A Labor Without End
Ruth Lubic defied doctors to change the way American women give birth. After more than four decades, her work isn't close to being finished.

By Phuong Ly
Sunday, May 27, 2007

THE PREGNANT WOMEN IN THE POWDER-BLUE WAITING ROOM PAY NO ATTENTION to the worried, white-haired grandmother walking through the Family Health and Birthing Center in Northeast Washington. They have no idea who Ruth Lubic is, and she doesn't stop to introduce herself. Nor does she pause to admire a large bulletin board that overflows with photos of cooing, drooling, napping babies, all of whom were helped into the world by the center's midwives. These babies -- born to low-income parents in a city with one of the country's highest infant mortality rates -- are part of Ruth's legacy, the culmination of her decades of work to transform the way American women give birth. The babies have defied the odds and are healthy and thriving. It is the birth center that is struggling to survive.

The birth clinic has operated precariously ever since Ruth used a $375,000 MacArthur Foundation "genius" award to open it in 2000. More than once, she and her husband have put up their own money to pay the center's midwives. Two years ago, the clinic nearly shut its doors when it was short a malpractice insurance payment of $22,000.

Now, on this mid-December morning, another crisis hits. In an office next to the waiting room, the clinic's director, Diana Jolles, hands Ruth a piece of yellow note paper. Jolles has written nothing on the note but a number: $248,000. Ruth doesn't have to ask what it means. This is the estimate of the malpractice insurance the clinic must pay for 2007. The bill is double last year's. Another spike is expected next year.

Ruth stares at the note for a few seconds. Under her thick glasses, her blue eyes harden. Without a word, she pockets the note and walks out of Jolles's office to deal with the problem the only way she knows how: Keep working; keep raising hundreds of thousands of dollars; keep publicizing the benefits of using midwives; keep lobbying Congress for liability reform that would help birth centers.

Ruth is not afraid of fighting. She has been doing it her entire life and winning. But now she is nearing her 80th birthday. And she knows that she is running out of time.

WEARING BRIGHT GREEN SLIPPERS AND BROWN CORDUROYS, Ruth moves quickly around her sunny condo in Southwest Washington. It is mid-morning, and she has been up since 5 a.m. Papers and notebooks are stacked neatly on her desk, where she does much of her work. Two calendars hang from the wall, and a pocket diary lies open. The laptop computer was turned on as soon as she got up. She has already sent out a barrage of e-mail.

She downplays her computer skills -- at her age, she says with a chuckle, "I'm lucky to be able to turn on a computer" -- and her packed schedule. She just returned from Boston, where she accepted an award for her service to mothers and children from the American Public Health Association. This weekend, she will ride the train to New York, where her husband of 52 years, Bill Lubic, lives in their rowhouse on the Upper West Side. The couple alternates weekends between New York and Washington, a long-distance marriage that would test couples half their age.

Bill, who is a month younger than his wife, has thought about retiring but continues to work at his law firm part time because Ruth is so busy. He's not complaining, though. Over the years, Ruth's crusade to make childbirth an intimate "low-tech, high-touch" experience for women of all backgrounds and income levels has become his crusade, too. He serves on the birth center's board, accompanies his wife to conferences and meetings and provides pro bono legal work. Ruth calls him "Father," which she has done since their son, Douglas, was young. The clinic's staff members call him that, too. He has come to believe that his wife's mission is of such great importance that it often has to come before him. Even family celebrations with their two grandchildren are scheduled around Ruth's work. "Whatever has to be done, has to be done," Bill says.

Whatever has to be done usually involves Ruth. Though she no longer runs the birth center day to day, she remains its driving force, its public face and its most relentless advocate. It is, she says, the only birth center of its kind in the country, founded as part of the DC Developing Families Center, an ambitious haven that offers poor women health care, family support services and child care, as well as prenatal care and a homey place to deliver babies. The birth center's six midwives and two nurse practitioners have attended and cared for more than 550 babies since the center opened, with far lower rates of C-section delivery and premature birth than the city as a whole.

