An Update to the Certified Nurse Midwife Regulatory Burden Rankings

In the United States, the ability of a healthcare professional to treat a patient is not determined solely by their training or skill, but by the specific laws of the state where they work. These laws, known as scope of practice regulations, act as a legal boundary defining exactly what tasks a provider can perform, such as diagnosing illnesses, ordering tests, or prescribing medication. For certified nurse midwives, who are highly trained nurses specializing in pregnancy and childbirth, these boundaries vary significantly from one state to another. In some places, they can practice independently, making all the decisions a doctor would make. In others, they must work under the direct supervision of a physician or maintain a formal written agreement with one. As the nation faces a growing shortage of doctors, particularly in rural areas, understanding whether these legal barriers help keep patients safe or simply limit access to care has become a critical question for policymakers and researchers.

For years, the standard reference for understanding these state-by-state differences was a study published in 2017, which ranked every state based on how restrictive its rules were for nurse midwives. That research became the foundation for countless subsequent studies on maternal health. However, the landscape of healthcare laws is not static; between 2017 and 2024, many states revised their regulations, often loosening restrictions to allow midwives to practice more freely. A team of researchers from the University of Virginia and West Virginia University recognized that the old data no longer reflected reality. They set out to update the 2017 rankings with fresh information, re-examining the legal codes of all fifty states to create a current, accurate map of where certified nurse midwives can work and what they are allowed to do.

The researchers began by refining the definitions used to categorize state laws. They identified that the original 2017 study had misclassified fourteen states based on the 2013 baseline, likely because the nuances of the laws had been interpreted differently or because the legal language had evolved. To correct this, they established four clear categories based on the actual requirements written into state law. At one end of the spectrum are states with "no barriers," where midwives can practice to the full extent of their training without needing a formal agreement with a doctor. At the other end are states with "high barriers," where midwives must work under the direct supervision of a physician, sometimes unable to even write prescriptions in their own name. Between these extremes lie "low barriers" and "moderate barriers," distinguished by whether a formal written protocol is required or if an informal collaboration is sufficient. By applying these updated definitions to the 2013 baseline and the 2024 landscape, the team corrected the historical record and captured the recent shifts in policy.

The updated analysis reveals a clear trend toward deregulation, though the pace of change is uneven. When the researchers compared the corrected 2013 data against the 2024 landscape, they found that eight states had adopted less restrictive policies, moving toward greater independence for midwives. These states include Arkansas, Delaware, Georgia, Illinois, Kansas, North Carolina, South Dakota, and Virginia. Notably, the data shows that no state moved in the opposite direction during this period to impose stricter rules. This shift is significant because it suggests a growing legislative recognition that expanding the role of midwives could help address the shortage of healthcare providers, particularly in the realm of maternal and infant care. The researchers also noted that while the original 2013 data suggested five states had become more restrictive between 2013 and 2024, this finding was an artifact of the earlier misclassification; once the definitions were corrected, the trend was entirely toward fewer restrictions.

Despite these positive changes, the researchers caution that the legal code is only part of the story. The data they provide reflects the laws as they are written on paper, but it cannot account for how individual hospital systems or state licensing boards might impose additional, unofficial restrictions in practice. Furthermore, even in states where midwives have full legal authority to practice, other hurdles remain, such as "Certificate of Need" laws that can prevent new birth centers from opening if the state decides there are already enough providers in an area. These facility-level barriers can limit the ability of midwives to establish the independent practices that the scope of practice laws theoretically allow. The study does not claim to have solved the debate over whether independent practice is safer or more efficient; rather, it provides the necessary, up-to-date evidence base that allows other scientists to investigate those questions with greater precision.

Ultimately, this update serves as a vital tool for health policy researchers who are trying to understand the relationship between regulation and patient outcomes. By offering a corrected historical baseline and a current snapshot of all fifty states, the study enables a more accurate analysis of how scope of practice laws influence maternal mortality, birth weights, and cesarean delivery rates. The authors hope that by making this data available, they will encourage further research into how these regulations affect the availability of care, the cost of healthcare, and the safety of mothers and babies across the country. In a time when the healthcare workforce is under strain, having a clear, factual picture of where midwives are allowed to work is the first step toward crafting policies that ensure every community has access to the care it needs.