Julianne Guy first saw a home birth in a village in rural Guatemala during her stint in the Peace Corps in the 1980s. She became friends with the village midwife, an Indigenous Mayan woman who spoke mostly Kaqchikel, who started bringing Guy with her to the homes of women who were giving birth. Guy was amazed at how births in the village seemed such a natural part of day-to-day life.
It looked nothing like any birth she had heard of in the United States, where births took place in sterile hospital rooms under bright lights, overseen by doctors and nurses who were often strangers to the woman delivering.
Back in the U.S., Guy became a Certified Professional Midwife, a process that involved three years of schooling and training (Guy also has a Master’s in Public Health). She began working across Colorado’s Western Slope in the early 2000s, in some of the state’s most rural and underserved communities.
Although midwives can work in hospital settings as specialized nurses, Guy chose to work with women who choose to give birth at home, what’s called a “direct-entry” midwife.
That meant not just bringing physical and emotional comfort through the labor and delivery process, but performing important medical assessments, including monitoring vitals on the mother and newborn, managing postpartum hemorrhaging, helping with breastfeeding, and crucially, advising patients on the appropriate testing and screening options and when to seek hospital care if complications arise.
After more than two decades of practice, though, Guy joined a group of direct-entry midwives in a class action lawsuit filed last week against the state agencies that regulate them, Colorado’s office of Direct-Entry Midwifery Registration and its umbrella agency, the Division of Professions and Occupations (DPO).
For years, the lawsuit states, Guy and other direct-entry midwives in Colorado have been subject to bias and discrimination by regulators.
“Practicing by myself, I kind of felt like maybe I was a one-off,” said Guy. Through the lawsuit, she realized she was far from alone.
A history of bias
According to data obtained in a CORA request filed by Elephant Circle, a Colorado-based birth justice organization, twice as many direct-entry midwives received summary suspensions from the DPO compared to doctors and nurses. On average, complaints against direct entry midwives are open for 500 days — twice as long as other regulated professions that were queried, leaving them unable to practice and, the lawsuit alleges, dealing with financial and emotional stress.
Another plaintiff in the lawsuit, Kalie Caler, is a licensed direct entry midwife in Archuleta County. She’s been unable to practice for over four years due to the DPO’s pending investigation of a complaint against her license — despite having documents that disprove the allegations against her.
Colorado’s office of Direct-Entry Midwifery Registration and the Division of Professions and Occupations (DPO), declined to comment on the litigation.
Indra Lusero, the founder and CEO of Elephant Circle and the lawyer representing Guy and the other plaintiffs in the lawsuit, said that there’s “a long history of bias against midwives.” Lusero said bias traces back to the 1920s when a national campaign tried to eliminate midwifery entirely, as a way to elevate obstetrics as a medical specialty.
The idea, said Lucero, was to impose “pathologic dignity” to childbirth, or the notion that “pregnancy is a sickness and you need doctors to solve it.”
That dynamic trickled into Colorado’s legal framework. When Guy first started practicing midwifery as an apprentice in 1990 under Bill Dwelley, a Montrose-based midwife, the practice was illegal in Colorado. Dwelley, a certified Emergency Medical Technician, operated underground. It wasn’t until 1992 that the state finally legalized midwifery.
A valley without a midwife
In the more than two decades that Guy has practiced midwifery on the Western Slope, she’s routinely driven around 5,000 miles per month. After stints in Norwood and Paonia, Guy settled in Carbondale in 2010, where she was the only direct-entry midwife living in the Roaring Fork Valley. In those 25 years, she said she never took a vacation.
Despite the grueling schedule, the work felt meaningful to Guy. Studies show that births attended by both nurse midwives and direct-entry midwives have fewer complications, but in the U.S., there are just 4 midwives present for every 1,000 live births. Other high-income countries have between 30 and 70 midwives present, and lower maternal and neonatal mortality rates.
Over time, Guy found state regulators treated her differently than other medical practitioners, particularly when it came to dealing with clients who declined her recommendation to seek more advanced medical care.
“A nurse, a doctor, a physical therapist can tell you what to do, but they can't make you do anything,” said Guy, adding that a nurse or doctor would simply note a patients’ decision to not follow medical advice in their records. But when those situations involved midwives, there was a different standard.
“We have been persecuted for that repeatedly, for not making the clients do what we said,” she said. Guy realized that regulators often seemed to be suggesting that midwives didn’t know how to make their clients follow their recommendations, “therefore, we didn't do the right thing,” said Guy.
In one case, Guy advised her patient to see a pediatrician for her newborn who was showing signs of jaundice and illness. She recommended repeatedly that her client take her newborn to a pediatrician, but the client declined because she said she had suffered previous trauma in the medical system.
Guy documented the client’s choice and her reasoning, but the DPO had her license temporarily suspended. During the course of its investigation, which lasted two years, Guy couldn’t work or support the families who had been in her care. She spent over $20,000 on legal fees until she was told she could relinquish her license, sign a statement that would go on her record saying she performed “substandard care,” or go to trial (Guy said she was told the case would be returned to the DPO and Zen Mayhugh, the DPO director could override whatever the judge ruled). Guy opted to sign the statement.
Guy often felt like she was caught between a rock and a hard place. “If we stay to provide stability and care, we are punished. If we leave, we have abandoned them, which is also illegal.”
The result, she said, is a system where, either way, midwives will end up with some sort of injunction from the state. “We are kind of damned if we do and damned if we don't, she said”
Last year, Guy moved to California to continue her work as a midwife. She knew she was at the end of her career and in her final years, she wanted to feel valued — and to do her work in a state that respected women’s autonomy when it came to how and where they wanted to give birth.
“I just didn’t want to be in that stress state all the time,” she said.
Guy’s departure means there is currently no direct-entry midwife living in the Roaring Fork Valley. Women who want to work with a midwife for a home birth have to drive to Delta or Grand Junction for all their prenatal care if they want the midwife to be present for the birth.
According to Lusero, the lawyer representing the Colorado midwives, the lawsuit could take several years to make its way through the court system.
Guy hopes the lawsuit will improve regulators’ understanding about what direct-entry midwives do and who they serve — oftentimes families who want to remain outside the mainstream medical establishment — as well as their shared goals of safe and healthy mothers and babies.