The clinic's midwives have never attended a birth that resulted in an infant death, Ruth says. One baby, however, suffered brain injuries in 2004 after the mother had an emergency C-section at Washington Hospital Center, which serves as the clinic's backup and where many of its expectant mothers give birth. The incident prompted a lawsuit by the baby's family that was settled out of court this year for an undisclosed amount of money, according to court documents. Ruth says it is the only malpractice suit ever filed against the birth center. But the clinic's malpractice costs are soaring anyway, part of a nationwide liability crisis that has prompted some ob-gyns to stop delivering babies and has forced birth centers around the country to shut their doors.

Locally, the Takoma Women's Health Center, a clinic run by midwives in Takoma Park, closed last month. The Maternity Center in Bethesda shuttered its birthing rooms this month, although the midwives will still attend births at Shady Grove Adventist Hospital in Rockville. Both clinics served a mostly middle-class clientele but couldn't escape the same financial problems that are threatening the D.C. birth center.

Reimbursements from Medicaid and other health insurance plans cover only about half the center's $1 million budget. The city provided $250,000 in 2006, but trimmed that to $200,000 this year. The rest comes from foundation grants and individual donors -- funds that are scrounged together by Ruth. What would happen to the birth center if Ruth got sick? How long would it be able to survive without her?

"Unfortunately, our model works on an 80-year-old woman bringing in $500,000 a year," says Jolles, 32, who became the center's director last spring and has taken on many of Ruth's administrative responsibilities. "The world can't run like that. She's the only Ruth. I definitely can't do it like Ruth does it."

Ruth is well aware of her own mortality. When she had her condo renovated recently, she ordered the biggest black knobs she could find for her honey-colored kitchen cabinets. "When you get older, your fingers have trouble," she says. She frowns and opens her palms, stretching her fingers. "Before, I made my body do what I wanted it to do. Now I have to listen to it."

Though she doesn't have any major health problems, her mother and sister both suffered fatal strokes in their early 80s, she says. She talks frankly about the need to get the clinic on stable ground before she dies.

"What I don't want to see is, the founder has a stroke, and everything falls apart," she says. "I want the thing to live. It's more important than I am."

TO ENTER THE BIRTH CENTER ON 17TH STREET NE, visitors must be buzzed in. A camera is pointed at the entrance. Last year, four people were shot to death in the surrounding neighborhood, which has long been known as "Little Vietnam" because of the violence. The building that houses the birth center is painted lavender to project a sense of calm. Inside on a cold January afternoon, seven women, their pregnant bellies stretched tight under their T-shirts, have settled on a futon and cushioned chairs. They munch on pretzels and carrot sticks that have been set out. The cozy room isn't well-heated, and the ceiling fan is spinning on full blast. Even so, all the women have their coats off.

When midwife Lisa Uncles walks in, she gasps: "Y'all are hot?"

"You have a room full of pregnant women in here," someone responds, and the group bursts into laughter.

This is the biweekly meeting of women who are due to deliver in March. A couple of them will have their babies in the birth center's bedrooms. The others will be attended by the midwives at Washington Hospital Center.

The logistics of poverty make it hard for women to deliver at the birth center, Jolles says. Most don't have cars or know someone who can drive them there after their labor starts. Cabs can be hard to come by in Northeast and Southeast Washington, especially at night. Many women have to rely on ambulances, which will take them only to a hospital. Some have to give birth in a hospital because of weight problems, diabetes or other health issues that could require a doctor. Others are simply scared of giving birth without painkillers.

That's not the case for Kisha Lindsey, a 26-year-old inventory clerk who is planning to deliver her second child at the birth center. She says she likes the center's informality and treasures the midwives who are "so nice and good, oh my goodness." Their care is particularly meaningful for this birth. Her child's father won't be in the delivery room; he is serving a three-year prison sentence for a crime that Lindsey doesn't want to detail.

