The battle over birth

By Sophie Elmhirst

When Lacey discovered she was pregnant with her first baby, she excitedly went to see the GP. The event felt ceremonial, the first of many meaningful encounters that she expected to have on her way to giving birth. The doctor, whom Lacey had never met before, didn’t congratulate her. She explained that Lacey, a 35-year-old life coach in London, would hop onto a conveyor belt that would take her from appointment to appointment. At each one she would be told exactly what to do and she’d end up with a baby. It would all be very straightforward. The doctor thought she was reassuring her. But this was the exact opposite of what Lacey wanted to hear. Having a baby, she thought, was the most extraordinary, ordinary thing a woman could do.

Perhaps the midwives would be more engaged. Yet at Lacey’s first hospital appointment the midwife was kind but impersonal. Lacey was told that, like every other expectant mother, she would have scans at 12 and 20 weeks, and blood tests to determine the risk of various fetal conditions, including Down’s Syndrome. Lacey recoiled at this blanket approach; she wanted to be treated like an individual. She wasn’t convinced by the rationale behind all these tests, and didn’t believe that ultrasound was safe (it poses no known risks to either baby or mother, according to the available evidence).

So Lacey decided to skip the scans and the blood tests. She and Flynn, her partner, transferred to a new hospital in east London when they moved flat, and registered with the home-birth team. They met another midwife, who questioned Lacey’s decision not to have any scans. She might have placenta praevia, a potentially dangerous condition that occurs when the placenta covers the cervix. When Flynn asked the midwife what the likelihood of this was, the midwife conceded it was slim (the condition affects one in 200 women by the end of pregnancy). Still, wasn’t it better to be on the safe side?

Lacey couldn’t understand why the midwife was trying to frighten her. Birth wasn’t an illness. She sensed that the midwife’s attitude came from a wish to eliminate risks and cover her back in case something went wrong. Lacey left the meeting in tears, upset by yet another encounter in which she felt that her instincts about childbirth had been doubted. Her last attempt to engage with professionals was during a home visit from a third midwife. Lacey made tea and thought that the intimacy of being in their living room might help. But the midwife was brusque and stressed.

By the end of her pregnancy Lacey knew she’d become the “difficult” mother-to-be on some warning list at the hospital. She received a call from a fourth midwife, telling her that she was endangering both her own life and that of her unborn child. Lacey said that she wasn’t going to be scared into complying. The only person who seemed to tolerate Lacey’s decision, if not actively support it, was the head of the home-birth team, who told Lacey that, within the scope of her job, she’d help her however she could.

Lacey decided to “free-birth”: to have the baby entirely outside the medical system. For women in parts of the world with minimal health care, free-birthing can be the only option. But in rich countries with ample medical support, only a tiny number choose this path each year. In America an advocacy group called the Free Birth Society has an increasingly active international network of adherents and “radical birth keepers”, as the society calls people who assist women giving birth. The precise number of free-births that occur every year is hard to estimate, though it seems to be growing. Of the 650,000 women who had children in Britain in 2018, 97% gave birth in an NHS establishment, either in a labour ward or in a birthing centre, and 2% gave birth at home. The remaining 1% gave birth in “non-NHS establishments”, which includes births in private hospitals as well as free-births. NHS England reckons that up to 200 women free-birth each year in London alone.

Lacey wasn’t familiar with the term “free-birthing” and discovered the movement only after the event. She is not a militant or dogmatic person, as some might assume of those who shun more established paths. She had come to free-birthing by inclination but she wasn’t taking lightly the decision to abandon the medical system. If something went wrong, she’d go to hospital. But she wanted to take responsibility for her baby’s life and her own, and wasn’t willing to entrust her birth to a system that she didn’t entirely believe in.

After she stopped attending appointments, she’d sometimes worry that she was being reckless. But then she’d check herself. Her baby was moving all the time, the medically accepted indicator that all was well. Caution can be a virtue. But why manufacture fear when it isn’t needed?

At 41 weeks, Lacey’s baby was full term. If she had been under the care of a hospital midwifery unit, Lacey would have been checking in with the midwife again. After a week, if she hadn’t given birth, she would have been induced. Instead, after a Thai meal one Friday evening, Lacey went into labour. Her friend Claire came over to help and take turns with Flynn keeping Lacey company through the night. After two days of visceral, womb-wrenching contractions and a mounting pressure in her back that made her bum feel like it was about to explode, she retreated to the bathroom.

