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

Background: U.S. state licensing restrictions requiring written practice agreements for certified nurse-midwives (CNMs) lack evidence of improved patient safety and instead contribute to maternity care workforce shortages. The objective of this study was to examine restrictive state licensing and practice policies for CNMs to identify the problem they were intended to solve. Methods: This was a qualitative content analysis of state policies that require CNMs to obtain written practice agreements, collected in January 2022, using the "What's the Problem Represented to be" framework. Analysis was completed by two midwife researchers with interpretation assistance from a panel of expert midwives. Results: Variation in written practice agreement requirements across states demonstrated that the regulations echoed historical physician complaints about the "midwife problem" first articulated in 1912. Effects of this problemization are inaccurate workforce data and persistent maternity care shortages. The problemization is maintained by the physician organization's advocacy against midwifery autonomy. The COVID-19 pandemic policy modifications demonstrated that states could eliminate restrictions when prioritizing access without compromising safety. Conclusions: Restrictive CNM licensing regulations perpetuate professional gatekeeping rather than ensuring public safety, directly contributing to maternity care shortages. State legislatures should eliminate written practice agreement requirements for CNMs and adopt evidence-based criteria focused on practitioner qualifications rather than supervisory relationships. National nursing organizations should advocate for regulatory reform, prioritizing healthcare access. Removing these barriers can expand the maternity care workforce and improve access to reproductive healthcare, particularly in underserved communities.