Another woman in the group is having her fifth child. Yet this delivery, she tells the other mothers, will be the first "that I'll have someone who cares about me in the room." She is engaged to be married, and her fiance's mother threw her a baby shower, another first for her. It is a marked difference from her last pregnancy; that child's father had threatened to kill her, she said. She still has a court protective order against him and doesn't want her name used because she is afraid of provoking him.

Autumn Wilson listens to the other women with a mixture of fascination and admiration. A 26-year-old yoga instructor, she is one of a handful of the clinic's middle-class clients and the only white woman in this support group. She had her first child at the Maternity Center in Bethesda, but she came here for her second baby because she heard the D.C. center was more intimate.

"The neighborhood is not the most welcoming," she says. "I certainly wouldn't walk around there at night. But once we were inside the building and met the midwives, we just had a great feeling. It's a small team, and it feels like everybody is watching out for you," including the other expectant mothers.

When Peggie Smith, a soft-spoken 19-year-old, says that she hasn't felt like eating lately, the other members of the support group jump in with comments.

"I've been getting indigestion," one says.

"You better eat. You'll be sick," another responds.

"Are you sleeping okay? That's probably it," someone ventures.

Uncles, a mother of two teenage sons, looks gently at Smith: "Your baby doesn't care if you're not hungry. Your baby wants food. Eat something every couple of hours, sweet pea."

Smith nods. She lives in a group home for other teenage mothers and is having her first child, a girl. She's full of questions and came here after she felt that the staff at a doctor's office was ignoring her. At the birth center, prenatal appointments can last as long as an hour. Expectant mothers say pregnant women are nurtured, educated and empowered at the clinic. "They explain stuff to you," Smith says. "They don't get irritated."

Her words would gratify Ruth, although she isn't in the room to hear them. Ruth hasn't attended a childbirth in decades and rarely interacts with the pregnant women being served by the center. She relinquished the role of midwife long ago to concentrate on the birth of a radical idea: that having babies should make women stronger, healthier and more confident as individuals and as mothers. It is a dramatically different approach to childbirth than the one she encountered a half-century ago.

WHEN SHE ATTENDED NURSING SCHOOL IN PHILADELPHIA IN THE 1950s, Ruth Watson dreaded working rotations in the hospital maternity ward. Labor was often induced. Women were pumped so full of narcotics and other drugs that they became delusional. Sometimes, Ruth remembers, patients were tied to the side rails of the bed so they couldn't climb out.

"It was inhumane," she says. "The women would come up to you later and ask what happened and who was with them during their labor. They had no idea."

After graduating from the University of Pennsylvania, she moved to New York to be with Bill and worked as a hospital nurse, caring for cancer patients. The couple longed for a child, but it took four years before Ruth was able to get pregnant and carry a baby to term. The timing, in 1959, turned out to be perfect.

Ruth's obstetrician, Edward Cullee Mann, had studied psychiatry and postpartum depression, and he had the then-radical notion that fathers should be allowed in the delivery room. Other doctors criticized him. They didn't think husbands could handle seeing labor. What if a dad-to-be fainted?

Bill Lubic didn't faint. He held his wife's hand and coached her through her breathing during a natural labor that took more than 24 hours. "It was a very long-lasting memory to see Doug's head come out in stages," says Bill, who describes it as "a close emotional experience between the three of us."

A nurse gave the baby to Ruth right away to breastfeed. The doctor and nurses left the new family alone for an entire hour, a rarity then. "It was the most important thing that has ever happened to me in my life," Ruth says, her eyes starting to water at the memory.

Later, she told her doctor that Douglas's birth had moved her to consider working in maternity care. He suggested she become a nurse-midwife.

"What's that?" she asked. Nobody in nursing school had ever mentioned the term.

