Midwife Crisis Why are women being arrested for delivering babies in Maryland?

Before she got pregnant, before she had even seriously considered getting pregnant, Sheila Clemmons knew just how her daughter would be born. She'd seen it on TV.

“I was a Little House on the Prairie nut,” she says, “and I thought it was really cool the way they had their babies at home. They had personal people there, it was a personal event—no strange people looking between their legs. It was just a beautiful thing.”

When Shannen Michelle Clemmons-McKay was born on Sunday, Oct. 2, 1994, in a little house on the exurban frontier of Howard County, Md., it was like a scene out of Laura Ingalls Wilder—updated with wall-to-wall carpeting and alternative lifestyle arrangements. Sheila's common-law husband, John McKay, was there, pacing in and out of the bedroom where she lay. Their friend Judie Pradier acted as midwife, with another woman assisting her. There was music playing, and food and drink and herbal tea. A couple of other close friends took turns videotaping the event for posterity. Sheila endured the 16-hour labor without painkillers, just like Ma Wilder.

But things didn't quite go as planned, and Shannen's birth ended up more like The Fugitive than Little House. Three days later, Clemmons and McKay bundled their daughter into the car and fled across the back roads of Howard County. The police arrived at their home barely a half-hour later, with a child-abuse investigator from the Howard County Department of Social Services in tow. Finding nobody home, Detective Larry Texeira put out a radio call, and police cruisers combed the county looking for the outlaws.

There had been a terrible misunderstanding.

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Shannen was a big baby, weighing 9 pounds 11 ounces. Sheila Clemmons is not a big woman, but her small frame is sturdy and strong. Clemmons, 30, used to work in a dental office; she quit when she got pregnant. When her labor began late Saturday afternoon, Oct. 1, it seemed as though she would have no problems. Friends came over, bringing food and gifts. “We had a little party here,” says McKay, a 34-year-old drummer who works construction. “We had music, we had our friends over, we'd take turns coaching her, and we'd eat stuff while we watched her try to dilate.”

By five the next morning it was time to call Pradier, the midwife, who came right over. Shannen's head emerged shortly after noon, but then her shoulders got stuck behind Sheila's pubic bone. This is a common problem—the medical term for it is “shoulder dystocia”—and Pradier knew just how to fix it. She reached in to reposition Shannen, while her assistant started to turn Sheila over. But at that very moment, Sheila felt the urge to push again. She inadvertently pushed Shannen against Pradier's hand, breaking the newborn's soft upper-arm bone.

The good news was that Shannen could then slide freely into this world. Once she had been wiped down, snipped free of the umbilical cord, and attached to her mother's breast, it was time to do something about her arm. Pradier wrapped it in light gauze as the couple debated the options. Theyweren't anxious to visit an emergency room on a Sunday afternoon—or any other time. Strong believers in holistic medicine, McKay and Clemmons distrusted hospitals in general, which is why Shannen was born at home, with a midwife and without painkillers. Clemmons had even bypassed such common medical tests as amniocentesis, a sampling of her amniotic fluid, and sonograms, which she feared could “fry the baby.” Nor could the couple afford a hospital birth, since both partners lacked health insurance at the time.

McKay started calling everyone he knew who worked in the medical profession. He called his family physicians, his dermatologist, and other doctors, leaving messages on several answering machines. He finally reached a cousin in New Jersey who works as a nurse. His cousin said that “the hospital would have to call in a specialist, and they probably wouldn't do anything until the next day as far as setting the arm.” That settled it. The arm waited until Monday morning, when a Greenbelt orthopedist examined the tiny limb and wrapped it in a cast. That was that, McKay thought.

On Wednesday morning, McKay was about to leave for work when a strange car pulled into his driveway. It belonged to Susan Glorioso, a county child-abuse investigator. “Are you John McKay?” she asked, although she knew the answer. She also knew—having been tipped off by one of the doctors McKay called Sunday—that there was a baby in the house with a broken arm.