There she felt a force take over her body, something emerging from within her but which was far greater than her. She knew she simply had to get out of her baby’s way and, after a series of giant contractions, in a great whoosh and with a deep roar, she gave birth to a baby girl while standing astride the toilet. Only Flynn was in the room and he helped catch the baby who was slippery as a fish and nearly fell into the toilet bowl. They both laughed and laughed and the baby gave a massive cry. After a couple of hours, Flynn cut the cord. A little later, Lacey gave birth to the placenta, which they put on a covered dish in the fridge (it’s still in their freezer, waiting to be planted on a piece of land that they hope one day to own). Then Lacey and Flynn and the baby sat in the living room together, marvelling.

Birth becomes a story the moment it’s over. New parents recount the event to each other, in disbelief, even as they hold their newborn. They tell it to their friends and families, who troop round for tea, cake and gawping. And they tell it to their kids, because what child doesn’t like hearing the story of how she came into the world? My brother, sisters and I all know the shorthand version of our arrivals: breech, fast, Paris, cold.

But in recent years, birth has also become a battleground. At its most polarised, the debate falls crudely into two halves: the natural-birth proselytisers versus the give-me-all-the-drugs brigade. On the internet, where judgments thrive, every choice feels loaded. On any birth-themed Facebook group or Mumsnet thread the atmosphere comes close to ignition. Women either tiptoe around each other to avoid offence or let rip with hostility. There is usually broad support for a woman’s right to choose, but beneath the veneer of sisterhood, there is no escaping the unpleasant, nagging question: whose side are you on?

In “The Politics of the Body”, Alison Phipps, a professor of gender studies at the University of Sussex, argues that the conflict around birth mirrors feminism’s own journey. In the early 20th century, first-wave feminists fought for pain relief in childbirth “to free women from the dominion of biology and the tyranny of their reproductive capacities”. The second wave, from the 1950s, turned against medical intervention, arguing that it was just another way for the patriarchy to control women’s bodies. For this group, “natural” childbirth is the purest expression of a woman’s unique power (although, ironically, it is also in keeping with many ultra-conservative and religious expectations about birth).

The differing views over how to give birth are a precursor to all that awaits you in motherhood. Do you breastfeed or bottle-feed? Use cloth or disposable nappies? Send your toddler to full-time day care or become a stay-at-home mum? Allow or forbid screens? And so it goes on. A morally competitive undertone can be detected in almost every decision to do with child-rearing. But that such toxicity creeps into preparations for birth seems strange, given that it is, by definition, an uncontrollable event that tends to unfold on its own terms. Women often report feelings of trauma after birth, because of unwanted or invasive interventions. But there are also women who suffer intense disappointment that they have not achieved the natural birth they wanted or felt they ought to have.

These anxieties have a historical dimension. Over the course of the 20th century birth rapidly became medicalised. Hospital births in England and Wales rose from 15% of all deliveries in 1927 to 98.8% by 1980. During this period birth became dramatically safer: in 1935, the maternal mortality rate in England and Wales was between 400 and 500 per 100,000 births, compared with seven in 100,000 in the UK now. Yet as birth has become safer, angst about how to do it has increased. In the 1950s the expectation that you would give birth in a hospital bed provoked resistance. The Natural Childbirth Trust, founded in Britain in 1956, was created to promote women’s right to labour in their own way (it was later renamed the National Childbirth Trust, and its courses are still attended by thousands of expectant parents today). From the 1980s onwards, the ideal of a labour without intervention was further redefined as a “normal birth”. In an illustration of how fraught the topic has become, the Royal College of Midwives in Britain abandoned its “Campaign for Normal Birth” in 2017 and now talks about “physiological births” instead.

Today there are broadly four different scenarios in which you may give birth: at home, in a birth centre, in a labour ward or in an operating theatre (for emergency or elective caesareans). In Britain birth centres are midwife-led maternity units, often attached to hospitals. You can give birth in water there, for example, but there are limited options for pain relief or immediate intervention by a doctor. In a labour ward you can receive stronger pain relief, such as an epidural, and obstetricians stand by to help when needed (in Britain, unlike America, it is not the norm to have a doctor present at a birth). Of all the hospital births that occurred in Britain last year, over half were “spontaneous” vaginal deliveries (a fantastically euphemistic term for anyone who has laboured). Of the rest, 11% required instrumental assistance, either forceps or a ventouse (a suction device), 13% were elective caesareans and 16% were emergency caesareans.

