A series of infant and maternal deaths overseen by unlicensed midwives led Hoosier lawmakers to a conclusion in 2013: legalize and regulate the practice to make it safer.
The deaths included a Columbia City mother who died with her baby in 2003 after the woman’s uterus ruptured during a delivery at her home, and the 2007 stillbirth delivered by a Goshen mother who suffered repeat seizures during a three-day home birth.
Both were attended by an unlicensed midwife in Indiana with no formal training who was recently ordered to cease and desist. Neither were taken to the hospital.
Would a path to licensure with formal training protect women who want to deliver their children at home?
Thirteen years later, Hoosier women are increasingly turning to midwives for care, as fewer obstetricians practice in the state and women report declining trust in the medical system.
Supporters say the outcomes show home birth is a safe option for low-risk pregnancies when attended to by a certified direct-entry midwife, but unlicensed midwives continue to work underground.
Out from underground
Lay midwives deliver babies outside the hospital, typically at the mother’s home with little to no medical intervention, under the belief birth is a natural process.
They did so at risk of prosecution for decades. Only registered nurses with advanced degrees could practice midwifery in Indiana until 2013, when lawmakers legalized direct-entry midwifery.
The term itself is a source of confusion: midwives care for women through pregnancy, childbirth and postpartum periods, but their training, educational background and scope of practice varies widely.
Unlike a certified nurse midwife, there was no formal standard of training for lay midwives, who often learned through self study or apprenticeships with other midwives.
The direct-entry certification offered lay midwives the chance to get on the right side of the law, so long as they underwent formal training and reported outcomes to the state’s newly formed midwifery committee.
Licensed midwives have delivered or assisted with more than 3,200 live births since Indiana issued its first direct-entry midwife certificate in 2017, with seven stillbirths and zero maternal deaths reported to the Indiana Department of Health in that time.
Women are choosing this option because “they want individualized care and the continuity of care,” said April Brake, president of the Indiana Midwives Association and the newest member of the state’s midwifery committee.
“You hire a provider to be at your birth and to walk with you through pregnancy, labor and postpartum with your newborn, and that provider is consistent. We aren’t doing prenatal with a provider that you’re never going to deliver you.”
What it takes to become a direct-entry midwife
Indiana requires midwives to be at least 21 years old.
Applicants must obtain an associate’s degree or higher in nursing or a midwifery program accredited by the Midwifery Education Accreditation Council.
An apprenticeship consisting of at least 80 births and certifications in emergency skills like CPR and neonatal resuscitation are also required, as is liability insurance and continuing education.
The final qualification: a supervising physician willing to examine a midwife’s clients and consult throughout the pregnancy.
“Indiana expects us to have more births and more experience to be a licensed midwife here, and I believe that’s only made our outcomes even better,” Brake said.
Only 24 direct-entry midwives in Indiana have an active license, according to the Professional Licensing Agency.
These midwives are supervised by the midwifery committee, a three-member board comprised of professional midwives who review annual reports and consumer complaints.
Unlicensed midwives are not held to the same standards, often operating outside the notice of authorities until there is a death or complaint.
‘Called by God’
Becky Cantieri says she was called by God 36 years ago to deliver babies for Christian women without medical intervention, relying instead on the “power of prayer.”
A homemaker and doctor’s wife in Mishawaka, Cantieri underwent one year of training toward a licensed practical nurse certification before she started delivering babies — 3,000 to date by her estimate.
At a cease-and-desist hearing last week, Cantieri said she does not advertise her ministry or accept payment, other than occasional gifts.
She did not seek certification when Indiana legalized direct-entry midwifery, becoming one of an unknown number of unlicensed midwives who continued to practice outside state oversight.
“I would not jeopardize the women and babies without the power of God to protect them,” she said, “because I know. I’ve seen it. I see how a woman can die.”
Carah Rochester, an attorney in the consumer protection division of the Indiana Attorney General’s Office, proceeded to ask Cantieri about six stillbirths and a maternal death.
Only one of the women went to the hospital.