Glorioso asked to come in to see the child. McKay suggested that she get the fuck off his property instead. She promised to come back with police and a court order. “You do that,” he said, and hurried back inside.

“All this stuff was flashing through my mind,” McKay says. “The house was cluttered, and here's this person who had the power to take my baby away.” So he and Sheila bolted.

Later that afternoon, not long after he and Clemmons and Shannen arrived at his mother's house 20 miles away, McKay's beeper buzzed. When he called back, the person who answered the phone said, “Howard County Criminal Investigations.” He hung up, but the phone rang a minute later. Detective Texeira was on the line.

All they needed to do, the detective said, was make a routine check of the child and the home. Just red tape, he explained—whenever an injury to an infant is reported, they have to check it out. McKay agreed to allow Texeira and Glorioso into the house the next day. When Texeira and Glorioso arrived, they were met by a small crowd: Pradier was there, along with McKay's mother, Clemmons' mother, and the two friends with the video camera.

“I didn't understand why they had all the people there, and why they had the camera,” Texeira says. “That heightened my suspicion that something might have been wrong.”

Something was wrong, but it wasn't child abuse. It was the midwife—the striking, 6-foot-tall woman who did all the talking. She explained what had happened during Shannen's delivery, plus a great deal more about midwifery and home birth in general. It took a single phone call for Texeira to learn that Pradier was practicing her ancient art without benefit of a nursing degree or a state license, which is a misdemeanor under Maryland law.

On Jan. 9, 38-year-old Judie Ray Pradier was charged in Howard County District Court with one count each of practicing midwifery without a license; practicing nursing without a license; and misrepresenting herself as a nurse. All the charges stem from Shannen's birth, and each count carries a maximum sentence of a year in jail and a $5,000 fine.

Pradier is one of three midwives to be criminally charged in Maryland in the past seven months. In August, a midwife named Judy Mentzer pleaded guilty to practicing midwifery without a license in Carroll County, northwest of Baltimore. Mentzer was prosecuted after a health care worker noticed that she had signed a birth certificate as the attending midwife. On Jan. 25, Karen Hunter was charged with unlicensed midwifery in Carroll County Circuit Court for assisting at a birth where the child died.

Both Pradier and Hunter refused to comment for this story, citing their pending charges and their attorneys' advice. This is not Pradier's first run-in with state authorities; she was charged with outlaw midwifery in a 1989 case that was later dismissed. Mentzer, who practices out of Orrstown, Pa., a small town just north of the Maryland border, was sentenced to 100 hours of community service, which she is serving by counseling pregnant women.

The three cases reflect a growing conflict between what Maryland law permits and what people like McKay and Clemmons want. McKay, for his part, has little use for the state's protection.

“If this had been an unexpected birth, and she was just a friend who happened to be there and helped us deliver the baby, she would have been considered a hero,” he says. “Instead, she's getting nailed for it.”

Although Shannen Clemmons-McKay was born last October, charges were not filed against Pradier until three months later, after the Carroll County infant delivered by Hunter died. The timing of the charges against Pradier suggests that the Carroll County infant's death may have inspired a crackdown.

“I think it's kind of a witch hunt right now,” says Anne Thompson, chair of the Maryland chapter of the American College of Nurse-Midwives.“We're not beating the bushes,” counters Donna Dorsey, executive director of the Maryland Board of Nursing, which initiated all three criminal cases. “The state doesn't permit the practice of midwifery—lay midwifery. If we find out that they're practicing, we're going to prosecute them.”

Why? “The Board of Nursing has the responsibility of protecting the public by assuring competent nurses and nursing care,” says Dorsey. “The problem we have with lay midwife practices is there is no formal education.”

But Pradier's credentials weren't an issue for McKay and Clemmons. She had delivered some of their friends' babies and she had an excellent reputation—that was good enough. They never even complained about Shannen's broken arm. “It's just one of those things that happens,” McKay says.

By outlawing lay midwives like Pradier, the state is also restricting the options available to Clemmons and McKay—and any other couple that chooses home birth. They are on the front lines of a new kind of reproductive-choice issue, one that comes into play at the end of a pregnancy rather than the beginning.

