The car service driver was right. We know that now.
“No,” he’d said, when he pulled in front of our Brooklyn apartment building in the predawn dark of late August 2016 and found me on the sidewalk on hands and knees, lowing in labor. “No-no-no-no-no. You need an ambulance. Not a cab.”
My husband, Jason, tried to reason. “Please, sir. She’s just having a contraction. This is a natural part of the childbirth process!”
Even through the contraction, a sensation like a fire hose blasting from sternum to thighs, I found this both charming and hilarious.
“She’s not going to have a baby in your car,” Jason added, in the indulgent tone one might use to tell a child there aren’t monsters under the bed.
My contraction passed. “I’m OK!” I exclaimed. I stood, brushed my knees. I might have given light jazz hands. “It was just a contraction! I’m not going to have a baby in your car.”
We believed it.
The driver let our certainty override his. He reluctantly opened a back door. I walked the few steps to the cab, then found myself sliding across the seat like a runner stealing second as another contraction came on.
A few hours later, after giving birth in the car’s back seat, there was paperwork to do. In my bed at New York Methodist, my daughter’s buttery newborn skin against my chest, I tabbed through papers in a blue folder embossed with the hospital’s logo: birth certificate and social security forms, lactation support resources, a brochure asking, helpfully, “Can Your Baby Hear You?”
One line on an insurance printout caught my eye. PLACE OF BIRTH: EXTRAMURAL.
Extramural? The other time I’d encountered the word was in sixth grade, when my teacher explained the Latinate adjective for after-school kickball and volleyball. Intramural: inside the walls. Extramural: outside the walls.
In obstetrical, midwifery, and public health scholarship, “extramural” can describe any birth outside a childbirth facility. More often, it means a birth both outside an intended, sanctioned location and without the supervision of a skilled birth attendant. A planned home birth with a certified nurse-midwife is not an extramural birth. A birth at a Chik-fil-A is.
Even though roughly 98.9 percent of all births in the United States take place in a hospital or birth center—78 percent globally, and as low as 56 percent for the world’s least developed countries—it seems almost everyone knows somebody who gave birth unexpectedly elsewhere. In the most recent CDC data, from 2017, only 3,273 births in the US—0.08 percent—indicated place of delivery as, simply, “Other.” Nonetheless, once you have an extramural birth, other stories find you. Oh, I have a cousin! someone will say. I have a friend. Often, these stories are accompanied by an “almost”—or, “I gave birth right after we got to the hospital”—but sometimes they’re true extramurals. And despite their rarity, or maybe because of it, there are “Woman Gives Birth in Unusual Location” headlines a few times a month:
There’s Amélia of central Mozambique—no last name yet published—who climbed a mango tree with her two-year-old when floods from Cyclone Idai ripped through her village this March. She birthed in the limbs above the waters, and the little family clung to branches for two days before neighbors rescued them.
There’s Tia Freeman of Nashville, who, after realizing she was in labor in an Istanbul airport last year, checked into her hotel and delivered her baby on her own using YouTube and Wikihow (in addition to a bathtub, a pocket knife, shoelaces, and an electric kettle). She brought the baby to the airport the next day, where she was questioned and examined on suspicions of child trafficking.
There’s Inés Ramírez Pérez of Oaxaca, Mexico, who, eight hours from the nearest hospital and afraid that she was about to lose her child in labor, as had happened once before, drank three small glasses of hard liquor, then used a kitchen knife to cut open her abdomen in a self-inflicted Caesarean. Both she and her son, Orlando, survived.
“The place that I feel the closest to God is in the ocean. I knew that I wanted to have my children there.”
The stories that intrigue me most are the ones in which I can see fingerprints of the mother’s agency, as in Freeman’s and Pérez’s. For Pérez, as for many pregnant people without access to safe, affordable health care, clearly her decision was driven by desperation born of this absence. But I’ve learned that, on the other end of the spectrum, there are “free births”—essentially, elective extramural births by women who opt out of the medical and midwifery paradigm of pregnancy. A 2006 documentary about free-birthing shows women laboring and bearing their children in the shallow lagoons of the Black Sea. A 2013 YouTube video of a woman delivering her own baby in a stream has nearly 80 million views.
