The screams rushing up the steps from the basement echoed in the snow-blanketed front yard and filled the small ranch house in North Canton.
In the candlelit basement-turned-birthing-chamber, the shrieks cut through the gentle white noise of lapping waves and the sweet scent of lavender.
Kelly Moscarello, a 37-year-old brunette whose stomach was swollen like an overripe fruit, was giving birth.
Her husband, Mark, a swarthy Italian body-builder, sat cradling her in the tub of water in which she was to deliver the baby. Carol, Kelly's birthing coach, a rosy-cheeked grandma, stood back, watching.
Brenda Scarpino, a slender woman with amber hair and electric-blue eyes, whose T-shirt bore the words "Addicted to Jesus," screamed from between Kelly's legs, "Push!"
The baby's head protruded, but its shoulder had become lodged behind Kelly's pelvic bone. The umbilical cord was pinched like a kink in a garden hose, cutting off vital blood and oxygen to the baby's brain.
"Get out of the tub!" Scarpino yelled. "Get out of the tub!"
Scarpino positioned Kelly on her hands and knees on the floor.
"Do you want your baby to die?" Scarpino screamed. "Push!"
Kelly fell forward onto her stomach, her body shutting down. "I can't do this anymore," she groaned.
Scarpino turned Kelly onto her back and directed Mark and Carol to pin her legs behind her head.
"If you don't push, the baby's going to die!" Scarpino screamed.
The baby's skin began to wrinkle and turn gray. Scarpino dialed 911.
"We have a mom giving birth," she said. "And the baby's stuck. "
Until the postwar era of the 1940s, most babies were delivered by midwives, especially outside big cities.
But with the baby boom came advances in medical care, and the practice of midwifery fell out of favor. Of the more than four million babies born in 2003, a scant 23,000 -- or half of one percent -- were delivered at home, according to the National Center for Health Statistics.
Still, advocates of the practice claim that it makes for healthier babies. They say that the care provided by an attentive midwife is far superior to the impersonal touch of the hospital.
"It goes back to the beginning of time," says Abby Kinne, president of the Ohio Midwives Alliance. "Who caught Eve's baby?"
Hospitals have even tried to carve out a slice of this niche market by employing Certified Nurse Midwives, or CNMs, who are licensed and required to have direct doctor supervision.
But those looking for the true homebirthing experience opt for a lay, or direct-entry, midwife. The close-knit underground community of practitioners is completely unregulated, and unlike nurse midwives, isn't required to obtain any kind of certification.
"There's some very excellent lay midwives out there in the community," says Sandy LaCivita, a local CNM. "But there's not a single standard that any one of them are required to meet."
While the law doesn't specifically ban lay midwives from delivering babies, it does forbid the practice of medicine without a license. But just where those rules intersect is still gray.
"The way most of us look at it is that it's not illegal, it's alegal," says Brenda Hensler, a Dayton-area lay midwife. "We don't want somebody pushing that button to take it to court to make it more or less legal."
In the absence of any real oversight, midwives operate under a vague system of self-governance. Many, including Scarpino, are certified through the National Association of Registered Midwives. Unlike a traditional licensing board, NARM's only disciplinary authority is the threat of revoking its certification -- which isn't even recognized by most states, including Ohio -- and even that's only happened three times in the past nine years.
A 2002 study by the American College of Obstetricians and Gynecologists, which examined home births in Washington State between 1989 to 1996, found that the infant mortality rate for home deliveries was more than double that of hospital births.
And that doesn't take account of the "near-misses," says Dr. Charles Brown, an obstetrician with the Cleveland Clinic. "In most cases, when there's a nearly disastrous outcome, you never hear about it."
Kelly and Mark, who works as a maintenance supervisor at Kent State University, met on a blind date two decades ago.
She'd recently gone through an ugly divorce; he had just lost his wife to anemia three months earlier. They fell in love quickly, married five months later on Valentine's Day, and started building a family.
Kelly turned to midwifery as many women do: after a traumatic birth at a hospital.
Her third child, Katie, was a big baby, weighing 9 pounds. She was so large, in fact, that she got stuck on the way out. Doctors had to push the baby back up into Kelly's uterus to hastily perform an emergency cesarean section.
In their rush, however, they didn't wait long enough for Kelly's anesthetic to fully kick in. She felt the blades slice through her belly -- first the skin, then fat, muscles, and finally the uterus.
"It's knives going through layers and layers and layers," remembers Kelly. "It's horrifying."
Katie was born healthy, but Kelly vowed never to go through such pain again. She'd heard about natural home-birthing as an alternative, so when she became pregnant with her fourth child, Dominic, she consulted the internet and found a nearby midwife named Brenda Scarpino.
