or practice,” said Burkhardt. “We felt it was critically important that there be some standards.”

In this case “standards” was as fungible a term as “direct-entry.” During the same time period, the Midwives Alliance of North America (MANA), representing community midwives, adopted Standards and Protocols for the Art and Practice of Midwifery and started developing a CPM framework. From 1989 to 1994, representatives from MANA and American College of Nurse-Midwives (ACNM) attended meetings, sponsored by the Carnegie Foundation, resulting in a document called “Midwifery Certification in the U.S.” that laid out a dual system: MANA would oversee direct-entry midwifery in U.S. and ACNM and its respective entities would oversee nurse-midwifery. It was essentially a peace treaty.

But Mielcarski and other nurse-midwives in New York believed in university-based training (even though when they had trained nursing school was a two-year program; today a CNM requires a master’s degree). They wanted to create their own “direct-entry” credential, but it was more than that: They hoped this credential would eventually become the United States’ singular midwifery credential, and they would pilot it in New York.

And so New York launched the Certified Midwife with a degree program at SUNY Downstate at the same time as MANA created the CPM. The curriculum was indistinguishable from nurse-midwifery education. (“We used to say ‘equivalent,’ and now we say ‘identical,’” the current program director told me.) When the home birth midwives’ license applications were rejected, they were told to go back to school and obtain a CM.

“New York is a beacon of midwifery and a shame of midwifery,” said Rannestad, who volunteered to lobby in the late ’80s and ’90s while a midwifery apprentice. Did the CNMs in New York know the CPM was being developed? “Yes. Did they include those people in developing the New York law? No.”

* * *

It’s not every day you get invited to a crime scene. This one is remarkably tidy: a large bedroom, looking otherwise ordinary, until I notice that the blue blob in the corner isn’t an oversize chair but an inflatable birth tub, and the step stool beside it is actually a birth stool, and the digital plastic thing near the bed isn’t an alarm clock but a Doppler monitor to measure fetal heart tones. The previous night, Shannon attended a birth here, and she’d agreed to meet with me provided I don’t use her real name and that I say very little about where we are other than that we’re in the state of New York, which doesn’t recognize her CPM credential and could charge her at any moment with felony crimes.

Shannon works within the “plain” Amish and Mennonite communities and is overbooked with due dates. She tells me she felt a calling: “The Amish look at birth very differently. You’ve got this big mountain in front of you, there’s no way around it. The English [secular society], we try everything: tunnel through, go the other way, chop the mountain down.” Shannon charges very little; sometimes she gets paid in goods — eggs, pies, the birth stool. She tells me about a family who live a mile off the road, up a dirt path. “I had to take a horse and sled to do a PKU [the newborn genetic screen required by the state]. There was no way to get a car up there,” There’s an Amish midwife, not formally trained, who charges less. “Sometimes I’ll get Mayday calls,” says Shannon. Infections, babies failing to thrive, postpartum depression, psychosis.

About a dozen CPMs are scattered throughout the state. Some work as “assistants” to licensed midwives. Some are licensed in New Jersey and ostensibly practice there. Some work part-time as doulas or nominal doulas. One midwife explained, “[The clients] would get in the door and there would be a wink and a handshake, because someone sent them.” This meant lying to her kids, lying to everyone. Hiding birth equipment in a neighbor’s house in case cops raided hers. It meant verbal contracts and not always getting paid, taking on a second or even third job to make ends meet.

“I mean, I got into all this because I feel it’s a woman’s right to fully embrace all of her choices around her reproductive health, and that doesn’t just include whether or not she wants to keep a pregnancy, it also extends to who she wants to catch her baby, where she wants to be, how she wants to do it. She should have all the information to make the choice that’s best for her,” said this midwife. “That’s why I did it, because women were asking me, because if I wasn’t there they’d do it alone. I was doing it because the state wasn’t allowing the women to get what they wanted. As a staunch feminist, this was my way of really being there to show up for women.”

