News Release

States where midwives practice independently have lower rates of cesarean deliveries

Peer-Reviewed Publication

George Washington University Milken Institute School of Public Health

WASHINGTON, DC (March 8, 2016) -- States that allow autonomous practice by certified nurse-midwives (CNMs) have a higher proportion of CNM-attended births as well as lower rates of cesarean sections, preterm births, and low birthweight infants, according to a study published today in Women's Health Issues. Women's Health Issues is the official journal of the Jacobs Institute of Women's Health, which is based at Milken Institute School of Public Health (Milken Institute SPH) at the George Washington University.

Authors Tony Yang of George Mason University and Laura Attanasio and Katy Kozhimannil of the University of Minnesota School of Public Health analyzed data on 12 million births from 2009 through 2011 reported by 50 states and the District of Columbia to the Centers for Disease Control and Prevention. They classified each state as either being subject to collaborative agreement, meaning CNMs must have physician supervision or contractual practice agreements in order to practice (28 states), or as having autonomous practice, in which no such agreements are required (22 states and the District of Columbia). The authors found that women giving birth in the states allowing independent midwifery practice had a 60 percent greater chance of having a certified nurse midwife as a birth attendant.

Past research has found that midwives are less likely than obstetricians to use interventions like labor induction and cesarean delivery that may have higher risks for women and infants when performed without definitive medical need. The authors of this study also found that women giving birth in the group of states allowing autonomous midwifery practice had 13 percent lower odds of cesarean delivery, 13 percent lower odds of preterm birth, and 11 percent lower odds of delivering low-birthweight babies when compared to women giving birth in the states with stricter requirements for CNM practice.

"Future policy efforts to enhance access to midwifery services may be beneficial to pregnancy outcomes and infant health," the authors conclude, adding that more midwife-assisted births could lead to better birth outcomes and lower costs. They note that cesarean deliveries not only come along with health risks but are approximately 50 percent more costly than vaginal deliveries.

The study, "State Scope of Practice Laws, Nurse-Midwifery Workforce, and Childbirth Procedures and Outcomes," has been published online ahead of print and will appear in the May/June issue of Women's Health Issues.


About Women's Health Issues:

Women's Health Issues is the official publication of the Jacobs Institute of Women's Health, and the only journal devoted exclusively to women's health care and policy issues. The journal has a particular focus on women's issues in the context of the U.S. health care delivery system and policymaking processes, although it invites submissions addressing women's health care issues in global context if relevant to North American readers. It is a journal for health professionals, social scientists, policymakers, and others concerned with the complex and diverse facets of health care delivery and policy for women. For more information about the journal, please visit

About Milken Institute School of Public Health at the George Washington University: Established in July 1997 as the School of Public Health and Health Services, Milken Institute School of Public Health is the only school of public health in the nation's capital. Today, more than 1,900 students from 54 U.S. states and territories and more than 50 countries pursue undergraduate, graduate and doctoral-level degrees in public health. The school also offers an online Master of Public Health, MPH@GW, and an online Executive Master of Health Administration, MHA@GW, which allow students to pursue their degree from anywhere in the world.

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