There’s an expression: you birth how you live. Since the 1990s pregnant women have been encouraged to write a birth plan, spelling out their vision for how they want the event to unfold. The conformist rides out the conveyor belt and hopes for the best; the super-organiser wants a fixed-date operation. Birth has become yet another way to exhibit your identity and values. The textbook birth, ideal for the system and perhaps for the mother too, might be the birth-centre version: a suck of gas and air, only a midwife present, a hop in the pool, a sub-12-hour labour and an intervention-free delivery. Supposedly, in this age of free choice, there is no judgment about how you choose to give birth. But everyone knows that’s bullshit.

The planning often ends up being academic: the vision of a water birth accompanied by a looping soundtrack of birdsong can turn into a rush from labour ward to operating theatre for an emergency caesarean. Many of us, in any case, muddle along somewhere in the middle, uncommitted to any tribe. I never wrote a birth plan. First time round, I started in the birth centre hoping to try out the pool. (It was like going to a theme park: I wanted to have a go on everything.) Within 24 hours I was clamouring for a C-section in the labour ward until a passing obstetrician persuaded me to keep going. Eventually I gave birth with copious drugs coursing through my grateful veins. I left hospital happy, yet with a creeping sense that perhaps I hadn’t been quite brave enough or given my newborn the purest start in life.

The second time it happened so fast I didn’t have time for the pain relief I craved and almost gave birth on the pavement outside the hospital. Technically, it was a “natural”, “normal”, “physiological” birth, but I’ve planned sandwich fillings with more consideration. Maybe I was being judgmental in my own way, questioning those who do have a clear vision for their birth. But equally, perhaps I was just birthing how I live. It just so happens that I think life is a crapshoot.

In the warm spring of 2020, as the world shut down, Lacey was pregnant again, counting down the weeks to the birth of her second child. She wasn’t sure precisely when the new baby would come, maybe late April, early May. Lacey was free-birthing again – no scans, no blood tests, no appointments – but this time she would be doing so in lockdown. Her friend Claire wouldn’t be there: it would be just her and Flynn and her daughter, now three years old. Unlike women who had wanted to have a home birth with a midwife present and been told that was no longer possible because of the pandemic, or women who were giving birth in hospital and worried about catching covid-19, Lacey felt the enforced privacy and intimacy of lockdown created the perfect circumstances for giving birth.

Lacey reckons that her decision to free-birth stems from traits that she inherited from her parents. Her father is a lawyer, devoted to argument and evidence. Her mother is a free spirit who has often switched tack: she was an airline attendant, went to clown school and performed tarot readings at home for private clients. There’s a part of Lacey ready to fight her corner and a part of her that wants to go her own way.

Lacey was born (hospital, vaginal, unremarkable) in 1984. She grew up in Nova Scotia in Canada, aced school and studied English literature and gender studies at university. For a while, she believed that motherhood was the worst choice a woman could make. She remembered her own mother’s sense of shame and loss of identity once she had left her job as a flight attendant to have children. Mothers seemed disrespected and undervalued by their families and society. “Why would anyone want to feel like that?” thought Lacey.

After university Lacey studied for a legal qualification but decided to become a yoga teacher instead. She moved to Berlin and held classes in a studio in Kreuzberg, supplementing her income by working as a sous chef in a paleo restaurant and teaching English to children. She partied hard and met Flynn. In one of their first conversations, Flynn asked Lacey if she wanted to be a mother one day. Lacey said no. “Oh that’s so sad”, he told her, “because you’d make the most beautiful mother.” And she was like, “Who is this? Who says this?” But once they’d been together for a while, Lacey started to question herself. If they had kids, she wouldn’t allow herself to turn into a person she didn’t respect. She would have to do things her own way.

When the couple moved to Britain, Lacey started to run online courses for women to develop their inner strength and confidence by learning about their bodies and sexuality. She wanted her birth, too, to serve as an example of the power of a woman’s body, rather than a sign of weakness or submission.

Earlier this year Anthony Silverstone, a former consultant in obstetrics and gynaecology at University College Hospital in central London, led me around the Elizabeth Garrett Anderson maternity wing. We could hear the high, insistent bleat of a newborn from behind a curtain. A mother in pyjamas performed the hunched, tentative hobble to a water fountain characteristic of someone who has just pushed a baby out of her vagina.

