The C-section was so quick that she hadn't had time to remove her own clothes. Careening down the hallway toward the operating room, just minutes after her arrival at the hospital, Danielle Yeager's team of nurses had torn the clothes off of her body, flinging them on the floor behind them as they ran. Normally, Yeager is warm and giggly, with long, corkscrew hair and a smile that makes her eyes crinkle and disappear. But, on the frantic ride toward the operating room, she was grim and silent, willing her baby to just hang on. Hurrying down the hall alongside the team were Yeager's boyfriend, Michael Brooks, and the family's home birth midwife, Christy Collins, who had detected poor heart tones in the baby with her Doppler device just an hour before.
In the operating room, seconds after the epidural had begun to numb Yeager, the obstetrician had already started to cut. And before Yeager could steady her breathing, the baby was out, wide-eyed and covered in a sticky, green gunk—his own stool, called meconium—that he had inhaled in utero. Meconium aspiration is a sign of fetal distress, and doctors would later surmise that the baby's heart had been failing for hours, possibly even days, before Collins had caught it on her Doppler. For a moment, the baby was alive, his eyes open and unblinking. And then—he wasn't. After 47 minutes of attempted resuscitation, the nurses slowed their work, fell silent, then stopped.
The next few hours for Yeager are blurry. She remembers the recovery room; Michael signing papers; the swarm of nurses who were all indistinguishable in the operating room, approaching her bed to offer their condolences. Unbeknownst to Yeager at the time, the head charge nurse had gathered the other nurses in the hallway and had each of them look at her dead son, a boy with plump lips and fine black hair. The charge nurse was furious—not at God or at Yeager, but at Collins, who hadn't left the family's side since their arrival at the hospital. Look at this baby, the charge nurse told the others. This is why we train. This baby's death was preventable. This baby did not have to die.
The baby, Gavin Michael Brooks, was not supposed to have been born at an unfamiliar, bustling hospital on the other side of town. Gavin, the couple's first child, was supposed to have been born peacefully at home in a planned water birth.
Yeager and Brooks are among the growing number of Americans who opt to give birth at home. Across the United States, planned home birth has become increasingly common, jumping in popularity by 29 percent between 2004 and 2009, and making up just under two percent of all births nationwide. Home birth is especially popular in progressive pockets of the U.S., such as the Pacific Northwest. In states like Oregon and Washington, out-of-hospital births comprise up to six percent of births statewide.
Yeager had “never wanted to birth at home” before she unexpectedly became pregnant with Gavin in May 2013. But after touring some local hospitals and being brushed off at a prenatal visit by a brusque obstetrician, she started to consider other options.
Through a website, Yeager got the number for a midwife named Christy Collins. The midwives, Yeager had heard, were friendlier, and their prenatal visits sometimes lasted hours, as if you were chatting with a good friend. Yeager liked that.
“You aren't a number,” Yeager says, when asked what had attracted her to midwives initially. “They'll actually pay attention to you instead of push you in and out of rooms. You're someone important to them.”
In choosing a home birth, Yeager first had to decide what kind of midwife would oversee her care. One choice was a Certified Nurse Midwife, a practitioner who holds degrees in nursing and midwifery. The vast majority of CNMs practice in hospitals or hospital-affiliated birth centers, sometimes working under a physician, and are often regulated by the state nursing board.*
Then there are Certified Professional Midwives, a credential exclusive to North America. Prospective CPMs need only to have a high school diploma and to apprentice under another CPM for 50 births before taking the certifying exam. CPMs practice almost exclusively outside the hospital, and, along with Direct-Entry Midwives (midwives who learn through “self study, apprenticeship, or a [non-nursing midwifery school”), CPMs attend 43 percent of all home births in the U.S.
In a 2009 online survey, 160 women who had given birth at home cited previous negative hospital experiences, a desire to avoid medical intervention, and “trust in the birth process” as reasons they'd chosen to forgo the hospital. The researchers noted that women “equated medical intervention with reduced safety” and trusted their bodies to give birth without interference.
But is a CPM-led home birth truly safe? According to the most recent medical literature, no. In December 2015, the New England Journal of Medicine published a study that followed the outcomes of 80,000 births in Oregon during the years 2012–13. The study showed that planned home births had a higher likelihood of neonatal seizures and carried twice the risk of neonatal death than did in-hospital births. These findings are perhaps not surprising, as they follow on the heels of a 2014 paper in the Journal of American Obstetrics and Gynecology, which found that planned home births with CPMs, despite making up only 0.46 percent of total births in the study, resulted in four times as much neonatal death as did hospital births attended by nurse-midwives.
