Journal of Midwifery & Women’s Health www.jmwh.

org
Original Research

The Practice of Midwifery in Rural US Hospitals

Katy B. Kozhimannil, PhD, MPA, Carrie Henning-Smith, PhD, MSW, MPH, Peiyin Hung, MSPH

Introduction: Workforce shortages limit access to care for pregnant women in rural and remote areas. The goal of this analysis was to describe
the role of certified nurse-midwives (CNMs) in providing maternity care in rural US hospitals and to examine state-level variation in rural CNM
practice.
Methods: We identified 306 rural hospitals with at least 10 births in 2010 using discharge data from the Statewide Inpatient Databases for 9 US
states. We conducted a telephone survey of hospital maternity unit managers (N = 244) from November 2013 to March 2014 to understand their
maternity care workforce and practice models. We describe the presence of CNMs attending births by hospital and state characteristics. Using
logistic multivariate regression, we examined whether CNMs attend births, adjusting for hospital characteristics, practice regulations, and state.
We also analyzed the content of open-ended responses about staffing plans, challenges, and opportunities that unit managers identified, with a
focus on midwifery practice.
Results: CNMs attend births at one-third of rural maternity hospitals in 9 US states. Significant variability across states appears to be partially
related to autonomous practice regulations: states allowing autonomous midwifery practice have a greater proportion of rural hospitals with mid-
wives attending births (34% vs 28% without autonomous midwifery practice). In rural maternity hospitals, CNMs practice alongside obstetricians
in 86%, and with family physicians in 44%, of hospitals. Fourteen percent of all respondents planned recruitment to increase the number of
midwives at their hospital, although many, especially in smaller hospitals, noted challenges in doing so.
Discussion: CNMs play a crucial role in the maternity care workforce in rural US hospitals. The participation of CNMs in birth attendance
varies by hospital birth volume and across state settings. Interprofessional practice is common for CNMs attending births in rural hospitals, and
administrators hope to increase the number of midwives in rural maternity practice.
J Midwifery Womens Health 2016;00:1–8  c 2016 by the American College of Nurse-Midwives.

Keywords: access, health policy, rural health, workforce

INTRODUCTION service line.6 From 2010 to 2015, 66 rural hospitals closed,10

Nearly half a million women give birth each year in rural hos-
pitals across the United States, but access to and quality of
maternity care are constrained in rural areas, owing, in part,
to challenges associated with low birth volume, as well as to
clinician workforce limitations.1,2 For example, of all hospitals
providing maternity services in the United States, just 15% ac-
count for nearly half of all births.1 In contrast, rural hospitals
have, on average, much lower birth volume, and low volume
has been associated with higher risks of some adverse out-
comes, such as postpartum hemorrhage, in rural settings.3,4
Outcomes are not independent of resources, and low-volume
hospitals have more limited staff, revenue, and facilities; ru-
ral areas also face crucial shortages in the clinician workforce,
including in maternity care.5
Birth volume and workforce issues impact not only qual-
ity, but also access to, maternity care. Rural women face par-
ticular constraints that limit their access to maternity care,
including the accelerating rate of hospital closures, discon-
tinuation of maternity services at some hospitals, health care
provider shortages, and fewer options for health insurance
coverage and provider networks.6,7 Low birth volumes and
challenges with recruiting and retaining a skilled maternity
care workforce8,9 have resulted in hospitals discontinuing this
Address correspondence to Katy B. Kozhimannil, PhD, MPA, Division of
Health Policy and Management, University of Minnesota School of Public
Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455. E-mail:
kbk@umn.edu
and many others terminated maternity services. The loss
of hospital maternity services could be detrimental to rural
women, particularly when more than 50% of them already had
to travel at least 30 minutes to the nearest hospital with peri-
natal services.11
Another constraint on access is financial; for women who
are uninsured or underinsured, prenatal and intrapartum care
can be costly.12,13 In 2010, rural women aged 18 to 44 years
were more likely to be uninsured, compared with their ur-
ban counterparts (24% vs 22%).14 While the Patient Protec-
tion and Affordable Care Act (ACA) has expanded access to
health insurance for many, in 2014, 18% of rural reproductive-
age women still lacked health insurance coverage.14 Yet issues
of access go beyond health insurance; the Medicaid and Chil-
dren’s Health Insurance Program (CHIP) Payment and Access
Commission (MACPAC)15 highlighted that having health in-
surance coverage for maternity services does not guarantee ac-
cess to care. Having a sufficient workforce is also necessary to
meet patients’ needs.
Nationally, the maternity care workforce is influenced by
the decline in family physicians attending births; the increas-
ing average age of rural obstetricians; variation in policies
across states and practice environments; and restructuring,
regionalization, and closure of many maternity care units.16
Workforce shortages have a particular impact on maternity
care in rural areas, where women have more limited access to
preconception, prenatal, intrapartum, postpartum, and fam-
ily planning care as well as worse health outcomes compared
with women in urban areas.7