Silverstone, a short man in a jaunty beret, is deeply empathetic, the kind of person who listens to a birth story like it’s the first he’s ever heard, even though he has been present at thousands. Everywhere we went he was greeted warmly by doctors, midwives, nurses, administrators – it was like touring with a beloved semi-retired celebrity.

Though Silverstone teaches at the hospital he stopped clinical practice in 2016. The contours of his 50-year career trace the changing approaches to childbirth in Britain. When he started out, on a maternity ward in Birmingham in the 1960s, women would often labour for two to three days, there were no epidurals and emergency C-sections were rare (at a rate of around 5%). “It was torture,” Silverstone recalled. “We used to treat cows better than we treated women.”

In Silverstone’s memory the wards were chaotic and women were left to labour on and on with no relief and no idea when it would end. The unpredictability of their experience led to the next phase, in the 1970s, known as the “active management of labour”. The idea was to reduce the length of labour to less than 12 hours. To control the process, obstetricians began inducing women by inserting pessaries of drugs into the vagina to stimulate labour, often long before their bodies had begun to release the hormones that naturally relax the cervical muscles and help them deal with the pain. Women were regularly given episiotomies, a procedure in which the perineum and back vaginal wall are cut to help the baby emerge. Silverstone recalled a doctor he worked with decreeing that all women should be induced at 38 weeks (babies are now considered to be full term at 40 weeks, and in Britain they are induced at 42 weeks). “They had no choice in the matter,” he said. “That’s what he thought was right and nobody could argue with him.”

This dogmatism provoked a wave of campaigning that continues to this day. In the 1980s Janet Balaskas started the Active Birth Centre in north London (a deliberate corrective to the idea of “active management” of women). Balaskas and others fought for the right of women themselves to determine how they gave birth, and in whatever position they felt most helpful and comfortable. No longer would women automatically lie down on beds, when the physiological evidence (and basic common sense) pointed to the fact that a baby moves down the birth canal more easily when aided by gravity. Women, it seemed, had only started lying on their backs to have their babies yanked out by a doctor after obstetric forceps were invented in the mid-1600s. (The story goes that the trend of women birthing in a horizontal position grew after Louis XIV expressed his desire for a full view of his mistress giving birth. “I’ve seen an engraving of her lying down and giving birth and a gallery above,” Balaskas told me. A gallery full of spectators? “No, really.”) Natural-birth campaigners championed water births and upright births, home births and midwife-led births with no doctor present.

Looking back over the past four decades Balaskas, now 76, told me that she was cautiously positive about the progress she’d witnessed: “If you’d told me in the mid-80s that almost every hospital in the UK would have a water-birth pool and a facility like a birth centre, that would be available to women, that would have seemed like a dream come true.” But there are still challenges. Midwives – the clinicians with the closest relationship to a pregnant woman and most likely to be present when she gives birth – are more stretched than ever. Carmel Lloyd, head of education at the Royal College of Midwives, told me that when she was practising as a midwife in the late 1970s, a single midwife would see a woman through her whole pregnancy. Now, the care tends to be more fragmented. “Women will often say I come to the clinic and see a different midwife every time.”

Many midwives and medics are also more fearful. The caesarean rate has hugely increased worldwide, nearly doubling from 12% of all births in 2000 to 21% in 2015, according to a report in the Lancet from 2018. There are a number of factors behind this – women are giving birth later in life and the risks associated with a vaginal birth increase with age – but there is also a more general inclination to put safety first. In some situations where women might once have been left to labour, they are now more likely to receive surgical intervention.

The risk aversion is understandable. Though the vast majority of births are straightforward, the consequences of a birth going wrong can be catastrophic and lifelong (a baby deprived of oxygen during birth can suffer brain damage, for example). Litigation in obstetrics represents a vast cost to the NHS. In 2018-19, only 10% of clinical claims were in obstetrics, but they accounted for half the value of those claims, and 70% of the £83bn provision reported by March 31st 2019. In a medical system that is already struggling financially, doctors and midwives are under enormous pressure to outline every possible risk. “Midwives will sometimes describe how they’ve always got to watch their backs,” Lloyd told me. When safety is paramount, options tend to close more quickly: doctors cannot force women to give birth in a particular way, but women can feel irresponsible if they do not follow their advice. As Balaskas put it, “Entrenched attitudes are very hard to change, especially…where you have two lives in your hands.”