In 1961, Ruth enrolled in the country's first midwifery school, run by the Maternity Center Association, a New York-based nonprofit that championed care for mothers and infants. Her class had just six students. The only hospital willing to give them clinical training was King's County, an overcrowded facility that served poorer families.

At a hospital meeting, Ruth remembers the head of the maternity unit praising the student midwives. He believed their attention to patients encouraged them to return for follow-up visits and helped reduce infant mortality rates.

But one doctor responded: "And what are you saving? You're saving material for the welfare rolls." Ruth was horrified. "How [that doctor] had the nerve to stand up and talk that way about human beings, I don't know," Ruth says.

Another time, a young doctor obliged a woman who wanted to deliver her baby vaginally, rather than by C-section. Ruth says she overheard an older doctor say to him, "Well, you just did me out of $150." Vaginal births were not as lucrative -- or often as dangerous -- as C-sections.

When Ruth received her certificate in midwifery in 1962, no one would hire her. Midwives, who have attended births since ancient times, were considered by doctors to be unqualified. Some worked as nurses in maternity wards and didn't tell people they were midwives. Half of the students in Ruth's class went overseas as missionaries, where their training was more appreciated. "You don't know how enormously frustrating it was," says Ruth, who left the field to get a graduate degree in anthropology. "There just weren't any jobs."

Ruth finally got the chance to change that in the mid-1970s. By then, she was the director of the Maternity Center Association, which wanted to open the country's first state-licensed birth center in an Upper East Side townhouse. It would be staffed by nurse-midwives and allow women to give birth in a family-oriented, homelike environment.

A furor ensued. Ten of the 18 doctors on Maternity Center's advisory board resigned to protest the birth center, and others threatened to follow. Ruth spoke before a state health committee and faced a barrage of hostile questions. Didn't she know that her plan was dangerous? Women would certainly bleed to death giving birth in a non-hospital setting. How could she risk that? Any birth outside of a hospital was unsafe. She didn't know what she was doing.

When the Childbearing Center opened in 1975, doctors lobbied health officials to shut it down. Some of the staff of the hospital that provided emergency backup to the center balked at working with midwives. Ruth held her ground. Denied Medicaid reimbursements, the birth center sued and won. Meanwhile, scores of women who were fed up with doctor-dominated childbirth were finding their way to the Childbearing Center and safely delivering babies.

In 1982, a Federal Trade Commission study concluded that the doctors opposed to the Childbearing Center were seeking to maintain a competitive monopoly on delivering babies. The FTC report praised the center for forcing hospitals to think about how to "humanize the delivery of obstetric care." By then, birth centers were opening across the country, and hospitals were responding by hiring nurse-midwives, creating welcoming birthing rooms in their maternity wards and offering classes in natural childbirth. Ruth had won.

Now she turned attention to a new cause: opening a birth center in the South Bronx, one of the poorest neighborhoods in New York City. In some ways, a Bronx birth center would be a tribute to Ruth's parents, who instilled in her a desire to care for those in need. Her father, a pharmacist, often gave medicine to the needy, and, during the Great Depression, her mother hocked her canary diamond ring to help others.

Once again, Ruth encountered opposition and suspicion, some of it based on race and class. During one meeting with the board of a health clinic already operating in the Bronx, a minister asked Ruth and her Maternity Center Association colleagues: "What do you think you white people are trying to do, coming in here and telling us how to take care of our babies?"

But Ruth believed that poor women in particular would benefit from the personal attention that midwives provide. And once again, she prevailed. The Morris Heights Childbearing Center opened in 1988, providing prenatal care to hundreds of women who hadn't had access to it before.

Five years later, on a June evening, Ruth and Bill came home from dinner to a voice mail from someone at the John D. and Catherine T. MacArthur Foundation. When Ruth returned the call, a giddy person on the other line told her that she had been named a 1993 MacArthur "genius." At 66, she would receive $375,000 over five years.

