“CPMs make 100% of their income from women who decide to give birth in a nonhospital setting; they are obviously motivated to do everything possible to convince as many people as they can that this is an excellent idea.”
— Leigh Fransen, former CPM, High Risk: Truth, Lies, and Birth
Conflict of Interest in the Certified Professional Midwife Model
Overview
Certified Professional Midwives (CPMs) are exclusively paid to attend births outside the hospital. They are not integrated into the broader health system, cannot bill for collaborative or hospital-based care, and lose income if a client is transferred. This creates a structural conflict of interest that undermines clinical objectivity.
At its core, the CPM model is designed around retaining patients in out-of-hospital care even when circumstances suggest hospital birth may be safer.
This is not just a safety issue, it’s a systems issue. It places midwives in an impossible position, where their financial viability and professional identity are tied to the location of birth rather than the clinical needs of the patient.
Financial Dependence Shapes Decision-Making
CPMs can only bill for services if the birth occurs outside the hospital.
They are not licensed or trained to continue care in medical settings.
A transfer means loss of income, loss of continuity, and in many cases, perceived failure.
This model places midwives in direct conflict with one of the most basic principles of ethical care: the ability to recommend the safest course of action without personal or financial bias.
System Design Reinforces Risk
Because CPMs operate in an economic and professional silo:
Transfers may be delayed or avoided to preserve the case.
High-risk births (e.g., VBAC, breech, twins) are often attempted at home due to lack of alternatives or support.
Adverse outcomes may be reframed as unavoidable or unrelated to the setting of care.
These are not isolated failures—they are the predictable result of a care model that offers no professional path except keeping people at home.
Midwives Trapped by Their Own Model
While families bear the ultimate risk, CPMs are also harmed by the system that sustains them.
Most CPMs are self-employed, unintegrated, and unsupported.
They often face public scrutiny without access to professional protections.
Their training does not prepare them for collaborative practice or emergency response, yet they are expected to manage both.
In many cases, CPMs believe they are offering safe, empowering care but the system has set them up to fail.