1526-9523/09/$36.00 doi:10.1111/jmwh.12474 
c 2016 by the American College of Nurse-Midwives 1
 ✦ Maternity care workforce shortages limit access to care for pregnant women in rural and remote areas.
✦ The goal of this analysis was to describe to the role of certified nurse-midwives (CNMs) in providing maternity care in
rural US hospitals.
✦ CNMs attend births at one-third of rural maternity hospitals in 9 US states, with significant variability across states.
✦ In rural maternity hospitals with CNMs, midwives practice alongside obstetricians in 86% of hospitals and with family
physicians in 44% of hospitals.
✦ The presence of CNMs attending births varied significantly by hospital birth volume; rural hospitals with larger birth
volumes were more likely to have CNMs attending births than rural hospitals with smaller birth volumes.

Historically, midwives have played a vital role in provid-
ing maternity care to vulnerable populations of women, such
as young, low-income, immigrant, and racial or ethnic minor-
ity groups.17 Further, the history of midwifery in the United
States is uniquely tied to providing care to rural populations,
beginning with the Frontier Nursing Service, which educated
nurse-midwives to provide high-quality care,18 resulting in a
long history of improved outcomes for vulnerable populations
with access to care from midwives.17 Midwives still have an
important role to play in providing care in rural areas, includ-
ing in health professional shortage areas, where there are cur-
rently more midwives than physicians in practices.19 There is
contemporary precedent for rural hospitals to increase their
maternity care capacity through midwifery,20 with positive
effects on maternal and infant outcomes. For example, use
of a nurse-midwife program in rural California was associ-
ated with increased prenatal care and decreased premature
births and neonatal mortality.20 Still, it is not clear the extent
to which such local successes have translated more broadly
across US states and regions.
The goal of this study was to describe the role of certified
nurse-midwives (CNMs) in providing maternity care in ru-
ral US hospitals, using quantitative and qualitative analyses of
survey data collected from rural hospital administrators about
their experiences providing maternity services. Additionally,
we examined state-level variation in rural CNM practice and
discuss the role of state regulations governing midwifery prac-
tice in rural maternity care.
METHODS
Data and Study Population
Data for this study came from 2 sources. First, we conducted a
telephone survey of all rural hospitals and critical access hos-
pitals (CAHs) that provide maternity services in 9 states: Col-
orado, Iowa, Kentucky, New York, North Carolina, Oregon,
Vermont, Washington, and Wisconsin. The 9 states were cho-
sen, in part, because of the size of their rural populations (to
ensure a large enough sample of women giving birth in ru-
ral hospitals), and also because they permit use of patient zip
codes and linkage with the American Hospital Association
(AHA) data in order to obtain hospital-level characteristics. A
CAH is a hospital with 25 or fewer inpatient beds that serves
the specific need of ensuring access in rural and remote areas.
Rural areas were defined based on the Office of Management
and Budget nonmetropolitan county definition.21
The target respondent group was clinical nurse managers
and medical directors for obstetrics, and all respondents pro-
vided their titles. Nearly all survey respondents (95%) had a
managerial role in the obstetrics or women’s health depart-
ment (eg, Director or Nurse Manager); approximately 5% of
respondents had a broader managerial role in the hospital
(eg, Chief Nursing Officer, Vice President for Patient Care).
The survey included closed- and open-ended questions about
the hospital’s maternity services, including information about
staffing. Survey questions were developed based on a review of
the literature, with input from an advisory committee of ma-
ternity unit nurse managers from 8 rural hospitals. The sur-
vey questions were revised following initial field testing with
3 advisory committee members and a family physician with
rural maternity care experience. Minor changes were made
following a second field test with 10 hospitals from the sur-
vey sample; results from these hospitals were included in the
final survey results.
The survey interviews were conducted by the Office of
Measurement Services at the University of Minnesota from
November 2013 to March 2014. The initial sample consisted of
all 306 rural hospitals in these 9 states with at least 10 births in
the 2010 Health Care Cost and Utilization Project, Statewide
Inpatient Databases (SID). The SID contain information on
100% of hospital discharges; live births were identified us-
ing a validated methodology.22 Data were also linked to the
AHA annual survey. A total of 263 hospitals (86%) responded
to the survey. Of those, 244 hospitals were currently provid-
ing maternity services, and 19 hospitals had stopped provid-
ing maternity services since 2010. Hospitals that responded
to the survey did not differ significantly from nonrespon-
dents in terms of organizational characteristics including size
(adjusted daily census, inpatient days, and number of beds),
number of births, accreditation, or system affiliation.8 More
detail on the survey and methodology has been published
elsewhere.8 This research was approved by the University of
Minnesota Institutional Review Board.
Measurement
Midwifery Practice
The primary outcomes for this analysis focus on the prac-
tice of midwifery by CNMs in rural hospitals. While other

