After being assessed at the neonatal intensive care unit a decision was made to withdraw ventilation and the baby died.
The commissioner's report said the midwife failed to monitor the woman during labour with reasonable care and skill, and stated it was her responsibility to provide all home birth equipment including oxygen.
It stated her actions following the birth were concerning and unprofessional.
The young woman's back up midwife was also found to have failed to complete antenatal growth chart accurately.
The commissioner found the midwife to have breached the Code of Health and Disability Services Consumers' Rights for her failures, and unfavourable comment was also made about the two back-up midwives.
As a result all three midwives were asked to provide written apologies to the woman.
The commissioner also emphasised the importance of midwives behaving in a manner that is objective and professional, while also being caring and compassionate.
He has recommended the lead midwife undertake further training on informed consent, record-keeping, and professional boundaries.
He has also recommended she undergo a Special Midwifery Standards Review through the New Zealand College of Midwives.