Very few are willing to take the risk of practicing illegally today, a risk that has become very real since Catlin’s arrests. Especially for midwives of color. Carmen Mojica, a CPM who lives in the Bronx and for a time worked as an assistant to a CNM told me, “The CPM was the closest I could get to being trained the way my ancestors were trained.” But then: “I’m a black woman. I can’t afford to do anything illegal.… I’m already in a black body that’s targeted for everything.” While she can’t currently practice midwifery, she is trying to midwife a legislative remedy: Mojica cofounded the advocacy group New York Certified Professional Midwives, which is lobbying for a new bill.

Asteir Bey is a doula, childbirth educator, and registered nurse in Syracuse who codirects the U.S. operations of Village Birth International with doula and childbirth educator Aimee Brill. The organization has a mobile clinic in Uganda and runs childbirth education classes and doula training in Syracuse. Bey, who is black, and Brill, who is white, are particularly focused on the large black and immigrant communities in Syracuse, both of which experience a disproportionate share of poor outcomes. In New York City, the maternal mortality rate for black women is 12 times that of white women. In Onondoga county, the maternal mortality rate is 31.6 deaths per 100,000 births, twice the estimated national rate, and infant mortality is three times higher for black infants than for white infants. The disparities hold whether the women are educated, well-insured, or upwardly mobile. When researchers drill down, the explanation is institutional racism — the physical stress of living in the U.S. as a woman of color, and still-mostly-white medical staff ’s refusals to take black women’s pain seriously.

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Both have thought of, and continue to consider, becoming midwives. “Aimee and I would have long conversations of tears and joy trying to figure it out. Maybe we’ll do the CPM as this active resistance, as a political thing. And then thinking about our organization [in Uganda], using our CPM to really build bridges there,” Bey told me. But then reality dampens these aspirations. The difficult life of a home birth midwife — physically demanding, unpredictable hours, low pay — is exponentially more difficult when the profession is legally marginalized.

Bey could go the CNM route, but she thinks of the loans she’d graduate with, which would force her to take a hospital job for at least a couple years, which would make it tough to start up a home birth practice. So “you get this institutional job based on your certification that pays your bills, but it doesn’t fit fundamentally with what you’re doing.… That’s not really how you learn how to do home births. They’re like two different worlds. The one thing I feel really clear about is that the kind of care that as a midwife I want to provide for people — I’m not sure I can do that in the hospital.”

Brill lands in a similar place: “It’s really hard to let go of the idea of midwifery, but I don’t think my idea of midwifery actually exists.”

And yet, the reason that the subculture of home birth inspires such passion in both consumer and midwife is that, at least in the United States, it is where both the person birthing and the birth attendant categorically have the most autonomy. It is an inherently feminist model of care. And issues of autonomy and bodily integrity are central to the crises plaguing maternity care across the country. Rinat Dray of Staten Island was forced into a cesarean in 2011, based on her hospital’s secret policy allowing doctors to use “the means necessary to override a maternal refusal of the treatment.” In California, Kimberly Turbin refused an episiotomy and the OB cut her 12 times (this was captured on video, which you can find on YouTube). “I’m the expert here,” he said. In Alabama, nurses pinned down Caroline Malatesta and held her baby in her vagina for several minutes until the doctor arrived, causing her lifelong nerve damage and sexual dysfunction.

These are extreme cases, but every day women who’ve had previous cesareans or whose babies are in the breech position are told they have no option but surgery. Perhaps the hospital “doesn’t allow” VBAC (vaginal birth after cesarean) or the doctors are unskilled in vaginal breech birth. Such practices violate the modern ethic of patients’ rights — and human rights — yet pregnant women are routinely treated like another class of patient. The midwives I talk to who serve the Mennonite and Amish communities, like Catlin, also emphasize the poverty, the poor nutrition, the infeasibility of the hospital for families that expand annually — hospitals that are often hours away by buggy, unaffordable, and frightening. Plus, they’ve got a brood of young children and animals who would need minding. When they go to the hospital, it’s an absolute last resort.