“When you get to the other side of it, I realized most women really don't have a choice,” says Jim Epstein, a Takoma Park resident whose wife, Jeanne Feeney, had their second child at home Jan. 17 with the help of a Virginia lay midwife.

“The freedom of choice issue doesn't end at the point where you decide to keep a pregnancy or terminate it,” says Epstein, a longtime proponent of reproductive choice who serves on the board of an international family planning organization. “The freedom really needs to extend all the way through birth.”

At issue is the right to choose between a hospital birth, which offers safety and convenience at the price of intimacy and control, and the unknown risks of home birth. By choosing the latter, Epstein and Feeney and Clemmons and McKay are raising questions about medical technology and the authority of doctors that were left largely untouched during last year's health care debate. Even if this country offers the most technologically advanced and therefore safest medical care in the world—a premise that many home-birthers dispute—should it therefore be mandatory?

Or, put another way: If a couple wants to have their child on the back porch, in a hay loft, in a cornfield, or on the set of Little House on the Prairie, can the state forbid it?

“Call me Leslie,” says the Maryland midwife in her plushly carpeted office, a converted two-car garage in Prince George's County, just yards from the D.C. line. Unlike Pradier, she is not yet known to the Maryland Board of Nursing—and wants to stay that way.

Leslie is a slim woman of 32, with dirty-blond hair and dark circles under her eyes from maintaining a full-time job as a health care worker while establishing her midwifery practice. Midwifery wasn't a career choice—it hardly pays the bills. It was more of a calling, she says: “It really, clearly spoke to me.” She talks loudly, partly out of conviction and partly to be heard over her squalling infant, who won't be quieted by any amount of swinging or rocking or heated formula. The girl was born two months ago (via midwife, of course), to Leslie's female spouse.

There are two kinds of midwives: certified nurse-midwives (CNMs), who have completed nursing school and passed a state exam, and lay or “direct-entry” midwives like Leslie and Pradier, whose training is mostly informal. CNMs are licensed by all 50 states and the District. Maryland is one of only 11 states that outright forbids lay midwifery.

Leslie has delivered—or “caught”— more than 50 babies in Maryland in the past two years, but has never signed a birth certificate. “That's pretty much of a red flag for the Board of Nursing to hunt you down,” she says. That was Mentzer's experience, despite living out of state. In Virginia, a midwife was once investigated for signing the birth certificate of her own daughter.

Like many lay midwives, Leslie probably could have aced nursing school and become a certified nurse-midwife, practicing legally. She graduated from one of New England's more prestigious colleges, and tuition wouldn't have been a problem. But she made a political choice to enter the profession directly, knowing full well that it is illegal in her native Maryland. Nurses, she feels, are too traditionally “subservient” to doctors.

“Nurse-midwifery, to establish itself as a profession, had to make compromises that I didn't really like,” she says. “It wasn't a sufficiently independent profession.”

“Direct-entry,” she adds, “really addressed what to me was the essence of midwifery.”

CNMs and lay midwives are separated by differences in philosophy as well as credentials and training. As lay practitioners see it, the autonomy of CNMs is compromised by laws requiring them to practice with theoversight of an M.D. Usually, that oversight is confined to a set of written protocols or guidelines spelling out what is and is not a “normal” labor. Only if a labor deviates from the guidelines—lasts longer than 24 hours, for example—is the nurse-midwife required to bring the patient to a hospital and turn her over to the backup physician. But even that is more than midwives like Leslie can abide.

“If you have to follow somebody else's rules instead of your own, it messes it up,” she says. “Our role is to be the guardian of normal birth.” What's normal, and when a mother should be taken to a hospital, are in her view judgment calls best left to the attending midwife.

CNMs, of course, don't see themselves as subservient to doctors. “I feel fine working with protocols,” says Marsha Jackson, a CNM who owns BirthCare, an Alexandria birthing center and group midwifery practice. “I don't think they tie our hands at all. It just clarifies how to deal with certain situations.” With “good, supportive, consulting physicians,” Jackson says, the guidelines are more flexible than Leslie and other lay midwives suggest.