"We just whooped and hollered," Bill remembers. "You hug, and you kiss, and you say, 'Oh, my God.'" The next morning, Ruth's thoughts turned to Washington. She was considering trying to establish a birth center in the nation's capital, where the infant mortality rate was double the national average. Better prenatal care for poor women was desperately needed there. And if federal lawmakers could visit a clinic a cab ride away from Capitol Hill, maybe they would fund centers like it across the country. Now, Ruth realized, she could take her MacArthur money and make it happen.

PLYWOOD BOARDED UP THE WINDOWS AND SHATTERED GLASS LITTERED THE PARKING LOT of the old supermarket in Northeast Washington. Inside, thick wire cables dangled in the darkness. The building had been vacant for years, as the neighborhood around it deteriorated and businesses moved to the suburbs.

Ruth remembers standing outside the chain-link fence that surrounded the building in 1994 alongside Dolores Farr, a longtime activist who ran the Healthy Babies Project, which counseled teenage mothers. Ruth recalls marveling over the vastness of the space, and her head spun with possibilities. She turned to Farr, who had brought her to see the building, and said, "We could even have a day care in there."

It turned out that the building was owned by hardware store magnate John W. Hechinger, and he wasn't interested in parting with it.

The District was a tough town, even tougher than New York, in which to get a birth center up and running. Ruth had to go through city officials to get a permit for a health facility, but the District was so broken that Congress had ordered a takeover of the municipal government by a financial control board. Nobody could promise her anything but more meetings. "I'm in my 70s," Ruth told city officials. "You've got to hurry."

She knocked on doors and networked her way around Washington. Through a friend of a friend, she had breakfast with Louis Sullivan, a former U.S. secretary of Health and Human Services. He became a major supporter of the birth center, raising $470,000 to help the clinic qualify for a $785,000 federal grant administered by the city.

Meanwhile, Ruth continued to pelt Hechinger and his real estate manager with letters and phone calls. She got nowhere until she contacted Donna Shalala, then Health and Human Services secretary for the Clinton administration. Shalala knew what Ruth had accomplished in New York and agreed to try to help her win over Hechinger.

Finally, in 1997, after three years of being hounded by Ruth and her supporters, Hechinger offered a deal: The center could lease the supermarket from Hechinger Enterprises for $1 a year, for up to 20 years. Ruth turned him down. Babies were dying, and Hechinger was a rich man, she said. Why couldn't he just donate the property?

Basil Henderson, a lawyer helping Ruth, tried to persuade her to accept Hechinger's proposal. "I thought it was a victory," recalls Henderson, still astonished at the way Ruth refused one of the city's most powerful business leaders. "I told her 20 years was a long time. But she didn't want something that wasn't going to be permanent for the community."

A few months later, Hechinger relented. Ruth could have the building outright. She was delighted, but she asked Hechinger to pay for a new roof. He gave in to that request, too.

At the groundbreaking of the $2 million DC Developing Families Center in 1999, volunteers handed out buttons that said "Listen to Women." Hechinger refused to wear one, telling the crowd that he didn't listen to anybody, not his wife, not his kids. But, he acknowledged, "I do listen to Ruth Lubic."

In a newspaper interview at the time, he said it was hard to ignore Ruth. "She can soften you up because she's so intellectually and emotionally sure of the rightness of her cause," said Hechinger, who died in 2004 at age 84. "When she's through with you, you have this guilt feeling."

Besides, he was tired of hearing from her: "Things were constantly cropping up where I'd say, 'Oh, no, Ruth Lubic again.'"

STANDING UNDER A GOLD CHANDELIER, Ruth sips white wine and scans the reception room. The stately Sulgrave Club in Dupont Circle is holding a panel on politics this evening. Ruth is a member of the elite women's club, though she looks a bit out of place. Many women are wearing suits from St. John's or Chanel and carrying designer purses. Ruth sports wool pants and a sturdy blazer from L.L. Bean.