In all the mid-’90s machinations over licensure and standards, the women who were about to lose their midwives never seemed to factor too heavily in anyone’s minds. “It was territorialism,” says Linda Schutt, a semiretired CM based near Ithaca. “It was never about the mothers and babies.”

* * *

Six years ago, I became an expectant New Yorker navigating the maternity care system, trying to find expertise and autonomy in the same package. I knew that the hospital was not where I wanted or needed to be, and that I would plan a home birth.

The CMs and CPMs I sought out were candid about their professional standing. They warned me that if we needed to transfer to a hospital in labor we’d likely encounter attitude if not outright hostility. They wouldn’t be able to stay and support me. One midwife looked me straight in the eye. “If we need to transport, I cannot guarantee that you’ll have a good experience.” By “experience” she wasn’t talking about whether I’d be able to dim the lights or play Adele or bring a yoga ball. What she meant was that she could not guarantee my physical and emotional safety. “There’s the phenomenon in hospitals that women are treated negligently or in a way that is punitive based on moral opprobrium that has nothing to do with fact. And that’s unsafe,” said Hermine Hayes-Klein, a reproductive justice attorney in Oregon and founder of Human Rights in Childbirth.

Eventually I connected with Cynthia Caillagh, who’d left New York in the mid-’80s after attending 2,000 births in the Buffalo-Syracuse corridor. By the time I was pregnant, Cynthia had moved to Wisconsin, where she finally got her CPM and could practice without restriction. She has attended around 4,200 births to date, and one quarter of them have been twins or babies in the breech position. In the medical system, these are “high-risk” — breech are usually an automatic cesarean, twins very often so — but for her they’re variations of normal that require particular skills, which she has, so just 2 percent of her clients end up needing C-sections. She’s also a safe harbor midwife: she gets calls from around the country from women in their eighth month who have twins or breech babies or are VBAC and are willing to travel to avoid surgery.

So as my third trimester began, I set about finding a place in Wisconsin for the baby’s father and I to stay. A friend of a friend knew a couple who had inherited a farm and were starting up an artist’s residency in their guest suite. The location was perfect, just 10 minutes from a hospital where Cynthia had good relationships. I made the cold call: “Hi, would you mind if I had a baby in your house?” Ali and Don got it. They had both their kids at home and flew in their midwife for the second one.

The residency would be empty in December, but Ali suggested we’d have more space and privacy in the “hunting man’s man cave,” though it lacked certain modern amenities, like a water hookup. We landed in Milwaukee in a winter fog, drove three hours to the farm, and opened the door to the man cave. It was more like an airplane hangar than the log cabin of my imagination, with a high ceiling, concrete floors, exposed insulation, and several mounted deer heads. Don’s dad Jim, who had originally owned the property, used it as his hunting lodge.

Some critics of home birth have called it selfish, for women looking for a spa-like experience. We had a woodstove and a makeshift toilet with a wooden seat poised over a bucket. On most days, the temperature outside hovered between 5 and 15 degrees. I did have a birth tub prepared — a black plastic cow trough from a farm supply store. My labor, as I see it, included the first two weeks in Wisconsin before the contractions started: dealing with the bitter cold, figuring out the woodstove, coming to terms with the pee bucket.

We set up the tub in the main house, where hot water actually comes out of the taps. And on the night of a full moon, after a night and day of contractions, I stepped into warm water hoping my baby would swim out, as I’d seen in so many orgasmic birth videos. But Cynthia understood that something was holding him back, and after nearly eight hours in that tub, she got eye-level with me: “You’re going to have to push this baby out.”

“I’m going to tear,” I said, which was really the best-case scenario in my mind; I was absolutely sure I’d split into two halves. Cynthia responded with the words every birthing human wants to (and more deserve) to hear: “I’m not going to let you tear.” And then I remembered: This is why I’m here. Not only because my midwife wasn’t going to intervene unless I or the baby was in danger; she was going to protect my body. But she was also going to protect my relationship with my baby — we would start our mother-child love affair under the most optimal, gentle circumstances.