2 Volume 00, No. 0, xxxx 2016

midwives (including certified professional midwives and Table 1. Proportion of All Rural Maternity Hospitals in 9 Statesb
certified midwives) practice in rural areas, CNMs are the With Midwives Attending Births, by Hospital Characteristics
predominant provider of hospital-based midwifery care,23 Hospitals With P (Differences
which is the focus of this analysis. According to sur-
CNMs Attending Between Hospital
vey responses to the question, “Do any certified nurse-
midwives/obstetricians/family physicians deliver babies at Births Groups)b
your hospital?” we constructed dichotomous indicators to n()
indicate whether CNMs attend births at the hospital and All sample rural hospitals 77 (31.6)
whether obstetricians or family physicians also attend births Annual birth volume
at the hospital.
1-130 10 (16.7) .004
131-260 21 (33.3) .754
State Policy 261-440 20 (31.8) .970
We included indicator variables for each state to assess 441+ 26 (44.8) .016
whether outcomes differed across states. One source of state- Hospital ownership
level variability in midwifery practice may be state laws gov-
Government 20 (26.3) .298
erning the scope of midwifery practice.24 We aimed to dis-
tinguish states with fully autonomous midwifery practice (ie, Private nonprofit 54 (34) .313
not subject to either collaborative agreement or physician su- Private for-profit 3 (33.3) 1.000
pervision). To that end, we included a dichotomous variable Critical access hospitals .168
indicating whether the hospital was located in a state that al- Status
lows midwives to practice without physician supervision or
Critical access hospitals 34 (27.2)
collaborative agreement. Based on a classification presented
in prior research,25 each state in our study was classified as Other rural hospitals (not 43 (36.1)
having autonomous practice for CNMs (Colorado, Iowa, New CAHs)
York, Oregon, Vermont, Washington) or not having such a Accreditation .256
policy (North Carolina, Kentucky, Wisconsin) based on Lexis
Accredited 53 (34.2)
legal search (http://www.lexis.com) and verified by the Amer-
ican College of Nurse-Midwives Government Affairs staff. Nonaccredited 24 (27)
System-affiliated .582
hospitals
Hospital Characteristics
Yes 36 (29.5)
Most data on birth volume and hospital characteristics came
No 41 (33.6)
from the 2013 SID data, except CAH status, which was identi-
fied using the Flex Monitoring Team CAH database.26 We ex- Obstetricians attend .033
amined several hospital characteristics in our analysis. First, births
we categorized hospitals based on a measure of hospital birth Yes 66 (35.1)
volume, split into approximate quartiles by number of births No 11 (19.6)
per year at each hospital (1-130, 131-260, 261-440, and 441
Family Physicians Attend .019
or more). Next, we included measures of hospital ownership
(government nonfederal, private nonprofit, and private for- Births
profit hospitals), whether the hospital was accredited, and Yes 34 (25.2)
whether it had system affiliation or not. We also used data No 43 (39.5)
from the AHA Annual Survey for other measures of hospi-
a
tal size, including total number of hospital beds, number of Colorado, Iowa, Kentucky, New York, North Carolina, Oregon,Vermont,
Washington, and Wisconsin.
obstetric beds, number of operating rooms, and average daily b
P values were derived from Fisher’s exact tests for differences in proportion of
hospitals with CNMs attending births between hospital groups for characteristics.
census.