Kelly and Mark met with Scarpino for a consultation at her ranch-style home in nearby Canton, where she lives with her husband and several children from their previous marriages. Toys, an aboveground pool, a swing set, and a treehouse clutter the backyard.
You couldn't ask for better credentials, thought Kelly. Scarpino had been delivering babies for over two decades and practiced what she preached: All her children had been born at home.
Scarpino was hired.
Several months later, Dominic's birth went off without a hitch. Kelly settled into an inflatable kiddie pool in her basement -- the water helps relieve some of the pain -- and waited. Scarpino brought her teenage daughter along to videotape the delivery as a memento. Together with Mark and Kelly's birthing coach, Carol, they crowded around the tub to watch Dominic be born. Kelly remembers everyone laughing merrily.
"It was like a party atmosphere," she recalls. "We had pizza and champagne an hour later."
What none of them realized was that Mother Nature had lent a hand. Like Katie, Dominic was expected to weigh 10 pounds at birth. But because he was born two weeks prematurely, he weighed only 8.4 pounds, making for an easier delivery.
The next baby wouldn't be so lucky.
In December 27, 2003 -- three weeks before her due date -- Kelly was unnerved by spontaneous contractions.
"I had a bad feeling something was wrong," she says. "I was so big, and I kept going into labor -- going out, going in, going out."
She decided to consult her family doctor, Kristin Trump, who runs Community Health Care Inc., in Barberton. But Trump was busy with other patients that day. Instead, she sent a nurse out to talk with Kelly. The doctor later ordered an ultrasound to put Kelly's mind at ease.
Because of the holidays, Kelly had to wait until the new year to have the test. It's unclear from medical records whether Trump ever saw the results. (Dr. Trump did not return Scene's phone calls requesting comment.)
But to a trained eye, the ultrasound should have been a red flag, says Dr. Gary Hankins, an obstetrician at the University of Texas at Galveston, who chairs a national task force on midwifery.
The baby was large: Estimates put the weight at 8.6 pounds, making it among the heaviest 10 percent of babies at that stage of development.
"That would de facto tell any doctor that this is going to be . . . a high risk," Hankins says of the ultrasound results. "Even bad doctors ought to be able to figure that out."
The conditions were ripe for shoulder dystocia, a complication during birth that results in the baby's shoulder getting lodged behind the mother's pelvic bone.
The problem is controllable in a hospital, where trained obstetricians can act quickly to save the baby with a variety of medical maneuvers.
But to try to deliver such a high-risk baby at home, without the benefit of medical supervision, is foolhardy, says Dr. Brown, of the Cleveland Clinic.
"Most lay midwives have seen one shoulder dystocia in their career," Brown says. "Shoulder dystocia, even for an experienced obstetrician like me, is a nightmare."
The problem can be magnified by a condition called gestational diabetes, when the mother temporarily becomes diabetic during the latter stages of her pregnancy.
Gestational diabetes produces babies that are barrel-chested and much larger, increasing the risk of shoulder dystocia.
Yet nothing in Kelly's medical records indicates that Trump ever tested her for the condition.
"That is unconscionable," says Dr. Brown. "In diabetics, it's not only how much the baby weighs; these babies are shaped differently. They have broad shoulders, fat necks."
The day after the ultrasound, Scarpino made her last house call to Kelly before the birth. She checked the baby's heart rate, then measured Kelly's belly.
In the third trimester of pregnancy, a general rule of thumb is that the length in centimeters from the pubic bone to the top of the uterus should be about the same as the number of weeks into the pregnancy.
In her 39th week, Kelly measured 42 centimeters. In previous weeks, the difference had been as great as 10 centimeters.
"That's absolutely abnormal," says Dr. Hankins. "She had everything to clue you that this is a big baby."
But Scarpino said everything was fine, Kelly says. (Scarpino did not return several phone calls requesting an interview.)
Kelly's maternal intuition was warning of danger. Just two weeks before she gave birth, she wrote her fears down in her diary: Am a little scared over the pending birth. Baby is too big, won't fit, etc. I am just hopeful the pain will be more tolerable.
As the due date approached, Kelly could no longer keep her worries to herself. On January 15, as she and Mark stayed up talking on the couch, she told him she couldn't go through with the home birth.
"Something's wrong," she told him. "I'm not going to wait one more day. This is it."
They decided they would call Dr. Trump the next day and have Kelly admitted to the hospital. Kelly went to bed soon after.
She awoke at 4 a.m. feeling as if she had to use the bathroom. As she flicked on the light, she felt a contraction. She was going into labor.
Kelly waddled downstairs and climbed into the tub. Mark lit the candles, turned on a CD with gentle sounds of the ocean, and put a bottle of champagne on ice.
