Advocacy, Research

State Level Midwifery Policy and Midwives Integration

I have been eagerly awaiting the publication of this paper on midwifery policy the United States.1 It represents several years of work by a large group of researchers to identify and measure the ways that state midwifery policies affect the overall performance of the health system. It is the first step in a lengthy process of unraveling the ways midwifery policy affects the health of mothers and babies.

To measure midwifery policy, the researchers created a midwifery integration score. This was a way to combine the many pieces of regulation that govern midwifery practice. This was necessary because the laws that define the scope of midwifery are scattered throughout state laws.  Certified nurse midwife practice is often housed within the state nurse practice act. Direct entry midwives are often regulated by a midwifery practice act. Medicaid reimbursement for midwives would require integration into the state Medicaid laws. For midwives to order medications they need to be provided with prescriptive authority. All these pieces of legislation need to have been modernized for a state to have full scope midwifery practice.

As you likely know, not all states have modern midwifery laws. Some states that have adopted midwifery modernization have missed key pieces of regulation that cause restrictions of practice. Some states still require midwives to have written collaborative agreements with a physician for legal practice. Collaborative agreements prevent midwives from providing care in areas without physicians.

What did the study show?

States that had the best integration of midwives had lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death.  States that had the best integration of midwives had more midwives and more midwife attended births. They also found associations between low integration of midwives and increased disparities for minority women.

An important point to remember is that this is a study of associations. We know states that do not integrate midwives are also more likely to have higher rates of some poor outcomes. We don’t know if this association exist because of the way midwives work in the health system. We don’t know if this association is because states that do not integrate midwives also do not adopt other important policies that affect women’s health.

Let me explain what I mean.  A state may allow Medicaid reimbursement to midwives which increases the midwifery integration score. The same state may have Medicaid eligibility requirements that prevent nearly all low-income women from using the system until they become pregnant. This increases the rates of unplanned pregnancy and decreases the number of women who initiate prenatal care in the first trimester. These separate pieces of Medicaid policy that may be related meaning states that do not reimburse midwives may also have the most restrictive eligibility. We don’t know until more research is completed.

But what we do know is that states with low midwifery integration scores can make improvements.


I encourage you to become familiar with this study. It provides multiple points of interest for law makers and can help advocacy groups identify areas for improvement within each. Print copies of the graphs and maps and share them with your state legislators. Work with advocacy groups in your state to identify the key pieces of legislation that are preventing midwives from being fully integrated into your health system.

If you need help connecting to midwifery advocacy groups in your state, check out Citizens for Midwifery, Midwives Alliance of North America, and your state affiliate for American College of Nurse Midwives.

Vedam S, Stoll K, MacDorman M, et al. Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. Li D, ed. P. 2018;13(2):e0192523. doi:10.1371/journal.pone.0192523
Jennifer (Author)