Chantel Hull, 35, a lawyer from Ambler, stopped in for an appointment at the Birth Center in Bryn Mawr in early October, three weeks shy of her due date. This was her third child.
"So how's the baby doing?" asked Ruth Wilf, her midwife.
"Very good," Hull said. "He's very active."
"Good," Wilf said. "The baby should always continue to be himself."
Hull smiled agreeably.
"No, seriously," Wilf insisted. "It's important the baby keeps his usual patterns.
"What's your body telling you?" Wilf continued.
"He's dropped. I can barely walk. Swelling has increased in my hands and feet. . . . I don't know if I can last much longer. I'm not getting much sleep."
Nearly all American babies are born in hospitals, about one in 10 with the help of a midwife. Two percent will be born in birth centers like this one, where mothers almost always take no drugs for pain; stand, sit, or squat during labor or do whatever feels right; and nine out of 10 have a vaginal birth.
In U.S. hospitals, one-third of births in 2012 were by Caesarean section.
Hull continued with her visit, telling Wilf she was not getting much sleep, had carpal tunnel syndrome in her hands and fingers and numbness.
Wilf, 83, who started teaching childbirth classes in 1962, and drives a Prius with a bumper sticker reading, "Midwives help people out!", got on her soapbox.
"This is where women run into trouble with their obstetrician," Wilf said to Hull. "They go to the doctor and say 'I'm so tired of being pregnant.' Well, of course you are. And the doctor says, 'You want me to deliver your baby, don't you? So why don't you just come in on Thursday and I can induce your baby?' So that way lies disaster.
"The mother and the baby are not ready. All these mysterious forces that we know so little about work together in complicated ways. So you induce the baby for nothing, and what happens? It doesn't work. The baby gets in trouble. The woman winds up with an unnecessary C-section and the baby winds up in intensive-care nursery. Bingo. And that's what's going on in the United States."
What is undeniable is that the importance and acceptance of midwives are growing globally.
The British medical journal Lancet devoted its June issue to midwifery in the developing world. "The return on investment for midwives," it concluded, "is similar to the cost per death averted for vaccination."
State of the World's Midwifery 2014, by the World Health Organization and the U.N. Population Fund, said that more midwives are the way to improve care in 75 countries with the highest rate of maternal and infant death.
In the U.S., there are more than 13,000 certified nurse-midwives today, compared with a few hundred when Wilf started in 1974. Midwives deliver more than 300,000 American babies a year - about 1 in 10 - but experts say more change is needed.
About 90 percent of American midwives work in hospitals, but many are still handcuffed by America's devotion to a medical model of childbirth and the fear of lawsuits, which, in the view of Wilf and others, is behind the high rate of C-sections. ("It's appalling," Wilf says.)
The professional groups of obstetricians and midwives dedicated 2011 to finding ways to collaborate and bridge the growing gap between the supply of ob/gyns and the demand for women's health.
The idea is that obstetricians handle the complex cases and midwives, working in consultation and collaboration with doctors, care for women with low-risk pregnancies, transferring care when indicated.
Economics and necessity may speed acceptance and proliferation of midwives. One study showed that half of U.S. counties have no obstetrician. Just as nurse practitioners help meet America's primary care needs, midwives may fill gaps in maternity care.
At Hull's 9 a.m. appointment, Wilf had her lie on her side as much as possible, taking the weight of the baby off big blood vessels in her spine. This encourages blood flow and reduces swelling.
"Is there a couch anywhere in your office?" Wilf asked.
"Maybe in the lobby."
"That's not exactly what I had in mind. I have had people bring in air mattresses."
"I don't know where I'd put one," Hull said.
"Are you in a cubicle?"
"Oh, phooey. You don't get any breaks. What sort of help will you have?"
Hull said she had help from her mother, her in-laws, and and of course her husband. Wilf said this sounded wonderful.
"What about pumping?" Wilf asked.
"Our work just installed pumping rooms . . . . That's kind of progressive."
"It's the law," Wilf said. "It's about time," she added. "I can tell you that back in the '50s, when I was breastfeeding and teaching at Barnard, I was a graduate student. In those days there weren't even breast pumps, and I went into the bathroom and I expressed into a wide-mouthed mayonnaise jar that I had sterilized."
"Are you serious?"
"Of course I'm serious. I got pretty good at it."
And then Wilf demonstrated the technique, over her sweater, on her own 83-year-old breast.
Wilf went to Girls High, and then to Wellesley College, majoring in biology and planning to become a professor. She fell in love in college with Herb Wilf, who had attended Central High and M.I.T. They married in 1952. Soon she was pregnant.
Many American women in the 1950s were drugged and knocked out during childbirth. Wilf took a biologist's view.
"If having a child was a good thing," she said, "then the act of having a child should be a good thing. It seemed to me a natural part of living and I wanted to experience it."
Some thought her mad.
Even though she and her husband were living in New York, her father, Henry Tumen, a gastroenterologist at Graduate Hospital, insisted she go to Pennsylvania Hospital, cared for by the head of obstetrics.
"He thought I'd melt like a snowflake," Wilf said of her doctor. He expected her to beg for drugs.