I spoke to one woman who has free-birthed six times—four at home, one on the beach, and one in the ocean. Chèrie Ward Suters, of Palm Harbor, Florida, is a former firefighter who homeschools her children and runs an assisted living facility with her husband. Suters says she knew when she was ten years old that she wanted no part of a hospital birth. “We had to get permission slips to see the sex-ed videos, and see how babies were born, and I watched the birth video [of delivery in a hospital],” she says. “I just felt so strongly like that was not natural.”
When Suters, now 35, was pregnant with her third child, she’d seen a YouTube video of a woman giving birth in the ocean. “Delivering out in nature,” she said. “For me, the place that I feel the closest to God, and just that supernatural feeling, would be in the ocean. I knew that I wanted to have my children there.”
The elements weren’t in her favor for the third birth—bacteria count in the water, rumored predators. She found an area that felt safe for her fourth birth, but the timing didn’t work out due to a storm and flooding, and after laboring on a beach on the West coast of Florida, she delivered baby Kierra at home. But with her fifth child, she got her ocean birth: off Anclote Key, under a bright, full moon, beside a boat called Water Baby. Most of her children slept through the birth in a nearby tent, but her older son, Kaiden, stood next to Suters in the water and witnessed the birth of his sister, Kaleigha Pearl Oceana. Suters’s husband took pictures. It was magical, she said. The worst part was the mosquitoes.
When discussing births like Amélia’s, and Freeman’s, and Suters’s, and mine, researchers of public health, midwifery, and obstetrics gravitate toward a host of more precise terms: unplanned deliveries; emergency or unplanned or unattended or accidental out-of-hospital births; or BBAs—born-before-arrivals. The variety is due, perhaps, to the motley range of births they attempt to describe and name.
For this reason, I like extramurals: the way it encompasses all of these but eschews exclamatory danger; how its echoes of extracurricular play allow that, just maybe, there’s something in these births a woman might elect, or even enjoy.
Our extramural birth was an utter surprise, but also felt inevitable.
“Call the second you think you’re in labor with your next one, or your doorman’s gonna deliver that baby,” a nurse had told me hours after I delivered our first child, my son, in 2012. That labor had begun gently, around seven in the evening, but when I arrived at the hospital, about five hours later, I was already at 10 centimeters.
This is the official story. The unofficial story would include that for the better part of the day before my son was born, I’d had what’s known as Braxton-Hicks contractions—false labor. My stomach tensed, then released, on and off, all day—painless, but attention-grabbing and exhausting.
My new midwife listened to the story of my first birth at our first appointment. “Remind me,” she said, “to tell you what to do if the baby’s born in the cab.”
As we moved into the ninth month of my second pregnancy, I had marching orders: to call my midwife practice the moment I thought I was in labor.
Everyone says second-time moms don't get fooled by Braxton-Hicks contractions, but when you’re told to call as soon as labor begins so you don’t give birth in a car, it’s perhaps particularly difficult to dismiss one’s stomach seizing every five minutes.
“Can we give you a midwifery secret?” offered Eline Skirnisdottir Vik and Gunn Terese Haukeland, both certified nurse midwives, one a student and the other a professor at Western Norway University of Applied Sciences, when I told them this part of my story. “We think it’s difficult as well. The same thing is happening in each. The only difference between Braxton-Hicks and real contractions is, is it making you give birth or not?” Haukeland had an extramural birth herself in 2008—an unexpected home birth, 45 minutes from the nearest delivery unit in Norway. “I thought, OK, how can I not recognize all the symptoms? How can this happen to me?” she said.
During my second pregnancy, it felt like I might be in labor for most of August. I got faked out only once, two weeks before my daughter was born—I headed to my midwife’s office to be told not yet.
