Pagosa Springs Midwife Sues State Over Discriminatory Licensing Rules

“Discriminatory and unlawful.”

That’s the charge Kalie Caler and a cohort of direct-entry midwives leveled at the state on May 5. They aren’t just complaining about paperwork. They’re suing the Colorado Division of Professions and Occupations, arguing that regulators are actively making it harder for them to do their jobs safely.

Let’s look at the numbers, because they tell a story of isolation. There are over 550 midwives licensed in Colorado. Just over 100 are direct-entry midwives. They account for roughly 1% of births in the state. On paper, that’s a tiny slice of the pie. In practice, for folks in rural towns like Pagosa Springs, Mancos, and Durango, that 1% is often the only option standing between a family and a 90-minute drive to a hospital with an obstetrician.

Kalie Caler knows this tension intimately. She’s the only midwife in Pagosa Springs. She delivered more than a dozen babies in her first year alone, driving an hour or more to support clients as far out as Crestone. She birthed all three of her own children at home. Then came February 2022.

One of her clients went into labor. The birth didn’t go as expected. The baby boy wasn’t breathing. Caler resuscitated him. Her assistant called an ambulance. But the mother’s vitals were crashing. They were transferred to Pagosa Springs Medical Center — where there is no obstetrician and no neonatal intensive care unit — during a snowstorm. From there, she was moved to Mercy Hospital in Durango. She died.

A friend of the mother, someone Caler had never met, filed a complaint through the Department of Regulatory Agencies (DORA). That was four years ago. The investigation is still ongoing. Caler hasn’t been permitted to practice. In July, she will become the first midwife in Colorado to go to trial in administrative court since the profession was legalized in 1993.

The lawsuit targets the Division of Professions and Occupations, a DORA department managing licensing for more than two dozen healthcare professions. It alleges that program director Zen Mayhugh and the division willfully disregard evidence that supports midwives during the complaint process. The argument is that the current regulatory framework limits midwives’ ability to practice to their full scope, which in turn limits parents’ access to community birth support.

Direct-entry midwives are distinct from certified nurse midwives. They don’t need a graduate degree. They are certified through the North American Registry of Midwives to provide prenatal care and birthing support in birth centers and homes. Yet, the state’s regulatory model treats them differently, and the lawsuit claims that treatment is discriminatory.

The Office of Direct-Entry Midwifery Registration would not comment on the pending litigation.

For context, consider the infrastructure gap. Pagosa Springs Medical Center has no OB. That means if a direct-entry midwife delivers a baby who needs more than basic resuscitation, or if the mother needs a C-section, the clock starts ticking immediately. The lawsuit argues that by keeping these midwives in legal limbo or restricting their scope, regulators are exacerbating that gap. They are removing local expertise just when the hospitals are most stretched.

This isn’t just about Caler. It’s about the structural reliance on a small group of practitioners to fill the void left by the hospital system’s retreat from rural maternity care. If the state continues to treat direct-entry midwives as second-class citizens in the eyes of regulators, it doesn’t just punish the midwives. It pushes birth out of the home and into the ambulance, where every minute counts.

The bottom line for locals in the San Juan and La Plata counties is simple: fewer licensed direct-entry midwives means fewer options for home birth and birth center delivery. It means relying on a single provider in town who might be tied up in court for years. And it means higher costs for the state, which pays for the legal and administrative machinery that keeps these practitioners from practicing.