Having a child is one of the most incredible and difficult things a woman can do. Supporting a woman’s physical and mental health during pregnancy, birth, and postpartum is vital and also very personal. Women deserve to have providers and caregivers who make them feel comfortable, respected, and empowered through their journeys.
Working with a midwife is often one of the best options available for women to have great experiences and outcomes. Receiving midwifery care is associated with lower rates of cesarean sections, third and fourth-degree perineal tears, and a higher likelihood of breastfeeding. They also produce great outcomes for the baby, such as lower risk of preterm birth and rates of infant mortality. Women also report higher levels of satisfaction with midwifery care due to the continuity of care.
Midwives also fill the growing gap in maternal care that we face today. The Department of Health and Human Services projects a shortage of over 5,000 OB/GYNs by 2030, and there was a net loss of 399 obstetric wards around the country between 2010 and 2022.
Despite the many proven benefits, access to midwives can be difficult due to legal limitations on their ability to practice. Regulations vary by state, which can make it difficult to navigate for providers, and can also undermine access to midwifery care for women that want and need excellent maternal care.
One of these barriers is collaborative practice agreements for Certified Nurse Midwives (CNMs). CNMs are advanced practice nurses who have completed a bachelor’s degree in nursing and a master’s or doctorate degree in midwifery. They are licensed by the American Midwifery Certification Board to practice in all 50 states. In 25 states, they have autonomy to practice to the full extent of their training, meaning they can evaluate, diagnose, and manage patients without the supervision of a physician, and also can prescribe medications. States with full CNM practice authority are associated with women attending their first prenatal care visit sooner, likely due to it being easier to schedule with more providers available. These states have also seen a slight decline in low infant birth weight.
However, 19 states still require a collaborative agreement where certain activities are required to be supervised by a physician, and an additional seven states require it if the CNM wants to prescribe medications. While collaboration is encouraged, a written agreement can be very limiting. Physicians may not want to enter them because they can be liable for any mistakes made by their supervisees. It’s also extra work to review charts and medical records, and regularly communicate with a supervisee. They risk spreading themselves thin, and some states even limit the number of agreements a physician can have. If a CNM cannot find a physician to enter a collaborative agreement with then they cannot practice. These states should push for full practice authority.
States should also recognize Certified Midwives (CMs). This position was created in 1994 to open the midwife profession to those who do not have a nursing background. They take the same core competencies and national certification exam as CNMs, have graduate-level midwifery education, and the same scope of practice. Despite not having a nursing background, there is no evidence that CMs perform worse than CNMs, and both professions have comparable or better outcomes than physician care. Only 12 states and D.C. recognize a legal pathway for CMs to practice and should be expanded to give all women access to their care.
Finally, there are Certified Professional Midwives (CPMs). These are direct-entry midwives who are specifically trained for out‑of‑hospital births, with hands-on clinical experience in homes and birth centers as a core requirement. They’re nationally certified by the North American Registry of Midwives and are skilled in providing prenatal, birth, postpartum, newborn, and emergency care (such as neonatal resuscitation and hemorrhage management) for healthy, low‑risk pregnancies. They are legally authorized to practice in 38 states, but that means that 12 still remain.
Expanding access to midwifery care is increasingly important as women are in need of greater access to safe and supportive maternal care. States can and should support this by ensuring all midwives have a legal pathway to practice to the fullest extent of their training.