My new midwife listened to the story of my first birth at our first appointment. “Remind me,” she said, “to tell you what to do if the baby’s born in the cab.”
But the signs of impending labor began to accumulate, and my husband and I went into higher alert. Thursday, August 25, I had my 38-week appointment: 50 percent effaced, 3.5 centimeters dilated, and “soft like butter.”
“Probably this weekend,” my midwife said. Friday, I lost my mucus plug—a sign that showtime is imminent.
Saturday, I woke around 5:45 a.m., with those light contractions starting again, quietly on and off for the day. We went to dinner with friends who were expecting their first child. “Wait, you're having contractions right now?” they asked in horror. “Yeah, but it’s not a big deal,” I said.
Sunday I woke, again at 5:45 a.m., with the same light contractions. I continued to try to ignore them—utterly painless still—but finally I buckled and called the midwife answering service. “Look,” I said, “I know this doesn't feel like the thing that led to my baby happening last time, but I’ve been given this don’t-have-your-baby-in-a-cab speech a couple of times, and I lost my plug Friday, and they just moved to two minutes apart.”
The midwife on call had me come to the hospital. My contractions stopped en route. In L&D, my midwife, who had just come on shift, told me I could go home. “It’ll probably happen today. You’re the ones I’m supposed to tell what to do if you have a baby in a cab, right?”
I braced myself to memorize details: turning the head, clearing the airway, cutting the umbilical cord.
“It’s simple,” she said. “Three steps: one, catch her—don’t drop the baby. Next, dry her off. Then, keep her warm. Wrap her in a clean towel or blanket, and hold her to you.”
"That’s it?" we said.
"That’s it,” she said. “Then just make your way here.” She gave me her direct cell number and said to keep in touch.
Our son was with neighbors, and we texted an update; they were happy to keep him for the day, to give us space. I went for a walk in the park, hoping to get things moving. The contractions started up again, seemed to get stronger, then died out. They began again a few hours later, strong enough now to at least pause my stride. I called my midwife. She told me to shower and call her back. “I already showered,” I pouted to my husband. I got in the shower. They stopped.
“Call me when you’re five minutes apart,” my midwife said this time.
I cried a little, in frustration and exhaustion. Jason put on a Jane Austen movie for me. I fell asleep. Later we went for a walk, got ice cream. Nothing happened all evening. We collected our son from our neighbors and went to bed.
When I researched extramural births, I saw the same risk factors repeated in study after study: long travel time to birthing unit, multiparity, poor prenatal care, lower educational levels, unemployment, drug use, lack of health insurance. But nowhere in these statistics did I see my story. Why had this happened, even though everyone involved was actively planning against it? Could I have done something to prevent this? Should I have?
With the exception of free-birthing advocates, almost everyone agrees that extramural births are to be prevented if at all possible. But in what’s sometimes called “the turf wars” around birth—midwives vs. doctors, home births vs. hospital births, birth as a natural vs. medical act, mother-focused vs. baby-focused care—there are many competing studies with even more competing biases and goals. And since extramural births are, by their nature, harder to track and research, it’s difficult to state the risks with certainty.
Nonetheless, most studies show a profoundly increased risk to the baby, with chances of infant mortality between six and ten times higher than for in-hospital births, due primarily to hypothermia (dangerously low body temperature). Babies born extramurally are also prone to longer NICU stays, though this finding, like the mortality statistics, is muddied by the fact that such babies are more likely to be premature and of low birth weight.
Data on the risks to mothers is harder to come by. Some studies find an increased risk of severe tearing and postpartum uterine hemorrhage, of eclampsia, of a condition called HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count). But others report no significant difference in outcomes between in-hospital births and unplanned BBAs. In addition, certain outcomes are better for women who give birth extramurally: far fewer C-sections, far fewer episiotomies.
“Three steps: one, catch her—don’t drop the baby. Next, dry her off. Then, keep her warm. Wrap her in a clean towel or blanket, and hold her to you.”
