The Midwife Problem: An Interpretive Analysis of State Requirements for Written Practice Agreements

Area of Science:

• Healthcare Policy
• Nursing
• Public Health

Background:

• U.S. state licensing restrictions for certified nurse-midwives (CNMs) mandate written practice agreements.
• These regulations lack evidence of improving patient safety and contribute to maternity care workforce shortages.

Purpose of the Study:

• To examine restrictive state licensing and practice policies for CNMs.
• To identify the intended problem behind these policies.

Main Methods:

• Qualitative content analysis of state policies requiring written practice agreements for CNMs.
• Utilized the "What's the Problem Represented to be" framework.
• Analysis involved midwife researchers and expert midwives.

Main Results:

• State policies reflect historical physician complaints about midwifery dating back to 1912.
• Restrictive policies lead to inaccurate workforce data and persistent maternity care shortages.
• COVID-19 policy changes showed states can remove restrictions to prioritize access without compromising safety.

Conclusions:

• Restrictive CNM licensing regulations perpetuate professional gatekeeping, not public safety, worsening maternity care shortages.
• State legislatures should remove written practice agreement requirements and focus on evidence-based criteria.
• Regulatory reform is needed to prioritize healthcare access and expand the maternity care workforce.