Birth has become a litmus test for an individual’s relationship with authority: you’re either inclined to escape the state’s attempt to monitor and control the process, or you find these efforts reassuring. Many of us assume that the system is based on sound evidence. We trust its practitioners and believe they have our best interests at heart. The very things that some people object to during pregnancy and birth – such as frequent monitoring of the baby’s heart rate – I remember finding as comforting as any number of meditative visualisations of my “happy place”.

But some question the assumption that the medical system always acts in a woman’s best interests. In her recent book, “Give Birth Like a Feminist”, Milli Hill drafted a manifesto for the birthing woman which declares that women should have the right, when giving birth, to make informed decisions for themselves and shouldn’t be interfered with without giving their full and unambiguous consent. She refutes the idea that the health of the baby should take priority: the mother’s experience, and long-term physical and mental condition after birth, is just as important. For many, this is a controversial idea. Surely, as long as you’re alive, nothing else matters so long as your baby is delivered safely. But Hill’s final line is clear: “You matter too.”

Hill gives the example of Kimberly Turbin, a Californian woman and two-time rape survivor, who gave birth to her first child in 2013. Given her traumatic experiences, Turbin had asked her doctor to be gentle with her and explain exactly what was happening during labour. A family member videoed the birth and as the baby began to crown the doctor “announced he was going to perform an episiotomy”. On the video, Turbin was heard pleading, “No! Why?” She asked for more time to push the baby out, but the doctor insisted, telling her: “I am the expert here.” The lack of consent led Turbin to file a case for assault and battery which was eventually settled out of court in 2017.

The counter-argument in this case might be that the doctor was acting to ensure that both Turbin and her baby were safe. The idea that the birthing woman should be the decisive voice in the room makes intuitive sense, but what happens when something suddenly goes awry? Uncertainty reigns throughout labour and interventions can save lives. Silverstone holds on to the idea, however dated it might seem, that a doctor’s job is to look after people. “That’s what we’re trained for, and we may have a different view, and we kind of want you to listen to what we have to say.”

Yet for some women, even the thought of birth can hold a terror that surpasses mortality. Kate, a therapist in Glasgow, grew up with the horror story of her own birth: her mother’s agonising labour lasted for days and the doctor had to use forceps, a particularly invasive intervention in which curved metal tongs are used to clamp the baby’s head and drag it into the world. Though her mother was generally stoical and uncomplaining about pain or illness, Kate was told repeatedly how awful the experience was.

When Kate began to have sex as a teenager, she realised that her mother’s fear had infected every aspect of her own thinking about having children: being pregnant, becoming a parent, the loss of control of one’s life and body, the sense of no return. She now realises she suffers from a rare and extreme fear of childbirth known as tokophobia, that can either be “primary”, when it emerges before you’ve ever given birth, or “secondary”, when it arises as a result of a previous, traumatic birth. More than anything, Kate fears the pain. She’s long had a terror of needles and vomiting, but the fear of pain in childbirth is the most extreme of all. “I have horrible images in my head that I will be stretched and ripped apart and that it will be horrific,” she told me. “I guess ultimately I think I might die from it.”

After getting engaged, Kate and her fiancé talked about having kids. He had children from a previous relationship, and she’d always assumed he wouldn’t want more – but he did. Kate panicked. She’d wake up in the night, crying, and found that she couldn’t think about anything else. She’s a therapist by training and knows the drill: confront your fears, explore them. She tried watching “One Born Every Minute”, a long-running British documentary series set in labour wards, but found it traumatising: everyone was screaming, every birth looked agonising. (Hill devoted a whole section in her book to the terrible effects the programme has had on some women’s attitudes toward birth.) Reading a book on the subject made her feel sick. An online course for tokophobia, involving meditation, helped a bit. But the idea of actually going through with a pregnancy or birth still felt remote.

Kate turned to the system and the system helped. She went to see an obstetrician, who was kind and understanding. He told her that if she decided to become pregnant they could plan for a different kind of birth: an elective C-section with a local anaesthetic, or if the panic descended in the moment, a general anaesthetic, so that she wouldn’t be aware of anything at all. There was a phase in the history of birth, in the mid-19th century, when women regularly gave birth like this, anaesthetised by chloroform (a practice made fashionable by Queen Victoria). But unconsciousness is not exactly in vogue now, when the Duchesses of Sussex and Cambridge both hypno-birth and the idea of a minimal-intervention birth is prized as an experience, a sign that you have achieved something remarkable without help.