Although Leslie practices without a backing physician, she admits, “I've courted a few.” Some Maryland midwives, including Pradier, maintain informal relationships with doctors in case of serious complications. By aiding unlicensed midwives, these doctors risk losing their own licenses.

Though not formally licensed, Leslie is formally trained. When she couldn't find an apprenticeship near Washington, she moved to El Paso, Texas, to study at the Maternidad La Luz midwifery school, 100 hours a week for seven months of birth, birth, birth. “That equals no sleep, in case the math escaped you,” she says. At the end, she passed an exam that qualified her to practice lay midwifery—in El Paso. She moved back to Maryland instead.

On the floor beside Leslie, a complicated-looking fetal stethoscope rests atop a black canvas bag—her birthing kit, replenished after a recent delivery. The bag contains a small oxygen tank, scissors to cut the umbilical cord, and a plentiful supply of wipes, pads, and wrappings. There is not a pharmaceutical product to be found; Leslie couldn't prescribe painkillers even if her patients wanted them, though she will offer a few “mildly sedative herbs.”

“When somebody is really freaking out and in pain, a little bit of skullcap or valerian just chills their butt out,” she says.

Leslie charges $1,200 per birth, an adjustable fee based on ability to pay. It includes a varying number of pre- and postnatal visits, house calls, her assistant's fee, and being on call 24 hours a day. The charge is mostly for her time. Leslie spends an hour or more on each prenatal visit, to help develop the relationship of trust that is crucial to a successful labor. The delivery itself can take up to 24 hours, sometimes longer. Afterward, she'll visit the new mom three times in the first week. She figures that works out to less than $20 per hour.

The going rate for a lay midwife—anywhere between $1,000 and $2,000—is about half what CNMs charge. In a hospital, a normal, uncomplicated delivery can cost upward of $7,000. Of course, a hospital birth may be cheaper for many couples, since no insurance company will reimburse for Leslie's services (in Maryland, anyway; lay midwives in Florida recently qualified for third-party coverage). One reason Leslie's rates are so low is that she has no nursing-school loans to repay; also, she carries no malpractice coverage.

“My malpractice insurance is my relationship with my clients, who I've spent a lot of time on,” she says. It helps, in this regard, that the parents assume part of the responsibility by choosing home birth. Nonetheless, Leslie has her clients sign a disclosure form acknowledging that she is not licensed or certified. She also screens patients for chronic ailments, drug use, and other factors that might complicate pregnancy.

A lawsuit would seem, at the very least, ungrateful. Like Pradier, Leslie performs a service that is otherwise virtually unavailable in Maryland. Doctors got out of the home-birthing business long ago, and Marsha Jackson's BirthCare, with four midwives on staff, is the only CNM practice that will do a home birth in the Washington area.

There used to be others. But in 1992, Maryland CNMs' insurance carrier stopped covering home births. In the year it took to find a new carrier, many CNMs abandoned the home-birthing business. If Maryland succeeds in stamping out lay midwifery, the only option for parents who want to have their children at home will be BirthCare.

Midwives have always been regarded with official suspicion—as charlatans at best, sorceresses at worst. The spiritual ancestor of the Maryland Board of Nursing, in terms of keeping tabs on this second-oldest profession, was the church. Specifically, male clerics, arguably the people least likely to know thing one about conception and birth.

One of the earliest products of the Gutenberg press was a how-to manual for the Inquisition published in 1486, provocatively titled The Hammer of Witches. Its authors, a pair of German friars named Heinrich Kramer and Jakob Sprenger, attributed to women all sorts of alarming traits, including the ability to “Deprive Man of His Virile Member” and an insatiable craving for relations with demons. Kramer and Sprenger specifically singled out midwives as “surpass[ing] all other [women] in wickedness.”