He called Carol and told her to come over. Then he called Scarpino.
"Kelly's contractions are two to three minutes apart," Mark told her.
"I'll be right there," Scarpino replied.
Carol showed up shortly thereafter and lit the lavender incense. But Scarpino was nowhere to be found.
Hours passed. The contractions were only a minute apart now. Finally, when Kelly was almost two and a half hours into labor, Scarpino burst through the door, appearing flustered. She claimed she'd run out of gas and had to wait until 6 a.m. for the gas station to open.
Scarpino tried to hoist Kelly out of the tub so she could empty her bladder to make as much room as possible for the baby. But as soon as Kelly stood up, she crumpled in pain. The baby was coming out face up, an unusual position that's extremely painful for the mother. Kelly returned to the tub and started to push.
Mark climbed into the waist-high water, and Kelly leaned against him. She felt the head come out. Any second now, she thought, I'll be holding my baby in my arms.
Then Scarpino noticed that the baby's chin was tucked into its neck like a turtle -- the classic sign of shoulder dystocia.
"Get out of the tub! Get out of the tub!" she screamed.
Kelly couldn't push anymore. The last vestige of strength ebbed from her muscles.
"My body fell over, just shutting down," she remembers. "All I was doing was screaming, wishing I was dead."
Once shoulder dystocia occurs, there's a window of five to seven minutes to get the baby out. If starved of oxygen for any longer, the baby can suffer permanent brain injury or death.
Scarpino didn't call 911 until several minutes had passed, says Kelly. By the time help arrived, it was nearing too late. The baby had been stuck for over five minutes.
Paramedics rushed down to the basement. With a bare minimum of birthing experience, there was little they could do.
Medics tried for 12 minutes to deliver the baby, at one point trying to pull it out by the head. When that failed, they decided to transport Kelly to the hospital.
As soon as they got her in the ambulance, the baby, now limp and flaccid, slithered out without resistance.
There was silence in the ambulance. The baby wasn't crying -- or breathing.
As the sun rose that bitter January day, Kelly lay numb in a bed at Aultman Hospital in Canton. Her baby was in natal ICU.
"He's dead, isn't he?" she asked her husband, Mark.
"I don't know," he replied, "but it's a girl."
Miraculously, the baby was still alive, albeit on a ventilator. Doctors estimated the chances of survival at zero.
Then the phone by her bed rang. It was Scarpino. She was crying.
"How are you doing?" Scarpino asked.
"The baby's on life support," Kelly told her.
"The baby's alive?" Scarpino asked, shocked.
Kelly told Scarpino she didn't really feel like talking and hung up.
Kelly named her daughter Isabella. Somehow, Isabella found the strength to cry. Then she started breathing on her own. Three weeks later, doctors told the Moscarellos that they could take her home.
But she will never recover.
Isabella suffers from a severe case of hypoxic ischemic encephalopathy, a condition caused by lack of oxygen to the brain. Symptoms include developmental delay, mental retardation, and cerebral palsy.
As any parents would, the Moscarellos initially blamed themselves for their daughter's suffering. Every fit of vomiting, every seizure, every sleepless night reminded them that the delivery should have taken place at a hospital.
But after doing some research on the internet, Kelly came to the conclusion that they weren't the only ones to blame. She filed a lawsuit accusing the midwife and the doctor of medical malpractice for allowing Kelly's birth to happen at home when there were abundant signs that there could be dangerous complications.
"If anybody judged the care of the family-medicine doctor, they would determine that there was absolute negligence," says Dr. Hankins, chairman of the midwife task force.
Like all lay midwives, Scarpino didn't carry medical malpractice insurance. Shortly after she was sued in July 2004, she filed for bankruptcy.
It's hard to put a dollar amount on Isabella's suffering, says one of her lawyers, Jim Casey.
"It will take millions of dollars to care for this child for the rest of its life," he says. "What is it worth to be trapped inside your body for your whole life?"
At home on a sunny afternoon, Isabella sits in her purple walker, glued to her favorite show, Sesame Street.
"Woo, woo, woo," she squeals, managing a blank smile.
Doctors say she will never hold a coherent thought, speak, or even feed herself. She is now three years old, an age when most parents delight in watching their child put sentences together, and the Moscarellos are focused on trying to wean her off a feeding tube. She can't crawl, let alone walk.
"She is rolling finally," says Kelly. "She really is trying. I'm not going to give up on her."
Today is a good day. On the bad days -- and there are too many bad days -- Kelly holds an oxygen mask to Isabella's face as her fragile lungs strain for air.
"I will spend the rest of my life caring for her and helping her to improve," Kelly says. "It's never going to be over. There is no amount of money -- none -- that can make this OK."