Analysis fication tests were performed to ensure the relevance of in-

Quantitative
We performed Fisher’s exact tests to examine bivariate associ-
ations between each hospital and state characteristic and the
presence of CNMs attending births. For the differences in the
distribution (median location) of each hospital volume char-
acteristic by the outcome, we used Wilcoxon tests. Logistic
regression was also used to examine the independent associa-
tions of each hospital characteristic with the outcome variable
(whether CNMs attend births at the hospital). Model speci-
dependent variables. Collinearity tests with variance inflation
factor indicators were performed to detect the multicollinear-
ity between variables. We also compared Akaike Informa-
tion Criteria and Bayesian Information Criteria27 across a se-
ries of models controlling for different volume variables on
Table 2. The final model controlled for hospital birth volume,
hospital ownership, system affiliation, adjusted average daily
census, and either presence of state autonomous midwifery
regulation policies or state location. We did not include in-
dividual state and presence of state autonomous midwifery

Journal of Midwifery & Women’s Health r www.jmwh.org 3

 Table 2. Hospital Characteristics by Whether or Not Midwives Attend Births Among All Rural Maternity Hospitals in 9 Statesb
CNMs Attend Births
Number of clinicians attending births
Number of obstetricians attending births
Number of family physicians attending births
Number of hospital beds
Number of obstetrics beds
Number of operating rooms
Adjusted average daily census
Proportion of births that are Medicaid-reimbursed
a
Colorado,Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin.
b
P values were derived from Wilcoxon rank sum tests for differences in median location between hospital groups.
regulation policies simultaneously in the regression models
because of multicollinearity. Instead, we used separate mod-
els to distinguish the associations between autonomous prac-
tice laws and the specific state environment on midwifery
practice.
Qualitative
We also used conventional content analysis28 to examine
open-ended responses about staffing plans, challenges, and
opportunities that unit managers identified, with a focus on
midwifery practice in these settings. We searched for the
words “midwife,” “midwives,” “CNM,” or “midwifery” within
the open-ended responses for the following question: “In the
next 3 years, do you expect the type or number of clini-
cians doing deliveries in your hospital to change? If yes, what
changes do you expect?” We assessed the number of times
midwives, CNMs, or midwifery was mentioned, and analyzed
relevant content for patterns/themes.
RESULTS
Quantitative Findings
Table 1 shows the percentage of hospitals with CNMs at-
tending births, by hospital characteristic. Overall, 32% of ru-
ral hospitals in our sample had CNMs attending births. The
smallest-volume rural hospitals, with an annual birth volume
of one to 130, were significantly less likely than larger hospitals
to have CNMs attending births, whereas the largest hospitals
(birth volume of 441 or more) were significantly more likely
than smaller hospitals to have CNMs attending births (17%
of the smallest hospitals had CNMs attending births, com-
pared with 45% of the largest hospitals). Hospitals with obste-
tricians attending births were significantly more likely than
those without obstetricians to have CNMs attending births
as well (35 vs 20%, P = .03), whereas hospitals with fam-
ily physicians attending births were significantly less likely to
have CNMs attending births than those without family physi-