The very nature of the midwife's trade made her a prime medieval suspect for witchcraft. Then as now, midwifery tapped into a strong undercurrent of female solidarity. Midwives possessed unique access to the secrets of birth. Midwives trafficked in such mysterious substances as placentas and umbilical cords and birth goop, which are thought by a variety of cultures to possess magical powers. (These mystical associations persist to this day, in the common male belief that rubbing placenta extract on one's head will forestall baldness.)

Part three of The Hammer is devoted to detailed instructions for torturing suspects. Today's lay midwife, traipsing about with her bag stuffed with herbal remedies and her head full of vaguely paganistic thoughts about the spirituality of birth, should probably be thankful she has only the state nursing board to fear.

Though midwives are no longer burned at the stake, their struggle for legitimacy has not abated. It takes place in courthouses and legislatures and health care bureaucracies, and has made some impressive gains. Birthing centers are proliferating, mainstream hospitals have added midwives to their staffs, and a growing number of insurance companies cover midwife-assisted births.

On one level, the midwife prosecutions in Maryland are part of a war that has been going on at least since the publication of The Hammer, with midwives and surgeons jostling for control of the birthing business. In general, the doctors have been winning—particularly since the Victorian era, when middle-to-upper-class women were encouraged to be frail, pale, and sickly. They clearly were not up to the task of childbirth, at least not without medical assistance.

The medicalization of birth accelerated early in this century, fueled by a steady stream of pronouncements from the American Medical Association promoting the idea that birth was a sort of disease. In an influential textbook published in 1913, a respected obstetrician named Joseph De Lee called birth “a decidedly pathogenic process.” Midwifery was disparaged as unsanitary and unprofessional, a folkway of the past to be obliterated in the name of progress.

Indeed, De Lee predicted: “If we will acknowledge the pathogenic nature of this function....that anachronism, the midwife, will spontaneously disappear.”

The upshot, as Jessica Mitford noted in The American Way of Birth, was “the passing of power over the birth process from traditional female to professional male.” Midwives continued to be blamed for such ailments as “childbed fever,” which struck women shortly after giving birth. Midwives were suspected of spreading the disease by their unclean and ignorant practices. Actually, Mitford wrote, the disease was spread by doctors who handled infected corpses and then treated healthy women without washing up in between.

As doctors locked in their market share among the paying public, midwives continued to work among the lower classes, rural people, and blacks. Some Southern states actually offered free training to rural lay midwives, so they could service rural and minority populations that were beyond the reach of hospitals and doctors. Curiously, these same states—including Virginia, Maryland, Alabama, and Arkansas—now have some of the strictest anti-midwifery laws. The laws are still relatively new: Arkansas didn't outlaw lay midwifery until 1980.

The baby boom marked a turning point for the profession. As late as 1940, almost half of all American babies (44 percent) were born outside of hospitals, according to the National Center for Health Statistics. Some 10 percent of all births were still attended by midwives. Among blacks, midwives delivered nearly half the babies. After World War II, everything changed. By 1955, 19 out of 20 American babies were born in hospitals.

Certainly some of the shift can be attributed to consumers' perception that hospitals are, in general, safer places to give birth than grandma's back porch. It's also safe to assume that—like Murphy Brown—many women actually welcomed the prospect of giving birth without pain.

In the hospital setting, modern childbirth has become a totally controlled process from beginning to end; the witchcraft is now performed by doctors and nurses. There are contraceptive drugs to prevent conception, fertility drugs to encourage it. Once conceived, a fetus is subjected to almost continuous monitoring, by ultrasound and amniocentesis and other forms of genetic screening. During labor, electronic fetal monitoring devices record the fetus's every heartbeat. If the pain is too great, an epidural (a shot to the spine) will numb the mother from the chest down.

Most of the standard interventions are intended simply to speed the process. A narrow birth canal can be enlarged with a snip of the scissors—the dreaded episiotomy. Sluggish fetuses are coaxed into the world with a dose of Pitocin, a labor-inducing drug, or, in a quarter of all cases, simply C-sectioned right out.

