Policies Are Needed to Support an Essential Health Workforce: Midwives 

More than 2.3 million US women of reproductive age live in maternity care deserts — counties with no hospitals offering obstetric care and no OB-GYN or certified nurse-midwife in practice. The Association of American Medical Colleges projects a shortfall of up to 86,000 physicians by 2036, with primary care and obstetrics among the hardest-hit specialties. Rural communities are bearing the brunt: nearly half of rural counties lack a single obstetric provider. 

At the same time, maternal mortality in the United States far exceeds that of peer nations. The crisis is not evenly distributed: Black women die of pregnancy-related causes at more than twice the rate of White women, a disparity that persists across income and education levels. Midwives are a central part of the solution to these intertwined crises of access, outcomes, and equity. But policy change is needed to enable this workforce to contribute to meeting care needs.  

Understanding the Scope of the Midwifery Profession  

Currently, there are about four midwives per 1,000 live births in the United States. In most other high-income countries, there are between 30 and 70 midwives per 1,000 births. In the US, the term “midwife” covers professionals with several distinct credentials, with variation in training pathways, scopes of practice, and practice settings. Policymakers seeking to expand the midwifery workforce need to understand these distinctions and the significant opportunity each represents. There are three primary credentialled types of midwives: a certified nurse-midwife, certified midwife, and certified professional midwife. 

CNMs, CMs, and CPMs all provide individualized, relationship-based care that centers the needs and preferences of the people they serve. And all are trained to identify complications and facilitate timely transfer or consultation when needed. 

Evidence: Outcomes, Cost, and Equity 

Sources: Yang YT, Attanasio LB, Kozhimannil KB. State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes. Womens Health Issues. 2016 May-Jun;26(3):262-7. doi: 10.1016/j.whi.2016.02.003. Butler J, Abrams B et al. Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. AJOG. May 1993;168(5):1407-1413. Janssen PA, Mitton C, Aghajanian J. Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians. PLOS One. July 17, 2015. https://doi.org/10.1371/journal.pone.0133524. University of Washington Center for Workforce Studies. https://familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2025/08/American-College-of-Midwives-Certified-Midwife-Practice-Authority-Map-2023.pdf 

The evidence base for midwifery care is substantial and growing. A landmark Cochrane review found that midwife-led continuity of care models are associated with reduced preterm birth, reduced likelihood of episiotomy, fewer regional anesthesia interventions, and higher rates of spontaneous vaginal birth with no increase in maternal or neonatal adverse outcomes. 

On cost, midwifery care consistently delivers value. Lower rates of surgical delivery, fewer elective inductions, and shorter hospital stays translate into significant savings. Medicaid, which finances nearly half of all US births, stands to benefit substantially from broader midwifery integration. 

Perhaps most importantly, expanding access to midwifery, particulary to culturally concordant clinicians, is an evidence-based strategy for reducing racial disparities in birth outcomes. Research from both domestic and international settings shows that continuity-of-care models in which patients see the same provider throughout pregnancy, labor, and the postpartum period are particularly effective at improving outcomes for Black and Indigenous people. Several community-based midwifery programs specifically designed to serve women of color have demonstrated measurable reductions in preterm birth and low birthweight rates. 

Barriers Limiting Midwives’ Contribution 

Despite this evidence, midwives attend only about 10% of U.S. births, compared to more than 70% in many European countries with superior maternal outcomes. The gap reflects structural barriers, including: 

• Limited education capacity. Accredited midwifery programs lack the clinical training sites needed to expand enrollment. Graduate medical education funding structures, largely unchanged since 1997, do not support midwifery training slots. 
• Restrictive scope-of-practice laws. In 23 states, CNMs and CMs must practice under collaborative or supervisory agreements with physicians.  
• CM licensure gaps. Only 12 states and DC recognize the CM credential despite the equivalency to the CNM credential. 
• CPM licensure gaps. Fifteen states still provide no legal pathway for CPM practice, effectively eliminating the option of legally attended out-of-hospital birth and driving some families to unassisted birth. 
• Reimbursement disparities. Only half of Medicaid programs have pay parity for CNMs, and Medicare pays CNMs at 85% of the physician rate for identical services. These inequities suppress workforce growth by reducing the financial viability of midwifery practice. 
• Hospital credentialing obstacles. Even in states with full practice authority, CNMs frequently face delays and denials in obtaining hospital admitting privileges. 

Policy Opportunities 

Federal and state policymakers have multiple policy options to consider that would help remove barriers to practice and expand the midwifery workforce. 

Creating a Policy Infrastructure 

The United States does not lack evidence that midwifery works. It lacks the policy infrastructure to let midwives do the work. As maternity care deserts expand, as maternal mortality climbs, and as physician shortages deepen, the cost of inaction is measured in preventable deaths, unnecessary cesareans, and communities left without any provider at all. 

Investing in midwives — all types of midwives, across all practice settings — is not a niche policy interest. It is one of the highest-yield investments available to policymakers serious about reversing America’s maternal health crisis. The evidence is there. The workforce is ready. The question is whether policy will catch up.