cians attending births (25 vs 40%, P = .02). There were no sig-
nificant differences in the presence of CNMs attending births
by hospital accreditation status, system affiliation, or owner-
ship. Among hospitals with CNMs attending births, midwives
4 Volume 00, No. 0, xxxx 2016
Median (Upper-Lower Quartile)
CNMs Do Not Attend Births
(n = ) (n = ) Pb
6 (5-8) 5 (3-7) ⬍ .001
3 (2-4) 3 (2-4) .077
4 (2-7) 4 (2-6) .971
49 (25-98) 33 (25-75) .183
6 (4-12) 5 (3-10) .169
4 (3-5) 3 (2-5) .056
75 (48-180) 84 (43-175) .883
54% (38-62%) 50% (38-67%) .780
practiced alongside obstetricians in 86% of these hospitals and
with family physicians in 44% of these hospitals (results not
shown.)
Table 2 shows hospital characteristics based on whether
or not CNMs attend births at that hospital. The median num-
ber of clinicians was significantly greater in hospitals where
CNMs are attending births than those where CNMs are not at-
tending births (6 vs 5 median clinicians, P ⬍ .001). There were
no significant differences in number of hospital beds, obstet-
ric beds, operating rooms, average daily census, or proportion
of Medicaid-funded births by whether or not CNMs were at-
tending births.
The distribution of hospitals with CNM-attended births
by autonomous practice policy status and state is shown in
Table 3. Across all 9 states, rural hospitals in New York (58%,
P = .010) and Vermont (67%, P = .029) were significantly
more likely to have CNMs attending births than those in other
states (range 23%-37%). These 2 states allow autonomous
midwifery practice. Overall, among states that allow au-
tonomous midwifery practice, 34% of all rural hospitals that
responded to our survey had CNMs attending births. In con-
trast, in states that require physician supervision or collabora-
tive agreement for midwifery practice, 28% of rural hospitals
had CNMs attending births. When states are grouped based
on scope of practice laws (ie, states with autonomous prac-
tice versus states with restrictions), there were differences by
state. For instance, in states with autonomous midwifery prac-
tice, 67% of rural hospitals in Vermont had CNMs attending
births, compared with 23% in Iowa. Between-state differences
(with a range of 44 percentage points across all states) were of
larger magnitude than average differences across policy type
(difference of 12 percentage points between states with au-
tonomous practice and states with supervision or collabora-
tive agreement requirements).
The adjusted odds of having a CNM practicing at a rural
hospital are shown in Table 4. In Model 1, controlling only for
hospital characteristics and annual birth volume, the odds of
having a CNM were highest for hospitals with the largest birth
volume (odds ratio [OR], 4.6; 95% confidence interval [CI],
2.3-9.3), compared with the hospitals with the smallest birth
volume. All hospitals with birth volumes greater than 130 had
significantly higher odds of having a CNM than hospitals with
 Table 3. Percent age of Rural Maternity Hospitals Where CNMs Attend Births, by Policy Type
Autonomous Midwifery Practice Subject to Collaborative Agreement

State CNMs Attending Births, n() State CNMs Attending Births, n()
Total 140 (34.3) Total 104 (27.9)
CO 19 (36.8) KY 20 (25.0)
IA 52 (23.1) NC 35 (34.3)
NY 19 (57.9) WI 49 (24.5)
OR 21 (33.3)
VT 9 (66.7)
WA 20 (25.0)

Abbreviations: CO, Colorado; IA, Iowa; KY, Kentucky; NY, New York; NC, North Carolina; OR, Oregon; VT, Vermont; WA, Washington; WI, Wisconsin.

Table 4. Adjusted Odds That a Rural Maternity Hospital Has CNMs Attending Births by Hospital Characteristics, State Policy, and Location
(N = 244 hospitals)
Odds That a Rural Hospital Has CNMs Attending Births

OR ( CI)

