Kalie Caler was 8 years old when she decided that she wanted to deliver babies for a living. Born and raised in Pagosa Springs, she completed midwifery school in Florida before moving home to start Mountain Roots Midwifery in 2019.
As the only midwife in town, she delivered more than a dozen babies during her first year, traveling an hour or more to support clients as far away as Mancos, Durango and Crestone. She also birthed all three of her own children at home.
Then, in February 2022, one of her clients went into labor and the birth didn’t go as expected. The baby boy wasn’t breathing when he was born. Caler resuscitated him, and her assistant called an ambulance. By the time they arrived, Caler says, the mom’s vitals were crashing. She was transferred, in a snowstorm, to Pagosa Springs Medical Center, where there is no obstetrician or neonatal intensive care unit, and then to Mercy Hospital in Durango, where she died.
A friend of the mother’s, who Caler had never met, filed a complaint against the midwife through the Department of Regulatory Agencies. In the four years since, Caler has not been permitted to practice. DORA’s investigation into her actions on that winter day is still ongoing.
In July, Caler will become the first midwife in Colorado to go to trial in administrative court since midwifery was legalized in the state in 1993 (after being restricted in 1976).
But she’s not waiting until summer to fight for her profession. On May 5, Caler joined a group of direct-entry midwives in a lawsuit against the Colorado Division of Professions and Occupations, a department within DORA that manages licensing and registration for more than two dozen healthcare professions plus other occupations. Direct-entry midwives are not required to have an academic degree but are certified through the North American Registry of Midwives to provide prenatal care and birthing support in birth centers and homes.
The lawsuit calls the agency’s actions against direct-entry midwives like Caler “discriminatory and unlawful”; alleges that the division of professions and occupations and program director Zen Mayhugh willfully disregard evidence that supports midwives during the complaint process; and says that the current system limits midwives’ abilities to practice to their full scope and parents’ access to community birth support.
The Office of Direct-Entry Midwifery Registration would not comment on pending litigation.
Colorado’s regulatory model is unique
There are more than 550 midwives licensed in the state of Colorado. Of those, just over 100 are direct-entry (or certified professional) midwives with currently active licenses. They are responsible for around 1% of births in the state.
In comparison, certified nurse midwives and certified midwives have graduate degrees and generally work in hospitals, and the former earns a nursing license before or during their midwife education. Each category has its own national credentials and standards as well as state licensing requirements and governing rules.
Midwife Kalie Caler’s Mountain Roots Midwifery paperwork and stethoscope, Tuesday, May 5, 2026, in Pagosa Springs. (Kierstan Renner, Special to The Colorado Sun)Unlike other medical professions regulated by DPO, including certified nurse midwives and certified midwives, direct-entry midwives are not overseen by a board. Rather, they’re regulated by a single person — in this case Mayhugh, who went to law school and does not have a background in medicine.
Colorado is the only state that operates with such a director model. Thirty-seven others rely on midwifery boards with midwives represented in the group.
The director format is a fundamental flaw, the lawsuit and many active midwives say. “There’s a lot of discernment that the program director has to use, and what we’ve seen from all these cases is that the program director’s fundamental lack of understanding of pregnancy, of basic things that midwives know and do, leads to too many investigations of the wrong things, and then the wrong focus during those investigations,” said Indra Lusero, the founder and director of Elephant Circle, a Denver-based organization that advocates for reproductive justice, and the attorney of record for the lawsuit, which seeks class-action status.
A Colorado Open Records Act request by Elephant Circle in November uncovered that midwives were more likely to have their licenses suspended during investigations when compared to other medical professions (14% of midwifery complaints included an interim cessation of practice agreements between 2015 and 2025, while only 2% of physician and 6% of nurse complaints did).
According to DORA, over the past five years, the Office of Direct-Entry Midwifery Registration has issued one suspension and eight final disciplinary actions and dismissed five cases.
The lawsuit is a culmination of years of what Lusero and practitioners say have been unproductive conversations with Mayhugh and the department. Four years ago, Elephant Circle created a certified professional midwife task force. The goal: revise and update how the state oversees midwives to make the practitioners and their patients safer and better align regulations with current standards of care.
Certified professional midwives’ regulations are due for a sunset review next year. DORA spokesperson Lee Rasizer noted that the rules guiding direct-entry midwives have been adjusted 19 times since 2006 — “demonstrating an ongoing commitment to ensuring regulatory oversight that reflects evidence-based practice and current practice standards.”
“We have some states that have incredible integration of certified professional midwives within the system,” says Cassaundra Jah, executive director of the National Association of Certified Professional Midwives. “And then we have states where it absolutely crosses over into bias. I would go so far as to say the laws and/or regulations were written in such a way that would allow the state to say they do license certified professional midwives, but it’s essentially impossible to practice in certain states, practice safely.”
The United States has the highest maternal mortality rate among developed nations, and more than 80% of pregnancy-related deaths are preventable, according to the Centers for Disease Control and Prevention. The most recent maternal mortality report for Colorado, released by the Colorado Department of Public Health and Environment in September 2023, found that 90% of the state’s 174 pregnancy-associated deaths between 2016 and 2020 were preventable.