Collins, a Navy veteran and perky mother of five, had an unusual amount of training for a CPM. Educated at the National College of Midwifery, Collins started assisting home births in 2005, before moving across the border to the Las Vegas metro area, an a-legal state with no CPM oversight. Most of the midwives in the area, Yeager had heard, were self-taught, with little more than apprenticeship training. But not Collins.
“She was one of the more 'medical' midwives in the area,” Yeager says. “She had gone to school, she had medical training in the Navy. I thought she was one of a kind.”
During their first meeting, in Collins' home office, Collins went over a list of requirements for patient care: Yeager would need to submit to urine tests at every prenatal appointment. Yeager would need a 20-week ultrasound, group B strep testing, and gestational diabetes screening. In her home office, Collins had a blood pressure cuff and an examination table.
“This person really seemed like she knew what she was doing,” Yeager says.
Yeager and Collins clicked instantly. Both women were talkers, buzzing with excitement over the impending birth, and the two spent nearly three hours at their first meeting chatting about Collins' midwifery experience. Yeager and her boyfriend hired her on the spot.
On February 19, two weeks past her due date, Danielle Yeager went in for a biophysical profile (BPP) of the baby, a diagnostic test designed to measure fetal well-being. The ultrasound found that Danielle had no amniotic fluid.
At 42 weeks' gestation, low amniotic fluid is one of the earliest signs of a failing placenta, which can spell death for the baby unless there's an emergency delivery. Under the care of a physician or nurse-midwife, Danielle almost certainly would have been admitted to the hospital for an immediate induction. But Collins decided to wait. Collins ordered a second BPP later that afternoon to confirm the absence of amniotic fluid and to check the baby's kidneys.
“I didn't know what the hell [zero fluid] meant,” Yeager says. “The only thing I knew was that you had a certain amount of time to get the baby out.” Yeager and her boyfriend started considering an induction at the local hospital. But Collins didn't seem to share her urgency.
“She just kept saying, 'you're fine, you're just dehydrated,” Yeager says. “She just dismissed me completely.”
Later that afternoon, the follow-up BPP still showed zero amniotic fluid. Yeager started getting antsy and pressed Collins further—should we head to the hospital? But Collins, in Yeager's telling, wanted to avoid the hospital for as long as possible in the hopes of having a successful home birth. She counseled Yeager to relax, drink water to replenish her amniotic fluid, and get another BPP in the morning.
"I was drinking so much freaking water,” Yeager says with a laugh. “I was peeing every 10 minutes. I couldn't hardly sit down."
Yeager agreed reluctantly to wait at home for labor to start, but privately, she was concerned. “I cried on the way home,” she says. “I just knew something was wrong. But we just felt like, she knows everything and we know nothing. I was trusting her.”
By the next morning, Yeager was frantic. As she texted Collins on the morning of February 20, Yeager's patience had worn thin. “We were really pissed at this point,” she says. “We wanted to go to the hospital. But Christy said she wanted another ultrasound first.” So Yeager, her boyfriend, and Collins met up for yet another ultrasound.
Earlier that morning Collins had contacted Jan Tritten, a colleague and editor of Midwifery Today, to seek her advice on Yeager's case. Tritten crowdsourced Collins' dilemma on the Midwifery Today Facebook page. She wrote: "What would you do? ... We're in a state with full autonomy for midwives and no transfer care regulations past 42 weeks. Absolutely no fluid seen. ... Can anyone share stories/opinions?"**
Dozens of midwives responded, advising everything from acupuncture to simply “trust[ing] mom's instincts.” One recommended eating stevia to increase the amniotic fluid. None of them recommended a trip to the hospital.
The third BPP on the morning of February 20 showed—still—no amniotic fluid. After the ultrasound, Collins pulled Yeager and Brooks aside into a private examination room. She wanted to discuss the situation, examine their options, and then make a plan. "I thought, we already made a plan!” Yeager says. “Why aren't we going to the hospital?”
In the exam room, Collins produced a piece of paper, printed from the Internet. On it were the dozens of comments from Tritten's Midwifery Today page. “She started reading these things to me,” Yeager says, bristling at the memory. “She had asked me, 'Do you want me to talk to some of my mentors [for advice]?' I thought she meant somebody above her. A doctor, somebody in charge. But they were just a bunch of midwives who had no clue. They had no idea it was a medical emergency. Nobody.”
Collins did not respond to multiple requests for comment, but screenshots taken from her personal Facebook page hours after Gavin's death give her recounting of what happened next. Collins maintained that she had urged Yeager “firmly but gently” to agree to an induction at the hospital, while Yeager had asked for “time and space to think.” It's an assertion that Yeager denies vehemently.
“I didn't refuse anything,” Yeager says. “Why hire someone to take care of you and refuse their advice? Why would I be paying her otherwise?”