These findings focus on physical outcomes, but what of the emotional? Mainstream discussion of birth safety in the United States has begun to acknowledge both the physical and emotional trauma that many women, particularly women of color, experience in hospital settings. Women are coming forward with stories of being ignored, bullied, coerced, and cut against their consent in hospital births; a reported 9 percent of women experience postpartum PTSD as a result of their birthing experiences. How, then, do extramural births affect mothers psychologically?
One study on extramural births, published in 2011, gestures at this concern. In “No fixed place of birth: Unplanned BBAs in Victoria, Australia,” authors Gayle McLelland, Lisa McKenna, and Frank Archer summarize, “The experience of unplanned BBA has also been shown to have some psychological effects on the mother but this needs further exploration.” This sounds like an allusion to trauma, but the cited study, “Mind you, there’s no anaesthetist on the road: women’s experiences of labouring en-route,” reveals the opposite can be true: in their interviews of women in rural Australia—where not a small number of drivers dodge kangaroos on the road to the hospital—the study’s authors report that one woman “found birthing en route to be a much more empowering experience than giving birth in a well-equipped hospital with an epidural in situ.” They don’t analyze why this might be, and hasten to add that the mother’s “resilience and resourcefulness should never be excuses for allowing a situation [of inadequate local childbirth facilities] to remain unchallenged.” In another, similar Norwegian study, women found their extramural births “dramatic, but at some point fear of giving birth alone was replaced by feelings of coping, and in hindsight they felt empowered.”
In their interviews with women who experienced BBA, Vik and Haukeland uncovered two more causes of extramurals outside the usual medical risk factors. First, that women are nervous about being turned away from the hospital, often seeing midwives as gatekeepers. And second: “There is no standard to when a woman is in active labor, and this complicates everything.”
At 2 a.m. on Monday, August 29, a contraction woke me that told me, finally, my labor was real. Early, wholly bearable, but real. I quietly got out of bed, letting my husband sleep. I sat on a labor ball in our dining nook with the lights off. I looked at the city night out the window, breathed. It was a relief to labor in private, in the dark, to have the sense, finally, that it was happening this time. I timed the contractions on my phone. Six minutes. Ten minutes. Two minutes? Five, seven. I waited for the green-light pattern to emerge: regular contractions, growing closer together, increasing in intensity.
I moved to the bathroom for a while, but eventually my contractions slowed again: ten minutes, 13, 18. Frustrated, I decided to go back to bed, to try for sleep until things picked back up.
I lay down. Then I shot up.
I shook Jason. “We have to go,” I said.
“What? What happened?”
Something had turned on a dime, and the firehose was suddenly inside my body. I struggled to keep breathing. Jason tried to apply pressure to my back, as he’d learned in childbirth classes, but I batted him away. “Call Alan. Call the car. We have to go, NOW.”
He pulled on clothes, called the midwife, the car service, the sweet neighbor who’d offered to stay with our son. I explained between contractions where our linens were, pausing mid-sentence to half myself over an armchair.
I had five or six contractions during the walk from our second-floor apartment to the front of our building. Outside, I could barely stand. We waited for the car. I hugged a large postbox for support. When another contraction came, it felled me.
This, of course, is when our car pulled up.
After we negotiated entry, I rested my head on Jason’s lap and lay my body along the back seat. We drove away in the dark. In a moment of panic, Jason started arguing with the driver that he was going the wrong way. (He wasn’t. Also, this was very unlike Jason. Labor is stressful for everyone.) They started jabbering back and forth.
More than pain, I experience labor as a complete overwhelming of sensory input. Sound, light, movement, touch—everything outside me feels like too much to process. “Please just be quiet!” I pleaded.
The driver muttered under his breath.
Three blocks from our house, I felt another powerful contraction.
“Jason,” I said. “I think that’s the head.”
“Whoa, okay,” he said. “You can feel the head coming? Do you think you need to push soon?”
The driver started cursing.
