The Business of Being Born: What Cameras Didn't Show

Interview with Cara Muhlhahn, CNM, and midwife featured in The Business of Being Born.

Why did you decide to become a midwife?

I knew from a very early age that I was destined for a medical profession. A series of events led to the decision, but the first birth I attended is what got me hooked. So much of what we do is helping women navigate their own process by giving them reflection and feedback about the normalcy of what’s going on from the outside—when they think they’re dying, splitting apart, falling into oblivion.

You started your career as a lay midwife in your early twenties. What made you decide to become a certified nurse-midwife?

When I was apprenticing for home birth I heard about a maternal death at home. I immediately thought, “I need to pay attention so I’m doing the safest thing.” I knew there was more education I could get. I also wanted legitimacy and legal protection. I didn’t want my entire career to be at risk in the event of an unavoidable bad outcome.

Did you ever consider becoming an ob/gyn?

When I went to college, everyone wanted me to be a physician because I was first in my premed science classes. I did consider becoming an ob/gyn for a while, but the one thing that held me back was that I did not want to do surgery. I was worried about becoming inured to the sacredness of the body and possible intervening unnecessarily in a natural process. Midwifery seems to be a better fit for me.

What made you choose to practice in a home setting?

I worked in a freestanding birth center for four years in New York. I loved the birth center, but I had to leave that setting in order to graduate to midwifery based on experientially honed clinical judgment call, rather than what I view as restrictive protocols. Adherence to institutional protocol can be a first step, an essential one for securing safe outcomes while working as a novice. Practicing at home allows me to make clinical birth plans based on the unique circumstances of each birthing woman’s labor and contributes to lessening the interventions that often make up the slippery slope of the descent into resolution by cesarean section.

How do you view your colleagues who practice midwifery in hospitals?

I’m not interested in promoting a division between home birth and hospital midwives. All midwives are making headway in the battle to bring the power of birth back to the woman—who is actually doing most of the work. If we legitimize home birth and hospital birth, people are going to naturally find their comfort level. Opponents of midwives will just use the old “divide and conquer” to keep us from our deserved triumph.

How did you get involved with The Business of Being Born?

Abby Epstein, the film director, approached me by telephone and said she was working with Ricki Lake. Synchronistically, a couple of weeks earlier, I said to one of my student midwives who had just gone to film school that we needed to make a film. Abby and I first met at a neighborhood café, Ciao for Now, and talked about the proposal. And I said “The film you are proposing is the one I wanted to make, but not being a filmmaker, I’d rather you do it.”

What was it like making the film?

It took us over two years. I created a persona that could completely tune out the cameras most of the time. If I hadn’t been able to do that, I can imagine things would have been quite difficult. Allowing the filmmakers into such an intimate personal and professional space was clearly an act of faith. At the end of it all, I can pretty much attest to Ricki and Abby´s adherence to portraying midwives as we would like to be seen.

How do you feel about how you are portrayed in the movie and what would you like to have changed?

First of all, I want to say that I’m very grateful for this film. However, it leaves some questions unanswered. One is that there is no clip of me listening to the baby’s heart beat in labor. I’m one of the stricter home birth midwives in terms of how closely I follow ACOG guidelines for intermittent fetal heart rate monitoring. It would have been better for the public to know that we do check on their babies when they’re in labor.

Abby ends up being one of your clients in the film, but it looks like she visits several care providers during the course of the movie. Were you Abby’s prenatal care provider?

I was not until very late in the game. I had two prenatal visits with her and another scheduled two or three days after she went into preterm labor at 35 ½ weeks. At 32 weeks, I knew the baby was breech.

The film ends with a lot of drama when Abby goes into preterm labor at home. What do you think about the transfer scene?

They don’t show all of the clips of me executing the decision to go. They don’t realize the drama in the lobby scene makes it look like I was not in charge of the transport. We were only at the house for about an hour, and Abby and I arrived at the hospital before the physician. I was in the operating room during the cesarean section at Abby´s head.

What do you envision as a positive future for midwifery?

