The deadly failure of American homebirth midwifery


It’s hard to become a real midwife.

American certified nurse midwives (CNMs) are the best educated, best trained midwives in the world. They have an undergraduate degree in nursing, a master’s degree in midwifery, and extensive hospital training in diagnosing and managing birth complications. European, Canadian and Australian midwives are also well educated and well trained; they have an undergraduate degree in midwifery and extensive hospital training in diagnosing and managing birth complications. In addition, American, European, Canadian and Australian midwives meet the International Confederation of Midwifery (ICM) Global Standards.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]No one should be allowed to call herself a midwife unless she meets the International Confederation of Midwifery Global Standards.[/pullquote]

But what if you couldn’t be bothered (or couldn’t handle) the necessary preparation to meet the ICM Global Standards but wanted to masquerade as a midwife anyway? You could take a correspondence course, attend a few dozen deliveries outside the hospital, pay money for an exam and you are a “certified professional midwife” (CPM). Actually, you don’t even have to complete even those minimal requirements. You can simply submit a “portfolio” of births that you have attended, pay the money and take the exam, and voila, you too are a CPM.

What would happen in a system where consumers couldn’t tell the difference between real midwives and lay people who awarded themselves the bogus CPM credential?

You don’t have to imagine. In a stunning journalistic review, Failure to Deliver, reporters Emily Le Coz, Josh Salman and Lucille Sherman, have produced a comprehensive look at the deadly failure of American homebirth midwifery.

The review is deep, wide ranging and involved dozens of professionals as well as grieving families and I encourage everyone to read every word. But, in truth, the entire review can be summed up in one sentence:

When you allow lay people who can’t meet the Global Standards of Midwifery to masquerade as midwives, babies and mothers die of medical neglect.

The stories are gut wrenching:

Baby Aquila never took a breath.

Her limp body slipped from between her mother’s legs in a river of blood during a Texas home birth in December 2009. The certified professional midwife, who missed a cascade of earlier indications of the baby’s distress, tried to save the girl. But she had locked her medical kit in the car and had to improvise…

Liz Paparella buried her daughter two days before Christmas.


The laboring mom didn’t know her son was breech when she checked into Gentle Birth Options, a freestanding birth center in the Florida Panhandle community of Niceville. Riley trusted the midwife to guide her through the process.

But Cynthia Denbow, a certified nurse midwife and birth center owner, didn’t check the baby for more than an hour. By the time she discovered its bottom-first position, Riley was fully dilated and ready to push, according to Florida Department of Health records D…

Denbow called no physician. She encouraged Riley to stay at the birth center and push.

Riley did so for 22 minutes, as her unborn son went into distress and Denbow finally called 911. Doctors at Fort Walton Beach Medical Center delivered Baby Franklin by emergency C-section and rushed him to the neonatal intensive care unit for resuscitation. They couldn’t save him.


…[Florida midwife Deborah Jacobs] Marin promised she would transfer Pino in case of emergency, as state regulations require.

Instead, the midwife let Pino actively labor for hours while her baby was stuck inside the birth canal, her head turtling in and out. The little girl suffered irreversible brain damage from a lack of blood and oxygen, court records show.

When Maddie finally emerged, she was covered in thick, pea soup meconium — the baby’s first stool — which stained her fingernails yellow, Pino recalled. She didn’t cry. She was purple and not breathing. Only then did Marin yell for someone to call 911.

The little girl lived in a semi-vegetative state until she died in February 2013, three days before her third birthday.

There are many more tragic stories in the piece, but all are eerily similar in their basic facts:

1. Failure to inform parents that CPMs don’t meet the Global Midwifery Standards.

These tragedies almost always start with a bait and switch. CPMs boast about the excellent out of hospital outcomes of Dutch, Canadian and Australian midwives without telling parents that they themselves wouldn’t be allowed to practice in those countries because of lack of education and training.

2. CPMs converting the liability of not being allowed to practice in any place with rigorous professional standards into the virtue of a homelike environment.

CPMs promote out of hospital birth because it is the ONLY way they can make money. Unlike ALL other midwives in the industrialized world, CPMs are alone in their inability to practice in hospitals and are therefore alone in their inability to manage their patients in both places. Therefore they have an incentive to ignore risk factors and avoid medically indicated transfers.

3. CPMs routinely violate the law.

Many CPMs practice illegally by ignoring state laws about who can be a midwife. In states that license CPMs, they also practice illegally by failing to meet even the minimal requirements promulgated specifically for CPMs including having a obstetrician to back up their practice, having a designated hospital to which they can transfer women experiencing complications, and by ignoring laws that bar them from overseeing high risk pregnancies and births.

4. Reckless disregard of the signs and symptoms of impending or ongoing life threatening complications.

If CPMs recognize complications (and many can’t), they have multiple incentives to ignore them. They lose control of patients they transfer. They are often practicing illegally and therefore need to hide their actions. They have represented themselves to their clients as knowledgeable but any transfer has the potential to reveal that they had no idea what they were doing.

Countries where homebirth is practiced routinely have strict criteria for transfer and high transfer rates. That’s why homebirth is relatively safe in those countries. Most CPMs have no transfer criteria and boast of low transfer rates. That’s why babies (and sometimes mothers) die.

5. Industry capture of regulatory bodies.

To the extent that CPMs are regulated, they are regulated by other CPMs, either those on state licensing boards or those who run CPM professional organizations. In other words, these regulatory bodies are captured by the industry they are designed to regulate. A medical equivalent might be if obstetricians served as the judge, lawyers and jury for obstetric malpractice cases AND believed that their primary purpose was to protect obstetricians, not patients.

Fortunately, the solution to these preventable tragedies is simple. All we have to do is what every other country in the industrialized world has already done: mandate that the ONLY people who can call themselves midwives are people who meet the Global Midwifery Standards. Contrary to the claims of homebirth advocates, this is NOT an issue of reproductive freedom or medical paternalism, it is an issue of truth in advertising.

We must abolish the CPM designation and make it illegal for these women to call themselves midwives. What should they call themselves instead? It doesn’t really matter so long as there is no possibility that mothers will confuse them will real midwives.