“No,” I said. “I think the head just came out.”
It was between my just-parted legs, and against my thigh, slippery and smooth like an avocado pit.
Jason sprang to the other side of me, whipped off his shirt, and stretched it like a net between my now-open legs. I was wearing loose, soft-knit pajama shorts and cotton underwear, and the baby had just—bloop!—poked through one leg opening.
I had another contraction, and my daughter was born.
Jason says it was a matter of seconds until she started crying, but for me time was suspended for long, terror-filled minutes until she took her first breath.
He caught her. He dried her off with his T-shirt, wrapped her up, and handed her to me. I nuzzled her on my chest. She quieted immediately.
We stopped at an intersection. The red glow from the traffic light filled the car, reflected in the tears on Jason’s cheeks and, I presume, in mine. We shook our heads in disbelief. Our driver was crying, too, and laughing and thanking God.
Jason called our midwife again. “We’re on our way,” he said. “There’s going to be three of us.”
We drove along the empty, tree-lined streets of Brooklyn to the hospital. “We should call the news!” our driver, now giddy, said. “No,” I said, and held his eyes in the rearview mirror to make sure he knew I meant it. I knew what the next two days would be like. I could not imagine the hell of a local news team cramming into a hospital room while I bled into disposable underwear and tried to establish breastfeeding.
We reached the walk-in emergency entrance. My husband is a slender, kind-faced person—curly brown hair, glasses. Imagine him running, frantic, shirtless, covered to his elbows in blood through a nearly empty hospital. Once he found someone, he ran back out, hopped in the car, and directed us to the entrance marked “AMBULANCES ONLY.” Outside the entrance to the ambulance bay, at least a dozen people were waiting for us. They descended on the cab like a NASCAR pit crew.
A man from this crew opened my door, and I carefully handed the baby to him, so I could hold on with two hands to step out. I waited for him to move from the doorway. “I can’t go without you,” he said. “You’re still attached.” I’d forgotten the placenta was still inside me, the cord dangling from my shorts. And until then, high on hormones and focused on the baby, I’d been oblivious to the bloody puddle we’d been stewing in.
They helped me onto a gurney, then rested the baby on my chest. Medical personnel jumped into the back seat, started scrubbing. Jason handed the driver all the money in his wallet and thanked him. The driver was still laughing.
If I were to explain why my birth went the way it did, here is what I would say: that the telltale pattern of active labor—contractions in regular intervals, moving consistently to five minutes apart—never happened for me. That after so much warm-up, my body was ready to do the work quickly. That I knew each time I called, my midwife was listening for distress in my voice that I didn’t feel until 20 minutes before the baby was born. And that I didn’t want to be the girl who cried labor anymore—to my midwife, my husband, my neighbors, myself.
In the weeks and months after our daughter’s birth, we were asked to tell our story so many times that my four-year-old, who wasn’t there, could recite the lines as if from a script. As my husband and I tell it, our birth story is an entertaining, can-you-believe-it tale, with twists and a happy ending. But two responses from our listeners surprised me after each telling.
One, I was receiving praise that didn’t feel earned. I recall the findings on the mental effects of extramural births on women: empowering, empowered. I did feel empowered. Jason did, too. I birthed that baby, he caught her—we’d done it all by ourselves, and honestly, it had been great. In contrast to the days following my son’s birth, I felt very little pain (though I did have a deep tear, called a sulcus tear, which required extensive stitches), and I felt calm and happy. Instead of the flashbacks of delivery terror I’d experienced both waking and asleep for weeks after my son’s birth, I had a warm, wonderful memory.
But I didn’t feel self-congratulatory, or even particularly brave, a word that people kept using. I knew I was in the possession of a killer story—and it is a truth universally acknowledged that a woman in possession of a birth story must be in want of an eager listener. But I didn’t see myself as the hero. As I said in an email to a friend, “the birth … is probably the most interesting thing that happened to me.” I remember pausing over that passive construction, poking it for the truth, and letting it stand.
