Author Response: Policy Context Matters for Midwifery

The authors thank Ms. DeLuca for engaging with our recent article and emphasizing the role of interprofessional collaborations and training to improve rural midwifery care access.¹ We agree and see this as both a policy and research issue. The questions raised are timely, as recent research has shown continued labor and delivery unit closures disproportionately impacting rural US hospitals,² further limiting rural residents’ access to local perinatal care.

The letter's author highlights numerous factors that may inhibit the growth of rural midwifery, including workforce shortages of other types of perinatal care clinicians, geographic barriers to care, and a lack of infrastructure to incorporate the midwifery model in established practices. Underpinning each of these barriers is the impact that state-level midwifery practice legislation has on the growth of the midwifery care workforce.

The American College of Nurse-Midwives has identified numerous state policies governing certified nurse-midwife and certified midwife (CNM/CM) practice that can expand the midwifery workforce. These include licensure policies for different types of midwives, Medicaid reimbursement parity between midwives and physicians, and whether midwives have the authority to prescribe medications and admit patients to hospitals without physician oversight.³ Researchers have demonstrated such policies’ potential impacts. States with independent practice legislation for CNMs have more practicing midwives per 1,000 births and fewer counties without midwives compared to those that require CNMs to hold practice agreements with supervising physicians.⁴

Enabling CNMs/CMs to practice independently may have particularly salient effects on the perinatal care workforce in rural areas. Though CNMs/CMs can provide safe, high-quality care within their scopes of practice without physician oversight,⁵ requiring physician supervision may restrict midwives’ ability to provide care in rural areas,^{3, 4} even if they desire a rural practice, because clinicians like obstetrician-gynecologists are more concentrated in urban areas.⁵ In contrast, independent practice legislation may enable CNMs/CMs to practice in communities that otherwise have shortages of perinatal care providers or are longer distances from high-volume or higher acuity clinical settings.

Similar policies that reduce restrictions for certain types of midwives, such as certified professional midwives (CPMs), may be particularly resonant in rural areas. CNMs/CMs are more likely to be concentrated in urban areas,^{3, 5} while a greater proportion of rural births are attended by CPMs and other types of midwives compared to CNMs/CMs.⁶ Further, as CPMs and other types of midwives are more likely than CNMs/CMs to attend community births (home births, freestanding birth centers),⁵ reducing practice restrictions for CPMs and other types of midwives could expand the midwifery workforce in rural communities without hospital-based childbirth services, where local care is needed. However, regulations regarding birth centers’ proximity to hospitals⁵ limit the ability of CPMs to expand the availability of birth center–based midwifery care in rural communities without hospital-based childbirth services, even if they can practice independently. To be sure, patient safety is paramount, so all clinicians, including midwives and physicians, practicing in rural or remote areas need support for ongoing training, partnerships, and access to urgent medical transportation for needed transfers.

Policies expanding midwifery practice may amplify interprofessional collaborations between physicians and midwives and support the incorporation of midwives into new training models for perinatal care providers. Interprofessional collaborations between physicians and midwives have been successful in rural hospitals,⁷ and the growth of such collaborations in rural communities could allow more rural residents to access the option of a midwifery model of care. In addition to the research questions proposed in the author's letter, future research could assess whether policies regulating midwifery practice have differential impacts for the midwifery workforce in rural versus urban areas.

The authors have no conflicts of interest to disclose.