The underlying assumption of the whole complicated affair is that the body can't quite manage to give birth by itself. Never mind that the Third World managed to overpopulate itself without benefit of board-certified obstetricians delivering babies only in hospital settings. Even as home and nonhospital births dipped toward a low of 0.6 percent in 1970, a countertrend arose, spurred in part by experiences like my mother's.

Twenty-eight years ago, when Mrs. Gifford was pregnant with her first child—me—she wasn't offered any choice. “They wouldn't tell you much,” she remembers. Arriving at Druid City Memorial Hospital, the finest in Tuscaloosa, Ala., she was greeted by an obstetrician who looked exactly like Lyndon Johnson. “Now don't you worry, honey,” he drawled, with a friendly pat on her shoulder. “Everything's gonna be juuust fine.”

Then he went home to get a good night's sleep, leaving Ma Gifford to toss and turn her way through a very uncomfortable evening. When he came back the next morning, I was ready to bust my way out via any available opening. Mom wasn't strapped to her bed, as she might have been a decade earlier. Then again, she didn't need to be, because the anesthesiologist had accidentally zapped her with too much happy juice, so she couldn't properly squeeze me out. She awoke 10 hours later with a Caesarean-section scar the size of the Natchez Trace—and no baby. I'd been whisked away to a nursery; Dad, waiting at home, was notified by telephone.

One of the earliest reactions to hospital birth was the “natural” childbirth movement, meaning childbirth without painkillers. First advocated in a 1933 book titled Childbirth Without Fear, the idea was refined by Dr. Fernand Lamaze during the '50s and popularized over the following two decades (although not in Tuscaloosa, evidently).

Today, natural childbirth has reclaimed a share of the birthing market. Home-birthers are a diverse group, ranging from back-to-nature types to strict fundamentalists, with just about every stripe in between, including Amish, Mennonites, and yuppies whose only temples are their hard bodies.

Other women are choosing to give birth in free-standing birth centers like Alexandria's BirthCare, with only midwives in attendance, or in hospitals with the help of CNMs. This is in part a reaction to Caesarean sections, which arouse particularly strong reactions among women who have endured them. So many women are now opting for vaginal birth after a first C-section that the procedure even has its own acronym: VBAC.

Christina Wypsjewska, 28, had to choose between a hospital and a birth center during her recent pregnancy. A D.C. resident and health care consultant, Wypsjewska was leaning toward a birth center, but remained ambivalent. Well-versed enough in feminist theory to feel that “hospital delivery is just another way to control women's bodies,” she also recognizes that “all of the interventions were really devised to help birth. Without C-sections, in a lot of cases, the mother and baby die.”

After touring maternity wards in the District and Arlington, she opted for a birth center. “The thing I noticed [in the hospitals] was that they were almost encouraging” anesthesia, she remembers. “It was almost as if by not taking any painkillers, you were a weirdo.” She was also alarmed that hospitals forbid pregnant women from eating or drinking anything but chipped ice, in case surgery is required. “It's like a major athletic event,” Wypsjewska says. “If you don't have anything in your body, you get exhausted.”

When her daughter was born last November at BirthCare, she came out at her own pace, with no inducement or episiotomy or C-sectioning. “They really let my body kind of call the shots,” Wypsjewska says. The pain, she admits, was “too much. But at least now I know that it was too much.”

Other home-birth mothers describe the pain as a sort of bonding experience with their child. “It just gets you ready for when they go wreck the car,” says Jeanne Feeney.

By 1990, out-of-hospital births had crept up to 1.2 percent, and home-birth mothers included such luminaries as Maryland Lt. Gov. Kathleen Kennedy Townsend, who had all four of her children at home. (Asked whether her midwives were certified or lay, her office did not respond.) Midwives' market share, in and out of hospitals, was up to 4 percent of all births—not counting underground midwives like Leslie and Pradier, who don't sign birth certificates.

Nevertheless, the American College of Obstetricians and Gynecologists (ACOG) continues to insist: “Labor and delivery, while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth. These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation.”