As Ruth circles the room, hardly anyone acknowledges her. Then she catches the eye of a tall, elderly gentleman in a pinstriped suit. She has no idea who he is, but she shakes his hand and introduces herself as a MacArthur Fellow and nurse-midwife. And what about him?

He is an economist who quickly finds himself listening to Ruth's spiel about the birth center. Though she doesn't ask him outright for a donation, she tells him about how the birth center has cut the rate of women who need C-sections and who deliver prematurely. He says that he wants to tell his wife about her.

During the question-and-answer period of the program, Ruth raises her hand first and launches into a mini-speech about the clinic and medical malpractice premiums. She asks the panelists for their opinions. She's off topic. The discussion was mostly revolving around partisan politics and Iraq.

Wherever Ruth goes, she turns the talk to birth centers. All her handbags have an outer pocket from which she can whip out brochures. She name-drops constantly. One of her oldest friends in Washington is Supreme Court Justice Ruth Bader Ginsburg. Their husbands once worked together in the same law firm, and they were the only two wives who worked outside the home. On Ruth's advice, Ginsburg delivered her second child without medication. Of the 1965 birth of her son, Ginsburg says, "I felt so satisfied, even triumphant." Ginsburg, just the second woman to sit on the high court, marvels at Ruth's accomplishments and how hard she is willing to fight for her cause. "I could never do what she does," Ginsburg says. "She could probably do what I do if she goes to law school."

Ruth isn't shy about invoking Ginsburg's name when she's trying to drum up donations. And, she'll add, did you know that Alma Powell, the wife of Colin Powell, has visited the birth center?

Ruth loves that a favorite opening line among Washington professionals is, "What do you do for a living?" "Then I get to talk about the birth center," she says.

During a vacation cruise along the Danube last fall, Ruth spent much of the time telling passengers about the birth center. Just before Christmas, a check arrived for $50,000. "We were just drawn by her passion," says Bob Wilson, a developer from Southern California, who, with his wife, Marion, sent Ruth the check. "She's obviously very genuine about it. She's not doing it to benefit Ruth. She's been doing it to benefit people who are totally in need."

Her passion is so great that some find it off-putting. She makes anti-doctor remarks that cause her colleagues to squirm. One friend who said she could no longer donate to the center because other charity work was taking precedence stopped hearing from Ruth.

Lucy Holmes, a longtime friend, says she wishes Ruth could lighten up a little. Once, she invited Ruth to a dinner with a wealthy relative -- with specific instructions to Ruth not to eye the woman as a pile of money. Ruth didn't listen. She gave a speech about the birth center and the need for donations, offending Holmes's relative. Another time, during a vacation to Aruba with Holmes, Ruth left the resort to look for needy maternity clinics. When she found one, she went back to the resort and started fundraising around the pool until the resort's managers told her to stop.

"She's become almost rabid in the past few years. I think she feels her mortality," says Holmes, who helped Ruth set up the birth centers in New York. "I can't take her anywhere anymore to dinner because she tries to recruit everybody to help the poor."

Ruth, a self-described "stubborn old woman," doesn't apologize for her relentless fundraising. "If you're honest and well motivated and not self-serving, some people will understand that," she says. "You just have to stick with it, and something will happen. Something will come along."

Jolles isn't so sure. As the birth center's director, Jolles wants to put the clinic on better financial footing by applying to become a federally qualified health center, which would eliminate its need for private malpractice insurance. Its Medicaid reimbursements also would increase.

But Ruth hates the idea and has fought it. She fears losing control of the center to federal bureaucrats, who could demand that midwives see more patients and reduce appointment times. The entire ethos of the birth center would change, Ruth argues. "I don't want to become more of the same," she says. "The system doesn't work. It just doesn't work, I tell you."

Last year, much to Ruth's chagrin, the birth center's board of directors voted to forge ahead, a process that could take a few years. Ruth isn't making it easy. When she and Jolles attend meetings about applying for the federal program, the older woman often mutters under her breath, "It won't work."