Before leaving the ultrasound technician's office, Brooks asked Collins to check the baby's heartbeat, just as a precaution before the long drive back home. As Yeager lay back on the examination table, Collins hovered over her stomach with the hand-held Doppler device, listening and smiling reassuringly. And then her face changed.
“She told me to move, lay on my left side, and then she had me sit up and lay back down again,” Yeager says.
The heartbeat had dropped, Collins told them, and immediately called the back-up physician she had told them was on call in case of emergencies. On the phone, the back-up physician didn't hesitate: Yeager was to drop everything and run to a nearby hospital, where he would be waiting. In one car, Collins led the way to Centennial Hospital, 20 minutes across town from the technician's office. In the other car, Yeager and Brooks followed closely behind.
At the hospital, Yeager was greeted at the door by a triage nurse and whisked up to the labor and delivery floor in a wheelchair. As the nurses set up for an induction, Collins' back-up physician entered the room. “Which one of you is the midwife?” He asked, looking between Collins and Yeager's mother.
Yeager was floored. “He had never even seen [Collins],” she says. Until that moment, Yeager had been under the impression that Collins' back-up physician had been working with her as a supervisor. Now, it was painfully clear that nobody had been supervising Collins at all.
In Yeager's recollection, it seemed instantaneous: The physician put the monitor on Yeager's stomach—and yanked it off almost immediately. “We don't have time for an induction,” he says. “We have to do a C-section right now.”
Within seconds, the nurses were flanked on either side of Yeager's bed, racing her down the hall toward the operating room, tearing off her clothes and dropping them on the floor as they ran.
It's an uncomfortable truth that Yeager's family has had to contend with: Had Gavin been born in a hospital under the care of a nurse-midwife or physician, he almost certainly would have lived. Yeager is still bubbly, quick to laugh, eager to share—but there is a current of righteous anger underneath her words when she relives her experience with Collins.
“People say, 'I'm so sorry you got a bad midwife,'” Yeager says. “But that's the thing—she wasn't a bad one. She knew more than other [midwives] in my area.”
A few weeks after Gavin's death, Yeager psyched herself up and did a Google search on Collins. What she found blew her away: In 2011, Collins—then a student midwife in California—has been charged with a misdemeanor for practicing medicine without a license. The state medical board—the governing body that oversees both CNMs and CPMs in California—fined Collins $10,000 and banned her from practicing midwifery for three years. But rather than live out her probation in California, Collins crossed the border into Nevada and continued to practice midwifery without stricture.
Upon finding this out, Yeager was devastated. Together, she and Brooks snapped into action, calling the local police, the state medical board, and the Los Angeles District Attorney's office—anything to sanction Collins and prevent her from hurting another family.
“We went to two cops,” Yeager says. They said there were no laws [concerning CPMs in Nevada]. They couldn't do anything.” According to the Las Vegas homicide division, the coroner would have had to find something purposeful about the baby’s death in order to recommend a police investigation.
In 30 states, CPMs are licensed to practice medicine and are regulated by some larger organization, such as the state medical board, that oversees them and determines their scope of practice. In California, for example, home birth midwives are required to transfer care to a physician if the mother has any risk factors, such as high blood pressure or infection.
But Nevada is one of 11 states where CPMs are a-legal—there are simply no regulatory agencies or safety guidelines for them whatsoever. And when a midwife is involved in a neonatal death, grieving families have next to no recourse. Had Collins broken the law in Nevada, she could have possibly been extradited to California for violating the terms of her probation. But Collins broke no laws by practicing midwifery—because there were none.
“The more I told my story, the more I looked at my records, I realized everything was a complete lie,” Yeager says.
“When someone handles you with such special care, you really think you're going to be OK,” Yeager says. “But [midwives] really just have no idea. They don't know how to recognize emergencies. They don't have the tools. They don't have the knowledge. They're con artists.”
In 2014, Yeager and her boyfriend wed, wanting to have “one nice thing” happen in the year their son died. In early 2015, the couple filed a civil suit against Collins, citing malpractice and wrongful death. But shortly after being served, Collins filed for bankruptcy, leaving the Yeagers at a dead end in terms of pursuing justice for Gavin.
Now, in her spare time, Yeager crafts, making decorative hats and bath bombs. She spends quiet nights at home with her husband, watching movies. And she blogs openly about her home birth experience, to remember her son and make sure other people remember him too.
“I write to her,” Yeager says of her former midwife, whom she has not spoken to in person since a week after Gavin's death. It's Yeager's way—the only way, now—of fighting back. Of getting justice.
“I will say her name,” Yeager says. “I will make sure everybody knows me. And I will never shut up.”
*UPDATE — January 19, 2015: This article has been updated to more accurately reflect the oversight process for CNMs.
**UPDATE — January 20, 2015: This article has been updated with further details about the day of delivery.