Among the committee’s recommendations: increase access to midwives.
“The midwifery model of care empowers patients to partner with their providers and recognizes the full spectrum of the needs of those who are capable of giving birth throughout the life cycle,” reads the report. “This model promotes low-intervention births, reduces health care costs, and ultimately improves patient outcomes.”
Research, including by the Yale School of Medicine and University of British Columbia, demonstrates that integrating midwives into maternity care improves outcomes, including lowering rates of preterm births, low birth weight infants, labor interventions and C-sections.
More than one-third of Colorado counties are considered maternity care deserts, meaning there are no birthing facilities or maternity care providers, and 49% of women in rural regions live more than 30 minutes from a birthing hospital. While many midwives work on the Front Range, a large number of direct-entry midwives are based in the state’s more rural areas. According to a forthcoming report from CDPHE (required under House Bill 1262), an early draft of which Lusero has seen, nearly 20% of births in La Plata County and almost 7% in Delta County were attended by certified professional midwives compared with the state average of 1.9%.
Between 2020 and 2025, four Colorado hospitals closed their obstetrics and labor and delivery services, and an outpatient birth center also shuttered, according to the Colorado Hospital Association. A new birth center did open in February in Grand Junction.
“Right now, we’re in a crisis,” says Justina Nazario, one of a handful of Black certified professional midwives in Colorado and the statewide operations coordinator for Elephant Circle. “We have hospitals closing down, L&D units closing down left and right. We don’t have a lot of providers. We need to figure out a way to make sure that these maternity deserts are being filled, and the midwives can do that, but it’s a rough landscape.”
Nazario had a complaint filed against her in June 2024. Though the investigation was dropped and the family she worked with wrote a letter in support of her actions, DORA informed her they would keep the complaint on file for five years and consider it if another complaint is lodged.
“What it feels like to me is that they (DORA) don’t want midwives practicing in our state,” Nazario said.
Investigations sometimes span years
Elise Hull has been working as a midwife on Colorado’s Western Slope since 2022. She sees clients from Aspen to Grand Junction. It’s not uncommon for her to travel two hours to attend a birth.
Early in a client’s active labor in November 2022, she and her midwifery partner couldn’t detect a fetal heartbeat. They immediately transported the mother to Valley View Hospital in Glenwood Springs, about 35 minutes away. She was taken into surgery for an emergency cesarean section, but the baby died in utero.
The hospital obstetrician filed a complaint against Hull on behalf of the family in March 2023. Hull says an initially favorable consultant report on what happened was thrown out by Mayhugh, while a second report contained what she called misunderstandings and factual inaccuracies. She didn’t receive a notice of charges until April 2025. She has been able to continue practicing while the investigation is ongoing, but her options for next steps are to relinquish her license, sign a stipulation that she believes is erroneous but would allow her to practice normally following a probationary period or go to a hearing.
Administrative law court hearings are not like criminal or civil court, Lusero said. The judge’s decision goes back to DPO staff who make the final call on whether to act on that verdict.
“This is just a really messed up system,” said Hull, who is also a plaintiff in the larger lawsuit. “It feels very punitive, and I want a more restorative process and way for midwives to become safer, families to have more options and ultimately have that ability to be collaborative, to have public trust and have accountability within midwifery.”
Complaint investigations can be costly and emotionally draining for midwives, stressful for clients who need to find new care providers and for other midwives who have to take on additional patients, create distrust with the area’s healthcare providers and leave communities without reliable obstetrics care.
Caler estimates that she’s spent around $15,000 on lawyers and lost out on at least $100,000 in income.
“I would like to see that department held accountable for the harm they’ve caused,” says Dia Ingalls, an Arvada-based midwife. “The first is a denigration of midwives feeling safe to practice in Colorado. Lots and lots of people that I know and have heard of have left the state because they do not feel safe to practice here, because of the financial risk, the professional risk of what I would consider to be a feeling of persecution by our regulatory agency. To avoid that, they just leave because they know it’s better in other states.”
The potentially lengthy timetables for investigations are another concern. According to DORA spokesperson Rasizer, “investigative timelines vary based on the complexity of the case, the depth and quality of the information provided and other factors.” A second open records request by Elephant Circle revealed that, “on average, complaints against DEMs are open for 500 days — twice as long as other regulated professions that were queried.”
In Caler’s case, an autopsy was completed on her client soon after her death, but it took three and a half years for Caler and her lawyer to receive the the results — which showed that the mother died of an amniotic fluid embolism, a rare complication that is life-threatening even in a hospital setting.
On the rainy first Tuesday of May — International Day of the Midwife — a group of more than 50 midwives, family members and supporters gathered under the awning on the second story of Civic Center Plaza to protest DORA’s regulations. They carried pink and yellow tulips and handmade signs that read, “Justice for Midwives” and “Midwives are Medicine.”
As they marched toward the Colorado Capitol, they began to chant: “Midwives help people out.”
Ingalls was among them.
“Our regulatory system is broken,” she said later. “We have no real recourse. We have no real capacity to collaborate with our regulators. There is such hostility and such a closed system of regulation that it is harmful for the way midwives practice.”
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