I pushed my son out at 3 in the morning, without tearing, without even much blood. He had wound the umbilical cord around his body like a silks acrobat — under his leg, around his waist, under his arm and around his neck — and thus couldn’t swim out so easily. Cynthia calmly unfurled him and put him on my chest.

He was wide-eyed and perfect and minutes-old when he reached out his tiny hand to touch my face.

At 5 a.m. we bundled up and the party moved back up the hill. I slept the kind of sleep I’d been wanting for weeks. Under “Notes” on my “immediate postpartum evaluation,” Cynthia reported: “Jennifer has moved back to the man cave.”

There were so many moments leading up to that day when I doubted myself, when I thought the whole plan was a mistake. “I’ve made a mess of things,” I wrote to Cynthia one morning. But what happens to our bodies is important. The way we are treated in our most vulnerable moments is important. What happens to our babies in their first minutes, hours, days out of the womb is important.

Cynthia responded with the words every birthing human wants to (and more deserve) to hear: ‘I’m not going to let you tear.’ And then I remembered: This is why I’m here.

I’m fortunate; not everyone has a flexible job, a supportive partner. Not everyone can labor in a cabin with the wisewoman of their choosing. Not everyone even knows that this kind of care exists — midwives’ expertise is so frequently hidden from discourse, eclipsed by the media’s focus on doctors and doulas. But everyone deserves the care I received, especially in the postpartum: Cynthia and her colleagues made sure I was healing and resting and that the baby, who we named Abe, was the right color and that his tiny system was functioning properly. Nursing hurts before the milk comes in, around day three, but the midwives brought me lanolin and reassured me that the colostrum Abe was eking out of my sore nipples was exactly enough food, that his incessant suckling was going to bring on the milk and establish my supply, which it did. “What you wanted was an expert in physiological birth with a secure, safe transfer [if necessary],” said Hayes-Klein. “It’s not too much to ask, Jennifer.”

In spite of having a full-body hangover, those first few days lying in bed with my baby were a magical, otherworldly time. In half-naked pictures I look up at the camera, bleary-eyed and blissed out. Everyone and everything, even the hunting paraphernalia, was sparkling. I suspect that many women don’t experience this euphoria because the hormonal physiology has been disrupted and they’re recovering from trauma instead of flying on an oxytocin-prolactin-beta-endorphin cocktail.

Several family members arrived the day after Christmas to meet the baby in our manger. It was a freak 45 degrees, brilliant sun on snow, and I went for my first walk with Abe wrapped to my chest. That afternoon, we hosted a goose dinner. Cynthia joined and held Abe while we all ate. By 3 in the afternoon, I was ready to be back in bed, and she helped clear the room so I could get there.

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In 1996, Hilary Schlinger moved back to New Mexico, one of the few states that never outlawed midwifery in any capacity. Today, the state is held up for its “European midwife-to-doctor ratio,” as she puts it, and downright Scandinavian outcomes. Midwives attend some 35 percent of births, and the state’s rates of cesarean and preterm birth are among the lowest in the nation (even though the population is higher risk than average).

When physicians claimed authoritative knowledge of birth at the turn of the last century, it nearly drove midwives and home birth out of existence; when nurse-midwives claimed it in the 1990s, it drove “other” midwives out of New York. Those midwives are pushing back, and CPM licensing is sweeping the country; there’s a chance New York will flip in the near future. Between 2010 and 2015, the CNMs and CPMs and their certifying and accrediting organizations held another summit to bring American midwifery education and certification in line with the standards set forth by the International Confederation of Midwives. In 2015, they published a statement agreeing that both pathways, CPM and CNM — and the all-but-forgotten CM — meet the international standard, and made recommendations for state licensure.

