It’s happening again.

Following a hiatus of more than a decade, pregnant Marshallese women are coming to Hawaii late in their pregnancies, having their babies and then placing the newborns with mainland families for adoption under suspicious circumstances, health care providers, community advocates and others say.

The cases that have surfaced since November are similar to what was happening here in the early 2000s, when Hawaii became a hub for unethical adoptions of Marshallese babies, according to the physicians and others who have voiced concerns about the re-emerging practice.

The critical question today, as back then, is whether the women understand that they are giving up their children permanently — a notion foreign to Marshallese culture.

While the answer so far has proved elusive to the advocates, due in part to strict confidentiality regulations that govern release of medical information, they say their suspicions were raised because of certain common threads with the recent cases.

According to the advocates:

>> The pregnant women have come to Hawaii in small groups, assisted by the same Marshallese facilitator, who handles translation and power of attorney services and accompanies them to their medical appointments.

>> They list the same local address.

>> They seem to be coached to answer questions in ways that would minimize suspicions and circumvent regulations meant to prohibit unethical adoptions.

“The question is whether these women really understand what they’re doing, that the babies may never come back to them,” said Barbara Tom, a retired public health nurse who heads the advocacy committee Nations of Micronesia, which met in May to discuss the adoptions. “That’s the part we don’t truly understand.”

The number of cases believed to have happened since November is relatively small, probably around 20, according to Dr. Michael Walter, a pediatrician and interim medical director at the Kalihi-Palama Health Center. But Walter, Tom and others say the numbers appear to be growing.

“Now they’re seeing more and more of these cases,” Tom said of health care providers. If the delivering mothers don’t fully understand what’s happening, “this borders on human trafficking,” she added.

A spokeswoman for the Republic of the Marshall Islands in Hawaii said in an email that her government still is trying to learn who is bringing the pregnant women to the islands.

But the possibility that unethical adoptions have resumed prompted Amenta Matthew, the Marshalls’ minister of internal affairs, to recently write Hawaii’s Family Court to request help in assuring any adoptions are carried out according to the “best interest of the child” and comply with Marshallese law and a mutual understanding between the two countries, according to the June 23 letter.

The court must approve any adoptions in Hawaii.

The issue came to light more than 15 years ago in Hawaii when pregnant women starting showing up at local facilities to give birth, and advocates discovered that some women didn’t realize the adoptions meant they would permanently lose contact with their children.

In the marshallese language, there isn’t even a word for “adoption,” although it is not uncommon for a child to be raised by extended family members, similar to the hanai system in Hawaii, according to adoption experts. But the child still interacts regularly with his or her immediate family and often returns as a teenager.

For many Marshallese women a Western-style, closed adoption would be completely foreign.

“It is antithetical to everything she knows,” said Kristine Altwies, executive director of the nonprofit Hawaii International Child.

Marshallese adoptions became relatively popular because of the ease of travel from the Pacific nation to Hawaii, the high per-capita birthrate in that country, the difficult economic conditions there and the lax regulations governing international adoptions.

In some cases the women coming to Hawaii in the early 2000s were promised lucrative post-birth benefits as part of the deal, but the benefits, such as having schooling and housing costs covered, often didn’t materialize, according to the advocates.

Tom recalls one case in which a woman was left to fend for herself immediately after giving birth.

To stem the flow of unethical adoptions, several measures were implemented in the Marshalls and here.

The Marshallese government tightened regulations regarding international adoptions. The Hawaii courts also started providing third-party interpreters at all adoption hearings for parties needing such services.

When the Hawaii pipeline largely shut down, adoptions started happening in other parts of the country, especially in Arkansas, where a sizable Mashallese community has formed.

In November, however, telltale signs appeared to indicate the adoptions were returning to Hawaii.

Walter said a physician colleague learned that a small group of pregnant Marshallese women had come to Hawaii to have their babies at Kapiolani Medical Center for Women & Children. Several other groups followed. The obstetrician- gynecologist was treating some of the women.

The common elements of each case “raised red flags for her,” Walter said.

But when the physician questioned several of the women, they denied being coerced, according to Walter. “That’s why her hands were tied. She had no proof.”

Kristen Bonilla, a spokeswoman for Kapiolani Medical Center, said in a written statement that any adoption agreement is between the infant’s mother and the adoption service and does not involve the hospital. But Kapiolani’s staff is aware of the issues involving Marshallese adoptions, she noted.

“While we must adhere to the requirements of health information privacy and security laws, our staff has been advised on steps they can take in these situations when there is sufficient factual information to warrant further action, including notifying the appropriate authorities and encouraging mothers to contact the Consulate General of the Marshall Islands,” Bonilla wrote. “In these situations — as it is with all of our patients — our priority is to address our patients’ medical needs and provide the highest quality care possible.”

The advocates say the women appear to be coached on what to tell the doctors and others to get around potential legal restrictions. Some, for instance, say at their initial appointment that they intend to take the babies back to their country — only to change their minds closer to the birth.

If they don’t state their true intention upfront, the women do not need a special visa that is required to come to the U.S. for purposes of adoption, according to the advocates.

“The regulations are very easy to skirt,” Altwies said, lamenting what she described as a vastly underregulated process.

The adopting families reportedly pay tens of thousands of dollars to adopt the babies. Without realizing some of the long-term ramifications to the babies, the women often are driven by an intense desire to become mothers and the belief that they are helping a child leave an impoverished country, the advocates say.

“The motivation can be so powerful it blinds you to everything else,” Altwies said of the adopting mothers.