Model  Model  Model 

Annual birth volume
1-130 1, (Reference) 1, (Reference) 1, (Reference)
131-260 2.3 (1.5-3.4) 2.4 (1.6-3.7) 2 (1.5-2.8)
261-440 2.2 (1.5-3.1) 2.2 (1.6-3.2) 1.6 (0.9-2.7)
441+ 4.6 (2.3-9.3) 5.2 (2.3-11.8) 4.9 (2-12.2)
Hospital ownership
Government 1, (Reference) 1, (Reference) 1, (Reference)
Private nonprofit 1.1 (0.5-2.2) 1.2 (0.6-2.6) 0.9 (0.3-2.4)
Private for-profit 1 (0.2-6.7) 1.4 (0.2-9.8) 1.1 (0.1-9.3)
System affiliation 0.7 (0.4-1.3) 0.7 (0.4-1.3) 0.9 (0.5-1.5)
Adjusted average daily census (100) 0.9 (0.7-1.2) 0.9 (0.7-1.2) 0.8 (0.7-1)
Autonomous midwifery regulation 1.8 (0.9-3.5) 1.8 (0.9-3.5)
State
Colorado 1.6 (0.5-4.8)
Iowa 1, (Reference) (1-1)
Kentucky 0.8 (0.2-2.7)
North Carolina 1.1 (0.4-3.3)
New York 5.7 (1.5-21.7)
Oregon 1.4 (0.4-4.5)
Vermont 7.2 (1.4-36.1)
Washington 0.9 (0.2-3.6)
Wisconsin 1 (0.4-2.9)

Abbreviations: OR, odds ratio; CI, confidence interval.

one to 130 births. In Model 2, we adjusted for whether or not
the hospital was located in a state allowing autonomous mid-
wifery practice and found that birth volume was still the only
significantly associated variable. While the point estimate in-
dicated higher odds that a hospital would have a CNM attend-
ing births in states allowing autonomous practice (OR, 1.8),
compared with states that did not allow autonomous prac-
tice, that estimate was not statistically significant (95% CI, 0.9-
3.5). Finally, in Model 3, we adjusted for individual state. Birth
volume remained significantly associated with higher odds of
having a CNM for hospitals with 131 to 260 births (OR, 2.0;
95% CI, 1.5-2.8) and with 441 or more births (OR, 4.9; 95% CI,
2.0-12.2), compared with the smallest hospitals (1-130 births).
Being located in New York (OR, 5.7; 95% CI, 1.5-21.7) or Ver-
mont (OR, 7.2; 95% CI, 1.4-36.1) was associated with signif-
icantly higher odds of the hospital having CNMs attending
births, compared with having a birth in Iowa (the state with
the lowest rate of CNM-attended births.)