For Kate, that version of birth is unimaginable. The idea of watching herself give birth, even with local anaesthetic, horrifies her. She doesn’t see birth as an aspirational experience – it isn’t something to strive for or an event with the potential to be positive. “I just see it as something to get through,” she told me. “To me, the idea of even attempting to give birth without medication or pain relief is a bit crazy. In my head, I just think why would you even try?”

In the field of perinatal psychiatry there is a growing focus on the idea of “matrescence”, a term propagated by Alexandra Sacks, a reproductive psychologist in America. Matrescence is the period in an expectant or new mother’s life, similar to adolescence, when her hormones and her sense of self are in flux. As the structure and meaning of her life shift dramatically, she clutches for an identity, in the same way that teenagers align themselves with a subculture. Am I a hypno-birther or an epidural-seeker? Are you routine-obsessed or a mum who feeds on demand? Finding answers to these questions becomes our way of working out who the hell we are now that we’ve become parents.

In adolescence such flux is expected and tolerated (up to a point). As a society we’re less comfortable with the idea that birth might change a woman just as deeply. We’re supposed to love and look after our babies, and then go back to work and our previous selves months later. We struggle to talk about birth and its effects honestly, Emma Svanberg, a perinatal psychologist, told me. “We find it complex and complicated and it raises a lot of anxiety in all of us. If you’re a natural-birth advocate, that can be a denial of the anxiety. If you’re a pro-interventionist then you’re really highlighting the anxiety around birth. But both...are a way of coping with what birth actually is, which is something that we can’t control and feel very uncertain about.”

Perhaps we could just try to accept the uncertainty, even revel in it. Maybe you can mix your choices, as Milli Hill suggests, and be a “formula-feeding, elective-caesarean-choosing stay-at-home mum or a home-birthing tandem-feeding high-flying city analyst”. Resist the mummy wars, she argues. But certainty is easier to communicate than ambiguity.

Deciding to free-birth reminded Lacey of her vegan phase a few years earlier. She could see that people felt judged as soon as she told them about it. “That’s why labels are tricky,” she told me. “I don’t think I’m going to use the term ‘free-birth’ this time.” So how would she describe it, the extraordinary, ordinary thing she was about to do, again? “Oh,” said Lacey, “I’ll just say I birthed my baby at home with my husband.”

On a Friday evening in late April of 2020, when much of the world was at home, hiding from covid-19, Lacey felt the first stirring, that deep interior shift. By Sunday she was having light contractions that continued all day and all night. There was a familiarity this time, she’d done this before. In the middle of the night, her daughter got into their bed, something she hadn’t done for a while, as though she knew the baby was coming. Lacey woke early, around 6am, and started stretching on the floor.

When Flynn and their daughter woke up a little later, Lacey told them, “I think it’s happening.” They put down a shower curtain and towels on the floor, brought a heater into the room to warm it up, ate food and listened to music – cheesy, spiritual stuff. They danced a bit. Lacey didn’t want to stop moving, and kept going up and down the stairs, while Flynn and her daughter laughed at her yo-yoing.

After a few hours, those deep gut-twisting contractions reached a point of extreme intensity, but Lacey’s waters still hadn’t broken. At some point Lacey lay down on the bed and fell into a deep, brief sleep, one of those strange time lapses that are not quite a rest. In a half-dream she saw the image of a gate, and then, with an audible pop, her waters broke, like a water balloon exploding. She rolled off the bed, worrying about it being damaged. Flynn told her that the bed didn’t matter. She went to the bathroom and sat on the toilet, just as she had last time.

Once again she felt a sense of surrender. It was like the baby was being wrung out of her and all she had to do was get out of the way. She bellowed and yelled, making noises she could never hope to re-create, noises that were guttural and deep and rolling and shrill all at once. Her daughter was standing right next to her and didn’t flinch. Lacey had prepared her, as best she could, for the noise. Every day in the run-up, her daughter had been pretending to give birth. Each time her imaginary baby would pop out silently and Lacey would say, “Remember, there’ll be a lot of noise.”

Three huge contractions and the head came out first. They let it hang there for a moment, knowing the body would come out with the next contraction. Out it rushed, but the feet were still caught inside her. The cord was around the baby’s neck. When they unhooked it, the toes slid out and, as she took the baby onto her lap, Flynn and their daughter cried out, “It’s a boy!” For a moment, he was quiet, and they were rubbing him and talking to him and laughing. Then he sputtered the fluid and mucus out of his mouth and nose, and let out a cry.■

ILLUSTRATIONS ANNA+ELENA=BALBUSSO