Emilee Saldaya, founder of the Free Birth Society, isn’t confused about this listener response. “It’s a fascinating example of the deep, deep, deep misogyny in our culture around birth,” she told me. “When a woman unintentionally births without a midwife or a doctor present, she’s revered as brave, and amazing, and a hero, and her story is lifted in her community and in media. You’re still a ‘good girl.’ Something crazy just happened to you; it's not your fault.
“But the second it’s clear that a woman chose to be her own self-authority and to exercise her own maternal, and legal, and human right to birth without the presence of a medical team, you are immediately dangerously labeled a dissenter, an irresponsible, stupid woman who put her baby at risk.”
I did not expect Saldaya, who supports women who conduct their pregnancies and labors outside the medical paradigm, to be the one to articulate with precision my unease about the praise I received for my birth. I also didn’t expect to recognize so much of my own story as she spoke about her experiences supporting birthing women both in and outside of sanctioned settings, about the violence and dismissiveness she no longer wanted to be part of.
Saldaya came under attack last fall when one woman, a member of the since-deleted Free Birth Society Facebook group, gave birth to a stillborn baby, Journey Moon, after six days of labor. Throughout labor, the mother had been encouraged by members of the group, Saldaya included, to trust the process.
As much as I feared exactly what wound up happening, my daughter’s birth felt like anything but a worst-case scenario.
I’d considered a home birth for my second, but after my nephew was born in 2015 with a rare, undetected heart defect that required immediate medical intervention to save his life, it steered me back to a hospital setting. In a free birth, what would happen to babies like my nephew, who would have died without immediate medical attention at birth?
“If you walk with women long enough, you will witness fetal death. You will witness stillbirth. You will witness a baby passing postpartum. It’s horrible. But it’s unavoidable.”
The World Health Organization states that 99 percent of maternal deaths are due to lack of access to the same care that free birth walks away from, and UNICEF cites that “stillbirth or death due to intrapartum-related complication can be reduced by about 20 percent with the presence of a skilled birth attendant.” There are, of course, a multitude of factors buffering someone in a developed country who opts out of care from the dangers faced by someone in a developing country who doesn’t have access in the first place. I can understand how some women, especially those who have experienced birth trauma, choose to turn their back on the whole system—choose a different, more empowered risk.
“No babies are allowed to die outside the hospital,” Saldaya continued. “When they die in the hospital, the narrative is, ‘Thank God we did everything we could.’ But if the baby dies outside the hospital, it’s, ‘You should be in jail, you fucking dissenter.’”
The other response to our birth story that surprised me was that, again and again, people teared up—even people I didn’t know that well. Curious, and also confused, I asked one friend why. “I think it lays bare just how close birth is to death,” she said.
Statistically, both my and my daughter’s chances of injury or death became much greater in the moment of her birth. But with the exception of the seconds where I’d waited to hear her cry, the experience was absolutely free of fear. Had adrenaline, and the fast pace of events, just not allowed room for it? Were the two of us ever truly in danger?
Atop my in-laws’ toilet tank is a small yellow book called The Worst-Case Scenario Survival Handbook. Pages 99 to 102 explain “How to Deliver a Baby in a Taxicab” in five steps, with a three-part infographic on supporting the baby’s head. It’s a bit more complicated than what my midwife told us, but the same gist.
The thing is, as much as I feared exactly what wound up happening, my daughter’s birth felt like anything but a worst-case scenario.
Knowing what I now know—that healthy, happy endings were in store for each child and for us—which would I choose? The on-paper perfect, quick birth of my first child, but with the agonizing 40-minute ride to the hospital in back labor, with the nurse who barked at me to get my shoes off the bed as I contracted at ten centimeters, when I screamed, when I breathed “wrong” during pushing—panicked, disorienting, terrifying?
Or the worst-case-scenario birth, with my husband, in the quiet dark back seat of a moving car: peaceful, intimate, miraculous?
It’s easy. I would choose the second. Every time.