In one case, Cantieri admitted she did not call 911 or check for fetal heart tones when a Goshen woman suffered 14 seizures during a three-day home birth she attended in 2007.
Cantieri said the woman refused to go to the hospital when she learned of her high blood pressure, a sign of preeclampsia.
Cantieri and the couple failed to notify police of the stillbirth for two days, according to Rochester.
Cantieri failed to call the police for four days following the 2003 deaths of a Columbia City woman and her baby, a delay she attributed to her prayer vigil over the woman.
“I just didn’t think I’d ever lose a mom,” she said. “I thought God would protect every one of them, but he didn’t. That was a real crisis for me. I stayed and prayed for that mother while she decomposed — prayed and prayed and prayed until God finally spoke to my heart and said, ‘Call.'”
The mother underwent cesarean sections for at least three previous pregnancies, which put her at high risk of uterine rupture.
Dr. Erin Cleary, a maternal-fetal medicine specialist for Riley Children’s Hospital and assistant professor at Indiana University Medical School, said women who undergo one or two c-sections can safely attempt to labor vaginally in the hospital if the incision was made through a thin part of the uterine muscle, but the risk of uterine rupture increases with each additional cesarean.
“That is absolutely a life threatening emergency for both the fetus and the pregnant patient,” she said. “Access to an operating room can be live saving.”
Cantieri said she informed the mother of the risks, as she does for the other women she ministers to, repeatedly telling the committee she “gladly” takes women to the hospital when asked.
But it has to be the mother’s decision, she said.
Cantieri said the woman wanted to stay home because she had contracted an infection and nearly died at the hospital during a previous delivery.
“I can’t make them go in. If they choose to stay home, then God has told me you stay with them and you support them and you help them.”
‘Cease and desist’
The case is familiar to Alicia Diane Holmes, a certified professional midwife who was appointed to the state’s midwifery committee in 2013, who said the woman had sought her assistance too.
“She said, ‘Diane, will you attend to me,’ and I said, ‘No, you’ve had four c-sections. That is not safe. I will not,'” Holmes recalled during the hearing.
Holmes said the coroner notified her the mother’s body had been left in the home for days, asking her advice for how to prevent such a delay in the future.
The Indiana Midwives Association started to work with lawmakers on legislation to require timely death notification, eventually culminating in the 2013 law on certification, she said.
Tom Dixon, a St. Joseph County attorney associated with the Alliance Defending Freedom, argued Cantieri’s practice is a ministry protected by the U.S. Constitution. Her refusal to accept compensation separates the activity from practicing midwifery without a license, he argued.
“My client has had thousands of successes — not just a couple, but thousands,” Dixon said. “So, in the entirety of her career, we have six or seven stillborns and one mother who died.” Investigators cleared Cantieri in each case, he said, and in some instances the stillbirths “occurred before she even got on the scene.”
The midwifery committee issued a cease-and-desist order to Cantieri.
Dixon said he is considering an appeal.
Other disciplinary cases
Cantieri is not the first midwife subject to discipline.
The committee reprimanded a midwife for performing a tongue tie procedure on an infant who was later rushed to neonatal intensive care for a severe hemorrhage. The infant survived, and the midwife later paid a $5 settlement to resolve the complaint.
Another midwife spent 17 months in probationary status following the stillbirth of a breech fetus, as the committee concluded she waited too long to initiate transfer to the hospital and did not develop a written emergency plan prior to the delivery.
The attorney general’s office is investigating three consumer complaints against other midwives, though details of those cases are not public.
A DeKalb County judge sentenced a St. Joe woman to a year of probation for practicing midwifery without a license in the 2012 delivery of four infants, two of whom died, though her attorney argued she did not contribute to the deaths.
A similar fate awaited two elderly Adams County Amish women convicted of practicing midwifery without a license in 2018.
Informed consent
Women must sign consent and disclosure forms before a certified midwife can work with them.
The forms outline an emergency plan, including with hospital the mother will go to in an emergency, and collaborative agreement with a nearby physician.
While midwives cannot prescribe medications, their supervising physician can order them local anesthetics, oxygen, vitamin K, anti-hemorrhagic and other medications.