Pat Burkhardt, who opposed licensing the progenitors of the CPM in the 1990s and championed the CM credential, is now on the legislative committee of the New York Association of Licensed Midwives, which has drafted a new bill to replace the 1992 law that could lift the ban on CPMs as early as this legislative session. Called the Unified Midwifery Practice Act, it is sitting on Dick Gottfried’s desk. Meanwhile, on the national front, two bills have passed the House that would expand Medicaid coverage to CPMs as well as mark federal funding to train more. “It makes no sense that if CPMs meet the standards they can’t be licensed,” Burkhardt now says.

Still, the turf wars over competency, authority, and autonomy continue, on the familiar battleground of women’s bodies. It’s very possible that in negotiating the regulations, CPMs will be restricted from attending people or births with certain characteristics, as they have been in other states like California, home to about 15 percent of the country’s licensed midwives, according to the National Association of Certified Professional Midwives. Until 2015, they practiced without restrictions. Now their scope of practice is ambiguous, and that ambiguity is being used against them. They can no longer attend breech or twins; they are being challenged on VBAC; and several are being investigated by the state board, drowning in legal fees, discredited for outcomes that don’t get a second glance in hospital settings. Many are letting their licenses expire and going back to practicing underground, and a growing network of “freebirthers” is shunning licensed providers altogether.

During my coffee with Roberta Devers-Scott, afternoon turned to evening, and we moved on to happy hour white wine. She told me that after Syracuse she thrived for several years as a legal CPM in Rutland, Vermont, attracting a sophisticated clientele and pulling in six figures. In other words, she was stiff competition. She was also lobbying the state to allow midwife-run birth centers; at one critical moment she was sitting in the governor’s office with the head of Blue Cross Blue Shield, asking why they didn’t cover CPMs. But then a poor outcome similar to Catlin’s turned into a lawsuit. She lost her license, went back to school to become a licensed therapist — got two masters degrees — but was denied that license because of her criminal record in New York. Today she is starting an artisanal soap business.

“We were on a roll,” she said. “I got eliminated before I could finish that work. It’s what happens to loud women.”

In Wisconsin, Cynthia is painting the walls of her new birth center colors like “blueprint” blue. In November, she organized a conference on vaginal breech birth, which brought together physicians and midwives from across the continent. Her next project is a small cabin for long-distance clients to comfortably stay.

Elizabeth Catlin had been keeping her head down, making ends meet working for the University of Rochester on a study of the low incidence of allergies and asthma in Old Order Mennonites — she’d been assisting with the study before, and undeterred by her arrests, the university hired her full-time. Then on December 17, 2019, she was indicted on 95 felony counts, including negligent homicide, carrying a possible prison sentence of 473 years.

Right up until her indictment, Catlin’s former clients would call and ask if she was working again. Now, their option of a skilled home birth midwife has been replaced by a wholly different model of care. In response to the void, several CNMs from Rochester opened a Penn Yan practice offering home birth services to the outlying villages Catlin had been serving, but with a fee that’s reportedly at least double Catlin’s, it’s not an option for local budgets. Then, in December, the Thompson affiliate hospital in Geneva announced it was adding OB-GYN services — and scheduled a ribbon-cutting ceremony and open house the same day as Catlin’s arraignment.

Update: In October, police seized property from the home of a Mennonite CPM and served another CPM a cease-and-desist order, and, just last week made another arrest in conjunction with Catlin’s case, confirming the commitment and scope of the state’s crackdown.

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Jennifer Block is an independent journalist and the author of Everything Below The Waist: Why Health Care Needs a Feminist Revolution (St. Martin’s Press). Her work has appeared in The Washington Post Magazine, The Cut, Newsweek, The New York Times, Pacific Standard, The Baffler, and many other publications. Her first book, Pushed, led a wave of attention to the national crisis in maternity care and was named a “Best Book of 2007” by Kirkus Reviews. A reporter with Type Investigations, Block won several awards for her investigative reporting on the permanent contraceptive implant Essure, which has since been discontinued. She lives in Brooklyn, New York, with her son.

Editor: Michelle Weber

Fact checker: Samantha Schuyler

Copyeditor: Jacob Z. Gross