Journal of Midwifery & Women’s Health r www.jmwh.org 5

Qualitative Findings
Fifty-four percent (n = 131) of hospital administrators that
responded to the survey answered that they expected the type
or number of clinicians attending births in their hospital to
change in the next 3 years. Of those responses, 34 mentioned
midwives as part of this change (26%). All but one of those
respondents indicated anticipating an increase in the number
of midwives practicing at that hospital. Most indicated that
they had either recently hired a midwife (n = 3; 8%) or that
they hoped to hire a midwife or midwives in the near future
(n = 30; 88%.) So, one-quarter (25%) of all respondents who
expected to have a staffing change in the next 3 years were
either hoping or planning to add at least one midwife to their
staff, or had very recently done so. This represented 14% of all
respondents, including those who did not expect to change
their staffing in the next 3 years.
Some of these respondents used language indicating their
confidence in hiring a midwife, for example, “I expect we will
get one or 2 OBs and one or 2 new midwives,” and “I expect to
add another midwife.” Other respondents used language indi-
cating that they were hopeful that they would add a midwife
or 2 to their staff, but they were less confident in their abil-
ity to do so, for example, “I hope that we get midwives!” and
“We want to have a midwife come here as well. I hope that will
happen as we grow.” Other respondents were less optimistic,
for example, “We would love to add midwives, but I’m not sure
that will happen.” One respondent explained that the desire to
add a midwife is motivated by perception that the midwifery
model would appeal to patients: “We have a desire to have a
CNM on staff to attract a patient population who wants that.”
DISCUSSION
CNMs play a crucial role in the maternity care workforce
in rural US hospitals, attending births at approximately one-
third of all rural maternity hospitals in 9 US states included in
this study. Interprofessional practice is common for CNMs at-
tending births in rural hospitals, where they frequently work
alongside obstetricians and family physicians. In addition, the
role of midwifery in rural maternity care is likely to grow, as
one-quarter of hospital administrators who anticipate changes
to their maternity workforce are planning or hoping to add
midwives as clinicians in their units. The growth of midwifery
practice in rural US hospitals has the potential to improve ac-
cess to high-quality maternity care for a population of women
that is currently underserved.7
Beyond the substantial and growing presence of CNMs
as birth attendants in rural hospitals, this analysis also re-
vealed factors that predict the chances that a rural hospital
would have CNMs attending births. These key predictors in-
clude hospital birth volume and state location. Even after con-
trolling for other hospital characteristics, the odds of hav-
ing a CNM attending births are higher among larger birth
volume hospitals, compared with hospitals that have 130 or
fewer births a year. Hospitals with lower birth volumes may
struggle to sustain employment for clinicians, such as CNMs
and obstetricians, for whom maternity care constitutes the
core of their practice. Rather, family physicians, who inte-
grate maternity care within their broad scope of practice, are
the most frequent maternity care providers for the small-
6 Volume 00, No. 0, xxxx 2016
est volume rural hospitals.8 Indeed, many of the patterns of
interprofessional practice detected in this analysis are likely
driven by the strong relationships between hospital birth vol-
ume and the types of clinicians providing maternity care at
that hospital.8 While CNMs specialize in care during preg-
nancy and childbirth, their scope of practice includes primary
care as a core competency,29,30 and a full-scope practice may
increase the viability of establishing a practice as a CNM based
at a rural hospital with low birth volume. Indeed, expand-
ing midwifery education and training in primary care shows
promise for increasing competency and interest in primary
care practice.31
It is important to consider our findings in light of the con-
text in which rural CNMs practice and rural women seek ma-
ternity care. For those midwives currently practicing in rural
US hospitals, it is important to understand the particular chal-
lenges and barriers that women face in accessing care in rural
and remote areas. A study in Canada categorized these barri-
ers into 4 main themes: geographic realities, the availability of
local health service resources, the influence of parity (the chal-
lenge of having other children at home), and financial implica-
tions of leaving the community to give birth.32 The harsh real-
ity of these challenges grows starker with each passing year, as
the pace of hospital obstetric unit closures has accelerated in
the rural United States.6,9 Distance traveled for maternity care
is not just a matter of convenience for women in rural areas;
longer travel distances are also associated with higher rates of
perinatal morbidity and mortality.33 In addition, known racial
and ethnic disparities in birth outcomes persist among rural
populations, where access challenges compound sociodemo-
graphic risk factors.34 Rural midwives can play an important
role in addressing a broad range of issues that rural women
face and may be uniquely situated to meet the needs of diverse
rural women, via effective patient-provider communication35
and woman-centered care.36
This analysis also detected meaningful differences across
states in the participation of CNMs as birth attendants in rural
hospitals. We analyzed the potential role of one state-level pol-
icy, autonomous practice laws, compared with restrictions re-
quiring physician supervision or collaborative practice. States
with autonomous practice laws did have a higher percentage
of rural hospitals reporting that they had CNMs attending
births (34% on average) compared with states with restric-
