EurekAlert reports on a study finding that states allowing autonomous certified nurse-midwifery (CNM) practice (no requirement for practice agreements or physician supervision) had more midwives per capita, more women attended by midwives, lower cesarean rates, and better outcomes.
Investigators used birth certificate data, state scope of practice laws, and American College of Nurse-Midwives workforce data to evaluate the relationship between outcomes and ability to practice autonomously in all 50 states and the District of Columbia from 2009 through 2011. States allowing autonomous practice had more midwives (5 vs. 2 per 1000 births). After adjusting for variation in demographic and health risk characteristics among states such as race/ethnicity, marital status, education, timing of initiation of prenatal visits and number of visits, and smoking, women were 60% more likely to be attended by a CNM in autonomous states. Women in those states had 13% lower odds of having a cesarean, 13% lower odds of preterm birth, and 11% lower odds of having a low birthweight baby (not defined, but the standard definition is 5 lb 8 oz or 2500 g).
Studies of midwife-led care consistently find that midwifery care improves outcomes while reducing use of interventions. It makes sense that the ability to practice free of the constraints of medical-model thinkers would strengthen its effects. However attractive the theory, though, we mustn’t jump to conclusions. For one thing, studies comparing populations (ecological studies) don’t allow you to connect the dots in any simple way because they don’t tell you what’s going on at the level of the individuals. The study authors themselves note that they had no access to information on women’s health status, and they couldn’t tie CNM care directly to cesarean rate because birth certificates for cesareans would be signed by the delivering obstetrician. For another, we don’t know the degree to which CNMs working for hospitals and physician practices in non-autonomous states influence care. Neither do we know the impact in autonomous practice states of the need to toe the line to maintain admitting privileges or keep back-up physicians sweet.
Still, that being said, based on a large body of research, having regulations that encourage more midwives to set up practice, which giving them independence appears to do, has benefits and no offsetting harms. This study adds to the pile.