Associations Between State Practice Regulations and Access to Midwifery Care

This study aimed to identify associations between state policies and access to midwifery care. Identifying policies that facilitate increased access to midwives will help policymakers determine the best methods for increasing access to midwives in their states.

This cross-sectional study was conducted at the county level as a secondary analysis of National Vital Statistics data from the Natality online database. The unit of analysis was counties with populations of at least 100,000, and the outcome was the proportion of births attended by midwives in 2019. The potential predictors of increased access to midwifery care were independent midwife licensure, independent midwife prescribing, midwife access to hospital medical staff membership, and midwife Medicaid parity. Medicaid provider resources and state statutes verified Medicaid reimbursement rates and eligibility for hospital medical staff privileges. Each state was categorized as an independent or restricted licensure state according to data from the American College of Nurse-Midwives. Data for the control variable, the presence of a midwifery education program, were gathered from the Accreditation Commission for Midwifery Education. The analysis was conducted as a Poisson regression.

There was no association between independent licensing and increased access among all states. Stratifying the analysis by independent licensing law revealed that all but one policy was related to higher rates of midwife attendance at birth. Maximum Medicaid reimbursement correlated with greater access regardless of licensing status. The rate of midwife-attended births in independent licensing states grew as the number of potential predictors in a county increased.

Regulatory policies beyond independent licensing are associated with women's access to midwifery services. In independent licensing states, adopting additional policies favorable to midwives may strengthen access to midwifery. Policymakers and regulators can use these findings to identify strategies for accelerating the expansion of midwifery access in their states.