The Business of Being Born can help initiate a necessary conversation between the birthing public and birth professionals. Here is an opportunity for an honest exploration and evaluation of what home birth midwives really do instead of reliance on the convenient and self serving projections of a suspicious and undereducated governing body. We need to make a stance and we need to make it strong. The women of this country desperately need midwives on their behalf to help them birth normally.

The Transfer Scene: What the Cameras don’t Show

If you’ve seen The Business of Being Born, you probably have some questions about the preterm labor and the cesarean section at the end. ACNM member Cara Muhlhahn, CNM, shares the details that didn’t make the final cut.


What do you think about how you are portrayed in the movie and what would you like to have changed?

First of all, I want to say that I’m very grateful for this film. I feel that midwives are portrayed in a very positive light. However, there are a few lapses that leave some questions unanswered. One is that there is no clip of me listening to the baby’s heart beat in labor. I’m one of the stricter home birth midwives in terms of how closely I follow ACOG guidelines for intermittent fetal heart rate monitoring. It would have been better for the public to know that we do check on their babies when they’re in labor.

Abby Epstein, the film director, ends up being one of your clients in the film. But it looks like she visits several care providers during the course of the movie. Were you Abby’s prenatal care provider?

Not until very late in the game. She was undecided about her choice of birth site and provider until after 28 weeks. Her early prenatal care was done by the physician in the film, Dr. Moritz. I had two prenatal visits with Abby and another scheduled two or three days after she went into preterm labor at 35 weeks. At 32 weeks, I knew the baby was breech.

Can you explain the events that led to your decision to do a transfer to the hospital?

The night Abby called me, she didn’t sound like she was in labor on the phone. She said that she might be having contractions, but she didn’t know. Since I live in the neighborhood, I decided to walk over and spend some time with her face to face. When I got there, I checked the baby. The baby was fine, but still breech. Abby was lounging in the tub, but I was watching her contract and saw that her affect had become less rational. When I examined her, she was already 3 – 4 centimeters. I also knew that Abby’s mother had a six hour labor with her first child, which meant that Abby was likely to progress quickly. So that’s when I said, “Let’s get this show on the road.”

The transfer scene seems pretty rushed. What are your thoughts on that scene?

Of course documentaries are edited for dramatic effect, which may be the source of my discomfort with how Abby´s labor transfer is portrayed. It appears that we were home for hours, which isn’t true. She had a precipitous labor for it being her first baby, which didn’t give us a lot of time. But they don’t show all of the clips of me executing the decision to go. They don’t realize the drama in the lobby scene makes it look like I was not in charge of the transport.

You and Abby take a taxi to the hospital. Why didn’t you call 911 instead?

911 is a slower transfer. It takes the ambulance an average of eight minutes to get to the house and a lot of important time can be lost just registering the patient to EMS. EMS would also take Abby to the hospital of their choosing, allowing institutional protocol to outvote my judgment call as an experienced midwife.

After Abby’s water breaks, you do not appear on camera during the rest of the transfer and cesarean section. Were you still with Abby?

Yes. Abby’s water broke in the driveway of the hospital. I examined her in the wheelchair on the elevator ride so that I could hold the head up in the event of a cord prolapse. (The baby ended up having the cord around his neck, which is why he didn’t turn vertex.) Abby and I arrived at the hospital before the physician. I was at Abby’s head in the operating room during the cesarean section.

Although Abby’s baby boy arrives safely, the physician says that Intrauterine Growth Restriction (IUGR) occurred. Do you want to talk about that?

In the film it appears like the baby was starving, everybody missed it, and the doctor saved the day. But the situation was misconstrued because of a critical detail that was lost during the emergency transfer. The physician who received the transfer was under the impression that the baby was 40 weeks. Abby’s baby was actually born at 35 ½ weeks. A 3 lbs, 5 ounces baby at 40 weeks would have been much more serious than at 35 ½ weeks.

Cara Muhlhahn's Home Birth Stats:

Years of CNM Experience: 18

Years in Homebirth: 16

Number of Births Attended: ~800

Transfer Rate: 9%

C-section Rate: 3.5%