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SPEAKER: In Minnesota, you need a license to cut hair, open a restaurant, or run a day care. But the state allows midwives to assist in home births with no license. The number of Minnesota women choosing home birth has skyrocketed over the last two decades. And even some midwives say the gap in state law poses a danger to mothers and to babies. And Catharine Richert has more in this report.

CATHARINE RICHERT: With her second baby, Paris Alvar knew she wanted a different birth experience than she'd had nearly a decade earlier with her son. It was a long and difficult labor. And she was unhappy with several medical interventions. Things didn't go well at home, either.

PARIS ALVAR: Right after I had him, I remember just being really exhausted right after he was born. I didn't really feel much of a bond at first. So I kind of felt really guilty about that for a long time.

CATHARINE RICHERT: A relative suggested a home birth, and Alvar chose midwife Margo Nelson.

PARIS ALVAR: When we met Margo, it was just we knew instantly that that bond was there.

CATHARINE RICHERT: Nelson doesn't carry professional midwifery credentials. And that actually appealed to Alvar and her partner.

PARIS ALVAR: For us, it was her experience that mattered more than any test that she took.

CATHARINE RICHERT: Nelson says she has extensive training through apprenticeships and coursework. She says her decision to practice without a license stems from her fundamental belief that her relationship with her clients doesn't require state oversight.

MARGO NELSON: By not being licensed, I can truly serve the families that I work with, as opposed to serving a third party. In the case of licensing, that's the state.

CATHARINE RICHERT: Nelson is breaking no laws. Minnesota is one of only two states where licensure is effectively voluntary for home birth midwives. The other is Utah. Nurse midwives who typically practice in hospitals must be licensed.

The Minnesota Board of Medical Practice has licensed 44 home birth midwives. MPR News has identified 16 more with no license, offering midwifery services. The split is emblematic of the debate over licensure among midwives.

Supporters say current state law poses dangers to mothers and babies. They argue there's no way to enforce standards of care and no accountability if an unlicensed midwife makes a serious mistake. They say consumers cannot be sure of an unlicensed midwife's training.

Opponents say licensure is a barrier for midwives who are low income or from diverse cultures and religions. And they say requiring licensure would infringe on a woman's right to choose home birth. Midwife Rebeca Barroso says she started practicing 40 years ago, before licensure was an option.

REBECA BARROSO: I got involved in it as a way to change the world.

CATHARINE RICHERT: It was the 1970s. Barroso assisted in home deliveries, a practice organized medicine generally frowned on then, as it does now. She believed the natural process of birth had become overly medicalized. Then Barroso presided over a tragedy.

REBECA BARROSO: The woman's way overdue. Things are not progressing. I miss that the baby is breech.

CATHARINE RICHERT: Barroso says the mother finally agreed to go to the hospital. Doctors performed a cesarean section, but it was too late.

REBECA BARROSO: The baby dies. I was beside myself.

CATHARINE RICHERT: The baby's death was a turning point for Barroso.

REBECA BARROSO: I started thinking, we got to regulate ourselves. We have to be accountable.

CATHARINE RICHERT: That conviction led Barroso to earn her nursing degree. And she was only one of several midwives talking to state officials 30 years ago about making home birth safer. Those discussions led to a bill sponsored by Republican State Senator Jim Abeler of Anoka, then a state representative. Five of his six children were born at home. And he supported bringing home birth into the mainstream.

JIM ABELER: There was a cry about women and families wanting the opportunity to deliver the child in the manner that they would choose. And so we created a guaranteed opportunity for people by getting licensed.

CATHARINE RICHERT: Abeler now says he wants to reconsider the legislation. The number of unlicensed midwives is a surprise to him.

JIM ABELER: We expected that the midwives would choose the option of being credentialed.

CATHARINE RICHERT: Home birth is considered safe as long as the mother's pregnancy is uncomplicated. Minnesota Midwives Guild President Tracey Lapointe defends the status quo as democratizing home birth. For Lapointe, the barrier to licensure was financial. Getting a license requires years of training, and it culminates in a test. It's $100 for a license and each renewal.

TRACEY LAPOINTE: I was a poor single mother. It is a nursing board-type test that's only offered in a few places in the country and only a few times a year. It would be an expensive test. It's travel that I didn't have. It's child care that I didn't have.

CATHARINE RICHERT: Lapointe also says the advent of licensure hasn't closed the philosophical rift between home birth midwives and some doctors, who believe hospitals are the safest place to deliver babies. And licensure forces midwives to accept state-imposed limits on their practice. So for instance, they aren't supposed to assist mothers who are pregnant more than 42 weeks. And they must inform their clients about the risks of home birth.

LEAH FITZGERALD: If you choose not to be licensed, you don't have to follow any of that criteria the state has set out.

CATHARINE RICHERT: This is Leah Fitzgerald. She spent 12 years as a labor and delivery nurse before getting her law degree. She's now a medical malpractice attorney with a major Twin Cities law firm. She says Minnesota law for licensing midwives has a large and potentially dangerous hole by leaving it voluntary.

LEAH FITZGERALD: When it's voluntary, we take away all of the oversight that's created by licensure statutes. If you don't have oversight, it's kind of the Wild, Wild West. And they can be providing care to a high standard, they may not be.

CATHARINE RICHERT: Fitzgerald acknowledges most babies born at home are healthy. But she points out a very small percentage are not, and they need immediate medical help. She says if unlicensed midwives lack adequate training, they may miss a dangerous complication.

LEAH FITZGERALD: You don't know until it's too late. And then when it's too late and your baby has a brain injury, that family's life is forever changed.

CATHARINE RICHERT: Practicing out of her home in Duluth, Licensed Midwife Tavniah Betts says licensure benefits families and midwives by providing a way to adjudicate complaints. She says unlicensed midwives are risking prosecution from a bad outcome.

TAVNIAH BETTS: If you have licensure and your license and you have some sort of lawsuit, you would be reviewed by the board. And there are these processes that actually are quite, for me, reassuring to have, instead of not knowing what's coming down the pike if you have a bad outcome.

CATHARINE RICHERT: Betts recently finished her master's in public health. She studied midwifery licensure throughout the country and says Minnesota's approach defeats the collection of meaningful data about home birth safety that could inform public policy.

Across town from Betts, Paris Alvar says the birth of her daughter Rosie was far more relaxed than her first delivery. But an early ultrasound revealed she was at risk of swift and severe hemorrhaging during labor. Obstetricians typically require follow-up ultrasounds to ensure the condition clears before delivery. Midwife Margo Nelson says the prospect of that complication can lead to months of anxiety during pregnancy. So she gave Alvar research, showing the condition would likely resolve on its own.

MARGO NELSON: So she was really grateful to have that information and then be able to make choices based off of that information, instead of just fear.

CATHARINE RICHERT: Alvar says she didn't bother with a follow-up ultrasound because Nelson showed her the odds were on her side. And she trusted Nelson to rush her to the nearest hospital, if necessary.

PARIS ALVAR: Margo wouldn't have wasted a second. If she thought we needed to go, we would have gone.

CATHARINE RICHERT: Nelson says she didn't insist on a follow-up ultrasound because supporting a mother's wishes, even if there are possible health risks involved, is paramount.

MARGO NELSON: Women are not machines. And so to apply things across the board to every birthing body just feels really wrong to me.

CATHARINE RICHERT: Tomorrow on the road with one of the busiest birth midwives in Minnesota, who says state licensure would prevent her from serving Amish mothers in her area. Catharine Richert, MPR News, Duluth.