tions on independent practice (28% on average), but this dif-
ference was not statistically significant after controlling for
hospital characteristics. Further, the between-state differences
substantially exceeded the magnitude of difference between
the policy categories (autonomous practice versus restrictions
on autonomous CNM practice). For example, among states
with autonomous practice, the percentage of rural hospitals
with CNMs attending births ranged from 23% in Iowa to
67% in Vermont. The reasons for these differences were not
explicitly elucidated in the analysis but may include other
aspects of midwifery training (eg, location of schools,
training programs), credentialing (eg, state licensure process),
payment (eg, Medicaid reimbursement rates), and policies
(eg, prescription writing, scope of services rendered, and hos-
pital admitting privileges).24,37
Federal policy may also influence the practice of rural
midwifery in the future, especially via national initiatives
to address health care workforce shortages in rural areas.
For example, the Improving Access to Maternity Care Act,
(H.R.1209/S. 628),38 which was introduced in March 2015,
would create health professional shortage areas specifically
for maternity care services. The legislation’s explicit goal is to
identify areas of the United States that are experiencing signif-
icant shortages of maternity care clinicians, including CNMs,
and to take steps to ameliorate these shortages by allowing
the US Department of Health and Human Services to place
eligible maternity care clinicians within the National Health
Service Corps. In addition, Section 3114 of the ACA estab-
lished payment equity under Medicare for CNMs and physi-
cians who perform the same services. This latter change may
have impacted our study results. Effective in 2011, Medicare
payment for CNM services increased from 65% to 100% of the
Physician Fee Schedule.39 This federal policy was an impor-
tant change because Medicare payment rates serve as a bench-
mark for other payers, including Medicaid programs, which
are administered by states. Currently, 22 state Medicaid pro-
grams do not pay CNMs the same fees as physicians for per-
forming the same service,40 a source of variability across states
and a potential policy lever for increasing access to maternity
care, especially in rural hospitals where Medicaid funds more
than half of births.41
Limitations
This study should be considered in light of its limitations.
First, our analysis is limited to 9 states, which may limit
generalizability. Additionally, our sample of hospitals is rel-
atively small (244), limiting our ability to detect small differ-
ences. Still, we found significant differences in use of CNMs,
especially by hospital volume and state. As with any sur-
vey data, there is a risk of nonresponse bias. Our relatively
high response rate (86%) gives us some confidence that this
does not compromise our results; however, we also compared
respondents and nonrespondents and found no meaning-
ful differences in measured hospital characteristics using the
AHA survey data.8 Finally, our survey questions specifically
asked respondents about “certified nurse-midwives,” rather
than about the full range of midwifery credentials. Future re-
search should explore the role of all types of midwives practic-
ing in rural settings. Further, respondents were not explicitly
prompted to discuss midwifery in the open-ended questions,
leading to potential subjectivity in who volunteered informa-
tion on CNMs. Yet this also gives us confidence that our ques-
tions were not leading and that administrators who brought
up CNMs on their own were truly motivated to discuss that
facet of maternity care.
CONCLUSION
Midwives play a vital role in the maternity care workforce
in rural US hospitals. In this study, we found that the par-
ticipation of midwives varies widely across state settings and
is related to state-level practice regulations, as well as hospi-
tal characteristics. Interprofessional practice is common for
midwives attending births in rural hospitals, although prac-
tice configurations vary considerably. Using analysis of open-
ended survey answers, we found that administrators hope and
plan to increase the number of midwives in rural maternity
Journal of Midwifery & Women’s Health r www.jmwh.org
practice. Increasing the number of midwives may improve ac-
cess to both maternity care and primary care for rural women,
and several state and federal policy levers are available for en-
couraging midwifery practice in rural areas across the United
States. Midwifery care is an evidence-based service model
with much to offer health care delivery systems and patients
in rural communities.
AUTHORS
Katy B. Kozhimannil, PhD, MPA, is an Associate Professor in
the Division of Health Policy and Management at the Univer-
sity of Minnesota’s School of Public Health and an Investigator
at the University of Minnesota Rural Health Research Center.
Carrie Henning-Smith, PhD, MSW, MPH, is a Research As-
sociate at the University of Minnesota Rural Health Research
Center.
Peiyin Hung, MSPH, is a doctoral student in the Division
of Health Policy and Management at the University of Min-
nesota’s School of Public Health and a Research Assistant at
the University of Minnesota Rural Health Research Center.
CONFLICT OF INTEREST
Financial support: This study was supported by the Federal
Office of Rural Health Policy (FORHP), Health Resources
and Services Administration (HRSA), US Department of
Health and Human Services (HHS) under PHS Grant No.
5U1CRH03717. The information, conclusions, and opinions
expressed in this manuscript are those of the authors and no
endorsement by FORHP, HRSA, or HHS is intended or should
be inferred.
ACKNOWLEDGMENTS
The authors gratefully acknowledge our Rural Hospital Ob-
stetric Advisory Group; the rural hospital survey respondents;
and the Office of Measurement Services at the University of
Minnesota, for fielding the survey.
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