And culturally, birth-as-it-was-meant-to-be still gets a bad rap. Kenneth Branagh's latest film, Mary Shelley's Frankenstein, was typical in its depiction of 19th-century childbirth as a screaming bloody horror in which one or both participants died, as a midwife looked on uselessly. Jakob and Heinrich's views may not be as dated as they seem. In his introduction to the 1948 edition of The Hammer, one Rev. Montague Summers wrote approvingly, “One turns to it again and again with edification and interest.”

“Hospital delivery,” wrote cultural anthropologist Robbie Davis- Floyd in a 1993 issue of Mothering magazine, “represents a ritual reenactment of the technocratic model of reality upon which our society is based.”

This just about sums up Karen Carr's feelings about the matter, although the Baltimore sheet-metal worker would never use such highfalutin jargon. Fourteen years ago, she was all set to deliver her first child in a Baltimore hospital when her nurse-midwife noticed that the baby was coming out butt-first—a breech birth. According to hospital rules, her nurse-midwife had to surrender control to a doctor, who without further ado sliced her open like a Mayan ritual sacrifice and took the girl out by C-section.

“I was in no position to debate it,” says Carr, 38. But she felt violated and powerless, and vowed never again to give birth in a hospital. Carr's second child was born in the bathroom on the second floor of her North Baltimore row house.

The experience was so powerful that it launched her on a second career. When not installing ductwork, Carr delivers babies as a lay midwife in training and a sometime assist ant to Pradier, as she was at the birth of Shannen Clemmons-McKay. A single mother, Carr has been assisting at births for more than two years. After 99 births, she is only now beginning to take on her own cases. She keeps an eye on the phone as we talk; one of her clients is on the verge of labor.

Carr remembers the way Shannen's shoulders wedged behind her mother's pubic bone. This is a relatively common problem, best solved by working the baby's arm free; the shoulders usually then follow. They had better, because by the time shoulder dystocia develops, going to the hospital is not an option.

“When can you go to the hospital?” Carr asks. “The baby's head was out. You have five minutes. After that point, you're looking at the possibility of the baby having brain damage or even dying.”

Pradier didn't mean to break Shannen's arm, but obstetricians and midwives alike will sometimes intentionally break a clavicle or arm bone to get the baby out. “That arm's gonna heal a lot faster than a mom's broken heart,” says Judy Mentzer. A common but dubious tactic used by obstetricians is to stuff the baby's head back inside, then do a C-section.

The bigger the baby, the greater the risk of shoulder dystocia. Cynthia Morgan, a 30-year-old Air Force sergeant, was attempting to deliver a 13-pound fetus Dec. 19, 1994, when the same problem developed. But this time the midwife, Karen Hunter, couldn't get the baby out. For 20 minutes, only the baby's head protruded from the uterus while its shoulders remained stuck inside. Hunter finally told Johnny Morgan, the father, to call 911.

When the rescue squad arrived, the baby had emerged but was not breathing and registered no heartbeat, according to a statement of charges filed in Carroll County Circuit Court. It was rushed to Carroll County General Hospital, where attempts to revive it failed. It's not clear exactly when the child died. Cynthia Morgan told police that she felt it moving right before labor, and Hunter said she detected a heartbeat during the delivery.

But the Baltimore medical examiner decided that the child had died in utero up to a day earlier and, he wrote, “was in danger by the lack of professional medical care.” Morgan was almost a month past her due date; an obstetrician might have decided to induce labor.

Sgt. Gary Childs of the Carroll County sheriff's office recalls the autopsy as unusually grim. “It looked like [the baby's] head was crushed,” he says, “and it had begun to decompose. There was nothing wrong with this child. It never should have died. It stayed inside the mother longer than it should have.”

“I've been around death all my life,” says the longtime Baltimore city homicide detective. “This was different.”

In January, Hunter was arrested at her Baltimore County home and handcuffed in front of her children. She was charged with practicing midwifery without a license, misrepresentation, plus two counts of reckless endangerment. Other midwives protested the arrest, as did Cynthia and Johnny Morgan.