By law, certified midwives must refer women with high-risk pregnancies like preeclampsia or hypertension to an obstetrician.
“It’s pretty apparent if they’re going to be high risk,” Brake said, “and at that point we turn them away.”
The same is true for labor and delivery: If a complication exceeds the midwife’s scope of practice, they transfer the mother to the nearest hospital, she said.
How safe is home birth now?
Certified midwives have reported zero maternal deaths since 2018, and while stillbirths have increased slightly since then, so too have the total number of live births they attended, according to annual midwifery reports.
Reports show midwives are referring women to obstetricians for high blood pressure, breech fetuses, twins, gestational diabetes, fetal distress and other complications before a woman goes into labor.
Midwives initiated 32 emergency transports during labor or postpartum last year, including eight newborns who were rushed to the hospital with respiratory distress, a slow heart rate and other complications, according to the 2025 report.
Jill Inderstrodt, a research scientist and assistant professor at Indiana University-Indianapolis, said the home birth population is too small to compare to hospital births, but the data that does exist looks good.
“If there were low transfers and high infant, fetal or maternal mortality, then we might be concerned,” she said.
Data on stillbirths isn’t a great metric of safety, as stillbirth can occur at any time after 20 weeks gestation. “So we don’t know when it’s happening and we don’t know who it’s happening to,” she said.
Maternity care deserts
Even uncomplicated pregnancies can become dangerous.
A woman may develop postpartum hemorrhage, or heavy bleeding after delivery that can become life-threatening in a short period of time, said Cleary, the maternal-fetal medicine physician.
Other complications like fetal distress can also arise during labor, which she said can be difficult to properly assess without the monitoring and quick intervention available in a hospital.
“Patients can be at risk for hypertension complications like preeclampsia that may not really appear until the end of pregnancy, or even for the first time during labor,” Cleary said.
The farther away the woman is from a hospital, particularly one with a dedicated labor and delivery unit, the less time doctors have to intervene.
One in four Indiana counties are considered maternity care deserts, either due to the lack of clinicians, insurance or birth facilities, according to the March of Dimes.
The group found that while Hoosier women travel an average of 14 minutes to reach the closest hospital with labor and delivery services, women in maternity care deserts travel twice as long than those in counties with full access.
Some 71,000 women live more than 30 minutes from the nearest hospital with labor and delivery services, the report found.
In response, the March of Dimes is pushing for policies to make it easier for trained midwives to work with low-risk obstetric patients.
Dr. Nathan M. Riley, a Louisville obstetrician who acts as the supervising physician for nine certified midwives in Indiana, said women are leaning into the idea that their bodies are capable of giving birth on their own.
“If we’re only looking at deaths, a lot of people can make a pretty good argument for the hospital system as the default,” he said. “But if we’re looking at the whole person, its really, really hard to make that argument, because a lot of women feel like they don’t have much autonomy” in the hospital.
Riley supports midwifery in 18 states. He estimates he supervises or consults with 100 or so midwives at any given time—ordering labs, medications and referrals to high-risk obstetricians as needed.
Supervision is minimal: Midwives call Riley when they have a question or need medication, but he doesn’t order them around.
“There isn’t a ‘Do it this way’ attitude from me,” he said. “It’s, here’s what the (American College of Obstetrics and Gynecology) says. Here’s what the medical board says. Here’s what my experience says. The midwife then takes that information, presents it to the family, so that the family can feel fully informed before they make a decision.”
In March, the medical board granted a waiver to Riley, allowing him to supervise more than four midwives in Indiana at once.
The alternative, Riley said, would be for women and midwives to go underground and practice without a license.
“Midwives, fortunately, are available. Otherwise, women would say, ‘I’d rather have a baby in my own backyard or in a cabin in the woods than go to the hospital, because they’re not oriented toward my interests.”
Indiana Capital Chronicle is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Indiana Capital Chronicle maintains editorial independence. Contact Editor Niki Kelly for questions: info@indianacapitalchronicle.com.