Jolles says she is still intent on the idea. Yet part of her wonders if Ruth is right. Maybe another solution to the center's long-term survival will come along. "She really does believe in things that seem impossible," Jolles says. "That's the only reason that she's gone as far as she has."

Larry Mirel, a former District insurance commissioner, agrees that it is a mistake to underestimate Ruth. Three years ago, she persuaded Mirel that the city ought to extend its malpractice insurance to cover nonprofit community health centers, which would solve some of the birth center's financial problems. (The city finally put money aside for the program in this year's budget, but more bureaucratic hurdles have to be worked out.)

Mirel left his city job in 2005, but he is still working on the project on his own time. "I'm doing it because of her," says Mirel, an attorney in private practice. "She believes strongly in what she's doing, and she makes you believe in it, too."

LEANING DOWN, RUTH COOS AT THE BROWN-EYED BABY GIRL IN A PINK KNIT CAP. "Do you want to be involved?" she whispers. "Would you like to be a lobbyist? Yes?" She wiggles her fingers at a baby boy nearby, who is sporting a blue bib that says "I Love My Mommy." She'd like to recruit him, too.

It is January 18, Ruth's 80th birthday, and she is presiding over a meeting in a downtown conference room. She has convened a group of midwives, health advocates and lobbying experts to brainstorm ideas for saving birth centers. The Manhattan birth center that Ruth founded closed in 2003. The birth center in the Bronx still operates, but as part of a larger community organization. Ruth believes the midwives are no longer in control and says the original spirit of the center is gone. She doesn't want the D.C. birth center to suffer the same fate.

Ruth picked her birthday for this brainstorming session, figuring that those invited, no matter how busy or far away, would feel obligated to attend. About 20 people have shown up, including her always supportive husband and two mothers who delivered at the birth center.

One of them, Aree Plunkett, gets up to describe her experience with the birth center. A tall, heavy-set woman with cropped black hair, she shifts her restless curly-haired son Mosha from arm to arm. As she starts to speak, her voice quivers, and she apologizes for getting emotional.

"This," she says, holding Mosha, "is sort of like my miracle baby." Plunkett, 32, had a history of ovarian problems, and didn't realize she was pregnant until after her first trimester. She heard about the birth center from a cousin who had received care there.

The midwives and staff, she says, were better than family. Plunkett's first child had been delivered in a hospital 12 years earlier, where the extent of breastfeeding education was a pamphlet laid on her bed. At the birth center, the midwives told her how breast milk provided better nutrition for newborns. Plunkett was skeptical that she could endure the pains of natural childbirth, but the midwives assured her that she could do anything she put her mind to.

During Plunkett's labor, her mother, best friend and a cousin burned incense, sang songs and cheered her on. "A lot of things I failed at in life," Plunkett says, "but delivering that baby that day was all me." Her voice gets louder and clearer. "Nobody could take that away from me. I had no medical assistance, no epidural, nothing . . . You know, I feel like I can do a lot. It's not too much that gets me down after delivering a baby like that."

When she finishes speaking, the conference room is quiet. Ruth pulls out a tissue and wipes her eyes.

A FEW MONTHS AFTER RUTH'S BIRTHDAY, the clinic receives a $150,000 grant from an advocacy group for community health centers. It's not to shore up the clinic's shaky finances. It's for the future. The advocacy group wants to see if it's feasible for the birth center to offer primary care in addition to prenatal care. Ruth is thrilled by the idea and has scheduled a visit by an engineer to explore adding a second floor to the building. She seems puzzled when asked why she would consider expanding the clinic when it's in danger of closing.

"There are elements who are more fragile than we are," she explains. "We have to try to help them. You can't stop [pushing] while you're waiting for good things to happen."

Then she gets back to work.

Phuong Ly is a freelance writer. She can be reached at phuongyenly@gmail.com. She and Ruth Lubic will be fielding questions and comments about this article Tuesday at noon.

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