KANSAS CITY, Mo. -- On the surface, nothing about last month's picture-perfect delivery of Linda Kerr seemed amiss.
Her mother needed no pain medication. The labor was quick. Excited family members gathered nearby to welcome the newborn into the world.
But in Missouri, where the Kerr baby was born in a carefully planned home birth, the experienced midwife hired to oversee the delivery was committing a Class C felony.
"Can you imagine that?" asked Jessica Kerr, the mother of the healthy newborn. "I make the personal choice to have my baby at home, assisted by a midwife of my choosing, and that is illegal?"
Even as midwifery grows increasingly popular nationwide, with an estimated 40,000 babies born outside hospitals last year, a handful of states remain severely restrictive of the profession. In nine states, including Illinois, Iowa and Indiana, some forms of midwifery are illegal, though not a felony. Missouri, the only state where midwives can be charged as felons, has long been the most hostile to the practice of midwifery, though hundreds of families like the Kerrs rely on an underground network of midwives who quietly operate outside the law.
Now Missouri finds itself in the national spotlight on the issue. A state lawmaker whose wife was aided by a midwife pushed through legislation this year that would allow midwives to practice freely in the state, and Gov. Matt Blunt signed the bill into law. But opponents quickly filed a lawsuit to overturn it, and state courts ordered an injunction. The law cannot go into effect until the Missouri Supreme Court rules on its legality, probably early next year.
What happens in Missouri is being closely watched by both sides: midwifery advocates who argue that childbirth is not a medical emergency and that women should be able to deliver at home with a certified midwife, and members of the medical establishment who argue that home births without physicians are perilous ventures.
"This case is on everyone's radar," said Debbie Pulley, director of public education for the North American Registry of Midwives.
Missouri and the nine other states restrictive of midwifery are certainly a national minority. In 40 states, some form of home-birth midwifery is legal, according to the group.
At issue for states distrustful of midwifery is the credentialing and training of the midwives delivering babies. "Lay midwives," unlicensed practitioners whose training usually consists of self-study and who have no state or national certification, are allowed to practice in a few places in the U.S. Missouri and the nine other states go further, outlawing "certified professional midwives," practitioners who are nationally certified through the Midwives Registry in a highly selective process that takes three to five years of study, including one year of clinic practice and an eight-hour written exam.
All 50 states allow "certified nurse-midwives" to practice. These are midwives who are registered nurses, or nurse practitioners, who work under the supervision of doctors, almost always in a hospital.
But midwife-assisted home births are the ones that spark much heated debate. The American College of Obstetricians and Gynecologists has said that it "strongly opposes" home births. Opponents of midwifery often point to hazards that can accompany childbirth, such as the need for an emergency Caesarean delivery. They often cite statistics that complications arise in up to 1 in 10 births.
Despite the illegality of having babies at home with a midwife's help, a significant number of women in Missouri are doing it anyway, a reality that mirrors the growing popularity of home births nationwide. An extensive underground network of illegal practitioners has developed in Missouri in recent years, according to Sen. John Loudon, the Missouri lawmaker who spearheaded the legislation. He says about 1,000 Missouri women give birth at home each year through "this sort of black market."
Kerr of suburban St. Louis said she had an easy time finding a midwife through friends. She said many women choose home births with midwives to limit hospital pressure to use drugs for pain or to have a Caesarean; to have a more intimate, controlled and personal birth; or because of religious beliefs that keep them away from hospitals.
"The bottom line is that there is no more important or personal experience than giving birth," she said. "We believe we should have the right to choose to do that in the way that's best for us."
Midwifery advocates often cite what they see as the biggest irony of anti-midwife laws: that a good Samaritan who helps a woman deliver her baby on the side of a road or in a taxi cab is not subject to prosecution, but a trained midwife who helps a woman carefully plan her out-of-hospital birth is.
"There is no reason Missouri should have the most draconian law on the books," said Loudon, whose wife gave birth to a healthy baby after the midwife identified why she had been having repeated miscarriages - a diagnosis that had eluded physicians.
Loudon said he believes there is a good chance the courts will uphold the legislation allowing midwifery. But even if the courts rule against it, the senator said he will continue to push for legislation to allow nationally certified midwives to practice in the state.
Kirsten Scharnberg writes for the Chicago Tribune.