When 33- year-old Kimberly Bonsignore learned in late March that her family members would not be able to join her at NYU Hospital during her labor and delivery, she began making plans for a home birth. Pregnant with her second child, she didn’t want to leave her husband, Al, and two-year-old daughter, Sativa, out of the experience.

“I wanted my daughter to be there, too, because I want her to really experience it,” says Bonsignore. “I didn’t want to come home and say, ‘here’s your sister,’ like she’s a puppy or something.”

After the New York-Presbyterian and Mt. Sinai Hospital networks banned all visitors from labor and delivery rooms in an effort to prevent the spread of COVID-19, midwives across the city received a surge of phone calls. Not wanting to give birth alone, many women searched for an alternative.

New York Governor Andrew Cuomo has since issued an executive order allowing one support person to be present in the delivery room as long as they are screened for COVID-19. However, the prospect of giving birth in hospitals filled with coronavirus patients has driven up the demand for home births—a practice that is relatively uncommon in the United States, but has been steadily rising in popularity in the last 16 years. According to the National Center of Biotechnology Information, a unit of the National Institutes of Health (NIH), home births accounted for more than 62,000 births, 1.61 percent of total in the U.S. in 2017. Certified nurse midwives attend about 10 percent of all births in the U.S., in the hospital or at home, though their role in patient care varies from state to state.

Women seek home births with a licensed provider—which can include a midwife or doula—for a variety of reasons: They want less medical intervention, such as pain medication and labor induction; they want the freedom to control their birthing environment; they feel a midwife would be more respectful of their religious values; or they feel dissatisfied with the hospital system. (Here's why giving birth in U.S. is surprisingly deadly—especially for black mothers.) 

Midwives generally take a different approach to hospitals. Instead of taking the lead and telling a woman when to push like a doctor might, they believe in letting a woman take the initiative herself.

“When we do birth at home we like to support something that’s called ‘physiologic birth,’” says Muhlhahn. “We tend to believe that in almost all cases births can proceed on their own if we support the woman, encourage her, do the best we can to provide pain relief, let her know that we are by her side, and [occasionally] give her guidance.”

Around noon on April 29, Clarke texted Muhlhahn, informing her that Bonsignore’s contractions had begun. Muhlhahn gathered her equipment and drove to Bonsignore’s block to stand by until the contractions intensified.

“I do that because I live under the fear of someone calling me too late when things advance really quickly,” she says. “Angi was communicating with me the whole time I was in the car across the street. She was telling me how far apart the contractions were and she took the lead in terms of knowing when to bring me in, which is often a role that doulas can play.”

Because she was at home, Bonsignore was able to move around freely. She took a shower while Clarke started filled the birthing pool using a hose connected to the sink. But after Bonsignore’s shower, they ran out of hot water and Clarke had to finish by heating water on the stove.

“I was able to do what I wanted,” Bonsignore remembers. “I got in the shower and the heat felt so good. And then when I got out I was able to walk around when I wanted, sit down if I wanted to. Stretch a little bit. When I got tired I was like, ‘I wanna lay down.’ When I laid down, Angi was massaging me. She was hitting the pressure points… Ten minutes after I laid down my water broke.”

A few minutes after Bonsignore’s water broke, at 5:27 p.m., Muhlhahn arrived at the front door, with her bags in tow and wearing a face mask.

“The first thing I do when I go in to a woman in labor is sit by her, greet [her] in the way that is appropriate, make her feel comfortable. I wait until the contraction is over and tell her I’m here. The first task is [to] listen to the baby’s heartbeat,” says Muhlhahn. “We listen right after the water breaks, and we like to know the color of the water breaking. Angi said it was clear, which is a sign that the baby is in [good] condition.”

For the next hour, contractions came and went. Bonsignore eventually climbed into the pool of warm water to help ease the pain. When she was too uncomfortable to lay on her back, she turned around to lean over the side of the pool. Muhlhahn checked the baby’s heartbeat every 30 minutes. At 6:32 p.m., Muhlhahn determined that Kimberly was fully dilated and could begin pushing.

A moment of uncertainty

“She said, ‘Just listen to your body. Whatever you feel, just do it,’” Bonsignore recalls. “Cara kept telling me, ‘You’re made for this. You can do this.’ I didn’t think I was gonna make it. It was so painful. It was the worst pain I’ve ever experienced in my life. But it was pretty fast and I didn’t have to deal with it for so long. And her encouragement helped me. Her guiding me and telling me, ‘She’s almost there. She’s right here. You can’t give up. She’s right here.’”

When Muhlhahn saw the baby’s head crowning, she used her finger to check if the umbilical cord had draped around the neck—a common occurrence that does not harm the baby while inside the uterus.

“When there is a cord around the neck, which happens approximately 40 percent of the time, we don’t consider it a high-risk situation but we do try a few maneuvers to make sure that this doesn’t hold back the birth of the rest of the body,” says Muhlhahn.

Managing the cord is a crucial task. “Once you cut the cord, you’ve cut off another lifeline that the baby has. It protects the baby’s brain from a lack of oxygen,” Muhlhahn explains. She considered three options: lift the cord from the baby’s shoulders and over the head; cut and clamp the cord in utero; or unwrap the cord simultaneously as the baby is delivered. Because the cord wasn’t loose enough to lift over the baby’s head, Muhlhahn decided on the last option.

At 6:46 p.m., surrounded by family in her living room, Bonsignore gave one final push. But there was no crying. The baby was limp and unresponsive. Removing her face mask, Muhlhahn immediately began CPR and started chest compressions with her thumbs. The room was silent aside from her measured breaths and the Grateful Dead’s “I Need a Miracle” quietly playing in the background.

Moments later, Suzette Indica Bonsignore took her first breath and let out a cry. “Talk to her,” Muhlhahn told the parents, passing the baby to Al. “Mom and Dad are here. We need you with us. You [have a] sister you gotta meet,” Bonsignore’s husband recalls saying.

At 7 p.m., minutes after the baby was born, the sound of New Yorkers clapping for first responders drifted through the window—as if the city were welcoming baby Suzette into the world, says Bonsignore. “The timing was impeccable, it couldn’t have been better!”

Despite the scare, Bonsignore’s husband found the birth experience “exhilarating.” “It’s so much more organic than when you’re in a hospital,” he says.

After the birth, Muhlhahn listened to the baby’s heart and lungs, gave her vitamin K shots, and weighed her in a sling scale as her mom and grandparents looked on. Suzette weighed in at 8 pounds, 6 ounces, and was 20.25 inches long. With the hard work done, Muhlhahn scheduled follow-up meetings with Bonsignore to check in on mom and baby.

Kimberly Bonsignore said that she didn’t realize how serious the moment of uncertainty had been. Or how crucial experienced providers are in an emergency situation. “When we spoke of it later, I cried and got really emotional. It’s more traumatic now than in the moment,” she remembers. “Every day we talk about it. We look at her and she’s such a beautiful, healthy girl. It’s so crazy it could have went either way.”