“As much as I have the grief....and even anger at the situation, I blame nobody,” Cynthia Morgan told the Baltimore Sun. “I know what happened. I was there.”

“These people develop a bond with these midwives,” Childs says. “If they say the midwife did something wrong, they're admitting it was their responsibility for having the midwife and they share the blame. They're going through a denial kind of thing right now.”

“The state isn't saying you can't have a baby at home,” Childs continues. “If you want to have a baby in a manger, that's fine. All the state is saying is that [the midwife] has to be registered.”

But that's not all the state is saying. By banning lay midwives like Pradier and Hunter, the Maryland Board of Nursing also restricts the options available to parents like Clemmons and McKay.

For them, the decision to use a lay midwife flowed out of a strong distaste for modern medicine. Initially, it seemed only slightly more dramatic than their decision to become vegetarians, or not to get married just yet, even though they've been together eight years. But it was also a function of financial circumstances. To follow the rules would have forced them to choose among options that they could scarcely afford.

Clemmons did visit Columbia Hospital for Women for her prenatal care, while continuing to consult with Pradier. When her doctor's advice began to conflict with what Pradier told her—the doctor insisted that she take phenobarbital, to prevent a resurgence of epilepsy—she stopped going to the hospital. Clemmons hadn't had a seizure in 15 years. “I came home and told John that I really hope [Pradier] can deliver this baby, because I don't want to go to the hospital,” she says. “I want Shannen to come on her own accord. I don't want people giving her drugs, or pulling her out with forceps or something.”

Shannen Clemmons-McKay is now a big, healthy four-months-old; she could easily pass for a year-old child. “She's in the 95th percentile [of size] for her age,” Clemmons says proudly. Whatever harm she may have suffered at the unlicensed hands of Judie Pradier is not evident. Her broken arm, now healed, vigorously clasps her mom's breast. When she's done eating, she regards a visitor with alert curiosity.

Clemmons and McKay paid Pradier a $1,000 “token,” and think of her as a friend. If Pradier didn't deceive them, one wonders, then why is she being prosecuted for misrepresentation?

“It's obvious,” says another midwife. “Judie and Karen were accounting for a major share of the [out-of-hospital] births in the Baltimore-Washington area.”

Another explanation might be that the midwives themselves inspired the crackdown by seeking greater visibility for their cause. “I think that the lay midwives are wanting to bring the whole thing to a head,” says Dorsey. “It was a decision they made, and it's not that we're doing anything differently.”

Some midwives have even sought confrontations with the state. Judy Mentzer, for example, signed Maryland birth certificates knowing full well that the Board of Nursing might take note—which it did. “We had asked her to cease and desist a number of times,” says Dorsey. The board even sent an investigator to Mentzer's Pennsylvania office, a woman who said she was thinking about having her second baby at home and wanted information.

Although she knew she was being investigated, Mentzer, 46, kept signing Maryland birth certificates. “I refused to go underground,” she says. “It's a state that doesn't want to know what is going on.” The way Mentzer figures it, if lay midwives don't sign birth certificates, then the state will have no statistics on lay midwifery. The more birth certificates that lay midwives sign, the more pressure on the state for formal recognition.

At Mentzer's trial last September, 60 midwives and supporters showed up outside the Carroll County courthouse in Westminster, Md. After Mentzer pleaded guilty, Judge Luke K. Burns Jr. responded by praising her work. “Obviously, you've been very successful with what you've done in Pennsylvania,” he told her, sentencing her to the lenient 100 hours of community service, which she served by counseling pregnant migrant workers. “The presence of this many individuals attests to their faith in your work.”

It helps, of course, that Mentzer is based just across the Pennsylvania state line, where midwifery is tolerated. Her Maryland probation has not affected her practice at all, she says.

“The women are coming up here in droves.”

Art accompanying story in the printed newspaper is not available in this archive: Darrow Montgomery.

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