Since this was 1953, her husband wasn't allowed in the room, but her father, without Wilf's consent, came in and stood at her side. When labor became intense and painful, she remembers the obstetrician saying, "You don't expect it to come out as easily as it went in, do you?"
Luckily - and this is the key to childbirth, she says - she had a good pelvis.
"A good pelvis means a good birth," Wilf said. "And you can't tell by looking. Little tiny women can have a generous pelvis."
Her baby came quickly.
"It was an epiphany of my life when I pushed Susie out," she said. "I had been to the mountaintop."
Wilf and her husband moved home to Philadelphia in 1962 when he became a math professor at the University of Pennsylvania. Pregnant with their third child, she became a childbirth educator, starting classes for expecting parents. "The idea of having your partner in the room - we called them 'husbands' back then - was a radical one," she said.
In 1966-67, her husband took a sabbatical to London, and the Royal College of Midwives sent Wilf to a hospital in the city's East End, where she sat in on hundreds of births - observing, learning, counseling, coaching. In today's terminology, she was a doula.
"I couldn't do anything medical," she recalled. So she had to learn by watching and studying.
This gave her a foundation, refined over the next half century. "When I'm sitting with a woman in labor," she said, "after a little while of just peace and quiet I can feel her labor in my body, and I know where she is. We don't do a lot of internal exams."
Back in Philadelphia in 1971, she and other pioneers converted a Salvation Army home on City Avenue into Booth Maternity Center, which focused on natural childbirth. She became a certified nurse-midwife in 1974.
In the mid-1980s, Wilf started the Nurse-Midwifery Service at John F. Kennedy Memorial Hospital in Turnersville, N.J., then worked at Pennsylvania Hospital, before moving six years ago to the Birth Center in Bryn Mawr, the nation's oldest, about to celebrate its 10,000th birth any day.
When asked how many babies she has delivered, Wilf said, "None. People deliver packages. A woman gives birth to a baby."
"I really don't like the term delivery," she added. "That implies the person who is the helper is the star. That's not true. It's the woman who is giving birth. She's doing the work. The balance of power should be with the woman."
As for total births, "I never bothered to count."
In 1995, when Mari-Carmen Farmer, a Drexel student, showed up with an unexpected pregnancy, Wilf became her advocate and supporter. "I didn't know the first thing," Farmer recalled. "She was so affirming. She talked to the baby when she was examining me. She would tell him how lucky he was. And I didn't feel he was lucky at all."
And then, after 42 hours of labor, and nearly four hours of pushing, Farmer was close to a Caesarean. "I couldn't push him out," Farmer said. "Ruth was steadfast. She said, 'No, you're going to push him out. Forget this nonsense about a C-section.' She was my defender, protector, affirming that I could finish what I started, and I did."
Farmer, now 43, became a midwife herself.
Bette Begleiter, deputy director of the Maternity Care Coalition, said Wilf is the "grandmother of the childbirth movement" in this region, has "been there every step of the way," and now, more than ever, "is advocating for safe, supportive, and medically sound birth experiences. She is wonderful."
In 1998, as a resident physician in obstetrics at Pennsylvania Hospital, Peter Gearhart met Wilf.
"She helped to train me," said Gearhart, whose practice is Penn Ob/Gyn and Midwifery, with four doctors and 11 midwives. "She taught me a lot about the art of obstetrics. One of the things I learned most from Ruth was how to take care of the human being, the person.
"She taught me very useful technical skills," he added. "It's a little bit of a mechanical process having a baby maneuver through mom's pelvis. Depending on the baby's position, relative to mom's, it can be easier and harder. Understanding those anatomic relationships, pelvimetry, can be very helpful in enabling a woman to deliver naturally."
All three of Gearhart's children were born with midwives. "I am privileged to work with midwives," he said. "I thank God for midwives."
A decade ago, Wilf gave up being present at births. It wasn't because she was older, or had lost her fire.
"My husband wanted us to have more time together," she said. "When I was on call, I was either working or sleeping."
He was later diagnosed with ALS and died in 2012. "We were married almost 60 years," she said. "It wasn't nearly enough."
She works three days a week doing prenatal and postpartum visits and general gynecological care.
Wilf asked Hull to sit on the exam table. She felt Hull's tummy and knew exactly where the head, back, and feet were located. She listened to the heartbeat.
"Ah, what a nice-looking baby," Wilf said.
"I would say you're about perfect."
While she couldn't guarantee it, Wilf predicted a fast, smooth birth.
"With the third pregnancy," Wilf said, "the baby comes down like it's on a sliding board, so you want to exercise control."
This is to avoid tearing the perineum. Many women in hospitals have the doctor cut it, called an episiotomy, to avoid a tear.
Wilf advised Hull to watch the midwife carefully, eye to eye, and follow her direction on when and how hard to push.
"It's kind of like getting a car out of a tight parking space," Wilf said. "And the midwife is the kid on the curb."
Wilf had more tips for Hull: get more folic acid to help with her iron deficiency, get out in the sunshine, lie down as often as possible. Hull got up to leave.
"I feel a hug coming on," Wilf said.
"You're awesome," Hull said.
On Oct. 25, her exact due date, Hull gave birth to Samuel Garrison Hull, nine pounds and six ounces, a beautiful, healthy boy.
Hull said of Wilf: "She was right about everything!"