Last Updated on January 19, 2026 by Chicago Policy Review Staff
For years, the United States has lagged behind other developed countries in its ability to keep mothers alive. A recent report from the National Center for Health Statistics found the US maternal mortality rate is 18.6 deaths per 100,000 live births, compared to an average of 10 deaths per 100,000 live births among OECD countries. This is partly attributable to maternity care deserts, a phenomenon that is growing due to obstetrics unit closures. These closures hit rural areas especially hard; percentages of hospitals without obstetrics units have increased every year since 2010, reaching a staggering 52.4% in rural America in 2022.
Behind each hospital closure is a web of stories: women who must travel farther and wait longer to receive care. For some, distance to a hospital can mean the difference between giving birth in an obstetrics unit and giving birth on the side of the freeway or in an ER. When hospitals are extended beyond capacity, mothers may find themselves unable to get appointments for prenatal care, and may face higher risk of medical neglect during labor. For low-income mothers with inflexible work schedules, time is money, and an hour spent commuting to a prenatal checkup is an hour of lost income during a time when they can least afford it. Inadequate prenatal care and overextended hospitals increase the likelihood of complications for both mothers and babies in a country whose medical system is already placing them at high risk.
It is more important than ever to expand care options for mothers, but many state-level policies are actively encumbering one critical avenue of care: midwifery. To address the growing issue of maternity care deserts, states must re-examine their policies to stop crippling the practice of midwifery.
Background
Over a century ago in the United States, births in immigrant and indigenous subcultures were often overseen by informally trained midwives who were members of the community. In the early 20th century, policymakers began to push for births to take place in hospitals and for midwives to receive certification. The latter half of the 20th century saw the founding of two certifying boards, the American Midwifery Certification Board (AMCB) in 1990 and the North American Registry of Midwives (NARM) in 1992.
People who intend to practice as midwives have multiple options for certification. Certified Nurse Midwives (CNMs) and Certified Midwives (CMs), both credentialed through AMCB, are similar in scope of practice. They can offer an expansive range of care, including sexual and reproductive health, gynecology, and family planning, as well as care before, during, and after birth. They can prescribe medication and practice in hospitals, offices, and birth centers, and can assist home births. To achieve certification, both CNMs and CMs must complete a graduate-level midwifery education program. The only significant difference between these certifications is that CNMs must earn a Registered Nurse license prior to or during the completion of the midwifery education program. While the CNM certification has existed since 1971, the CM certification was established in 1994 as an avenue for those without nursing degrees to offer the same care as CNMs, which is the reason behind the certifications’ similarity.
In contrast, the Certified Professional Midwife (CPM) credential, granted through NARM, encompasses a narrower scope of practice. CPMs provide counseling and hands-on care to expectant mothers and their families before, during, and after birth. Those wishing to pursue the certification need at least a high school diploma, and the education process is apprenticeship-based. While CPMs are trained to diagnose and treat conditions, they cannot prescribe medications or practice in hospitals, and must refer complicated pregnancies to hospitals for treatment.
Policy Issues
While CNM, CM, and CPM certifications are nationally recognized, their practice in individual states is dependent on state law. In all 50 states, CNMs are licensed to practice and prescribe medications, and their services are covered by Medicaid as well as most private insurance. In contrast, many states limit the practice of CMs and CPMs; CPMs are licensed to practice in 37 states, while CMs are only licensed to practice in 12 states and DC. Furthermore, CMs and CPMs are only included in Medicaid plans for a handful of states, and their services are not required to be covered by private insurance in all states. States that do license CMs and CPMs often limit their scope of practice; for example, over half of states that license CMs prohibit them from prescribing medication.
One phenomenon of particular concern is that CMs are not licensed in some of the states with the highest rates of obstetrics unit closures. The University of Minnesota School of Public Health performed a study of the increase in obstetrics unit closures. Among these states were Pennsylvania, South Carolina, West Virginia, Florida, Kansas, North Dakota, and Iowa, all states that do not license CMs. While CPMs are more broadly licensed, many states with maternity care deserts such as Pennsylvania, West Virginia, Kansas, and North Dakota still refuse to offer them licensing.
These policies present multiple risks. First is the risk of closing off avenues to those without nursing degrees who want a more comprehensive midwifery certification. Second is the possibility that policies that prohibit or severely limit the practice of CMs or CPMs in a particular state could push midwives across the border into states with more favorable policies. Thirdly, when states do not require insurance to cover the services of midwives, this can make critical maternal care unaffordable for those who need it most. These effects could exacerbate care shortages in states that are already maternity care deserts.
Further problems arise when CMs and CPMs are subject to the same regulatory framework. Although CMs and CNMs are certified by the AMCB to have the same scope of practice, the two certifications have been codified into state law very differently. In some states, CMs are governed by the same regulatory framework as CPMs. As the CPM certification equips midwives for a smaller scope of practice, regulating them together runs the risk of unduly limiting the scope of practice for CMs.
In some cases, the effects of these policies are dire. A recent New York Times article reported on midwives in rural West Virginia, where CMs and CPMs are neither licensed nor prohibited from practicing. In this state, certified midwives face the danger of fines and charges for practicing medicine without a license, and sometimes have to accept bartered payments because their patients cannot afford to pay for services that are not covered by insurance. However, given West Virginia’s rapid rate of obstetrics unit closures, these midwives continue to practice in adverse circumstances to protect the lives of mothers and their babies.
Recommendations
In order to unencumber the practice of midwives, leaders within the midwifery profession contend that CMs should be subject to the same state-level licensing and regulation as CNMs. In 2011, the AMCB, the American College of Nurse Midwives (ACNM), and the Accreditation Commission for Midwifery Education (ACME) collaboratively wrote a white paper recommending that CMs and CNMs should be subject to similar licensing and regulations, citing that the two certifications “have the same core education requirements, attain the same theoretical and clinical competencies, and take the same certification examination.” On the basis that CNMs are covered by Medicaid and are allowed full prescriptive authority in all states, similar regulation would ideally involve expanding these standards to CMs.
This has several potential effects. If licensing was extended to CMs in new states, this would open new avenues for people without nursing degrees who want to become midwives, which may increase the obstetric and gynecological care available to women. Ensuring that the services of midwives are covered by insurance could make the care of midwives affordable for many communities that need it most while helping to insure income stability for the midwives themselves, making midwifery a more stable career path. In states where midwifery is unregulated, licensing would allow some midwives who have been tirelessly standing in the maternal care gap to enjoy the protection of state law.
Critics may raise concerns that such a policy change may actually cause a rise in maternal deaths due to an increase in births occurring outside of a hospital setting. While midwives may not be equipped to oversee certain high-risk pregnancies, midwives are trained to identify complicated pregnancies and refer those pregnancies to obstetricians when they require more complex care than the midwife can provide. Furthermore, the increased availability of prenatal care will likely result in high-risk pregnancies being identified earlier and more effectively among populations that are living far from hospitals, helping mothers to plan ahead and seek the care of a specialist.
In a healthcare system that is failing to protect mothers, the above recommendation is more than a simple policy question; it is a matter of life and death. Expansion of midwifery practice can create a world in which alternative forms of care can alleviate overcrowded hospitals, in which mothers living in maternity care deserts can receive prenatal check-ups in their own homes, in which low-income families can use their insurance to cover the services of midwives, and in which midwives can serve their communities with reasonable compensation and without fear of legal recourse. Cumulatively, these effects serve to fight back against the United States’ staggering maternal mortality rate, making it a safer country for birthing mothers.