FORT WAYNE, Ind. (WOWO) — A growing number of Indiana women are choosing home births with midwives, but a recent disciplinary case involving an unlicensed birth attendant is renewing questions about emergency care, medical oversight and the risks when complications develop outside a hospital.

An investigation by the Indiana Capital Chronicle examines the divide between certified midwives, who must meet state training and safety requirements, and unlicensed practitioners who operate outside that system. The issue has particular significance as some women report declining trust in the medical system and access to obstetric care becomes more difficult in parts of the state.

Indiana lawmakers legalized and regulated direct-entry midwifery in 2013 after a series of infant and maternal deaths involving unlicensed attendants. Among the cases cited in the debate were the 2003 deaths of a Columbia City mother and her baby following a uterine rupture during a home delivery, and a 2007 stillbirth involving a Goshen woman who suffered repeated seizures during a three-day home birth. Neither woman was taken to a hospital during the incidents.

Since Indiana issued its first direct-entry midwife certificate in 2017, certified midwives have attended or assisted with more than 3,200 live births. State reports recorded seven stillbirths and no maternal deaths in that period, according to the Indiana Capital Chronicle.

April Brake, president of the Indiana Midwives Association and a member of the state’s midwifery committee, said women often seek midwives because they want personalized care and a consistent provider throughout pregnancy, delivery and the postpartum period.

Indiana’s certification requirements include a minimum age of 21, an associate degree or higher in nursing or an accredited midwifery program, an apprenticeship involving at least 80 births, emergency certifications such as CPR and newborn resuscitation, liability insurance and continuing education. Applicants must also have a supervising physician who can examine clients and consult throughout pregnancy.

Only 24 direct-entry midwives held active Indiana licenses, according to the state’s Professional Licensing Agency.

The state’s oversight system is at the center of a case involving Becky Cantieri, a Mishawaka woman who has attended home births for decades without obtaining certification. Cantieri told a recent cease-and-desist hearing that she viewed her work as a Christian ministry and estimated she had attended about 3,000 births.

During the hearing, an attorney with the Indiana Attorney General’s Office questioned Cantieri about six stillbirths and one maternal death associated with cases in which she had been involved. The attorney said only one of the women had gone to a hospital.

In discussing the 2007 Goshen case, Cantieri acknowledged that she did not call 911 or check fetal heart tones when the mother experienced 14 seizures during a three-day home birth. Cantieri said the woman had refused hospital care after learning she had high blood pressure, which can be a warning sign of preeclampsia.

The attorney also said Cantieri and the couple waited two days to notify police about the stillbirth. In the 2003 Columbia City case, police were not contacted for four days after the mother and baby died. Cantieri attributed that delay to remaining at the home to pray.

Cantieri said she had warned the mother about risks and maintained that women should make their own decisions about whether to go to a hospital. Her attorney, Tom Dixon, argued that her unpaid religious ministry was constitutionally protected and said investigators had cleared her in the cases. The state’s midwifery committee nevertheless issued a cease-and-desist order, and Dixon said he was considering an appeal.

Medical specialists caution that even pregnancies considered low-risk can develop life-threatening complications during labor or after delivery. Dr. Erin Cleary, a maternal-fetal medicine specialist at Riley Children’s Hospital and an assistant professor at Indiana University School of Medicine, said uterine rupture is a potentially fatal emergency for both the pregnant patient and the fetus. Access to an operating room can be lifesaving, particularly when a patient has undergone multiple previous cesarean sections.

Other emergencies include postpartum hemorrhage, fetal distress and preeclampsia, which can emerge late in pregnancy or during labor. Such complications can require rapid assessment and treatment that may be difficult to provide outside a hospital.

Certified midwives are required to refer patients with high-risk conditions, including hypertension and preeclampsia, to an obstetrician. They must also transfer patients to a hospital when complications exceed their scope of practice. State rules require informed-consent documents and an emergency plan identifying the hospital to be used if a transfer becomes necessary.

The state’s annual reports indicate certified midwives initiated 32 emergency transports during labor or the postpartum period in 2025. Eight involved newborns experiencing problems that included respiratory distress and a slow heart rate.

Jill Inderstrodt, a research scientist and assistant professor at Indiana University Indianapolis, said the number of home births is too small to support a direct comparison with hospital deliveries. Still, she said the available data does not raise the same concerns that would emerge if high mortality were occurring alongside few hospital transfers.

The safety debate also intersects with gaps in maternity care access. The March of Dimes classifies one in four Indiana counties as maternity care deserts because of shortages of maternity clinicians, insurance access or facilities offering delivery services.

Hoosier women travel an average of 14 minutes to reach the nearest hospital with labor and delivery services, according to the organization. Women in maternity care deserts travel about twice as long as those living in counties with full access. Approximately 71,000 Indiana women live more than 30 minutes from the nearest hospital offering labor and delivery care.

The March of Dimes has advocated policies that make it easier for trained midwives to provide care for low-risk pregnancies, arguing that qualified providers can help address gaps in maternity services.

Dr. Nathan M. Riley, a Louisville obstetrician who supervises nine certified midwives in Indiana, said some women are drawn to home birth because they want greater autonomy during pregnancy and delivery. He consults with midwives on matters such as laboratory testing, medication and referrals to high-risk obstetricians.

Riley said a formal relationship with a supervising physician can help midwives give families information they need to make decisions, while keeping the practice connected to medical standards. In March, Indiana’s medical board granted him a waiver allowing him to supervise more than four midwives in the state at one time.

The debate ultimately centers on balancing patient choice and access to care with safeguards for mothers and newborns. Supporters of certified midwifery say formal training, screening, physician consultation and emergency-transfer plans can make home birth a viable option for carefully selected low-risk pregnancies. Medical experts warn that complications can develop suddenly, making access to emergency services critical.

The recent case involving an unlicensed practitioner highlights the distinction between regulated midwifery and birth assistance outside state oversight, as Indiana continues to confront shortages in maternity care and questions about how best to protect women who choose to deliver at home.