The Nature and Scope of Nurse-Midwifery Practice in One U.S. State: Implications for Global Midwifery

Worldwide, midwives provide substantial amounts of care to underserved and vulnerable women and infants. However, workforce surveys regarding midwives are conspicuously absent across much of the globe. The United Nations Sustainable Development Goals for 2030 establish metrics for Goal #3: Global Good Health and Well-Being; many require midwifery care to achieve. There is an urgent need for healthcare policymakers to understand the nature and scope of midwifery care to improve healthcare across the globe. As the largest state in the U.S.A. with a diverse population and shared border with Mexico, Texas encompasses key issues encountered by midwives across the globe. The purpose of this study was to understand the scope and nature of the practice environment for certified nurse-midwives (CNMs) licensed in Texas. A previously developed practice survey (160 items) was adapted for electronic online use, exploring practice in eight areas: demographics, type of practice, compensation, leadership, legislative priorities, teaching involvement, and practice satisfaction. Emails with a link to the survey were distributed to Texas CNMs (n=438), resulting in a response rate of 33%. SPSS v 21 was used to analyze data. The survey found that most midwives in Texas are white, practice in hospital settings or physician groups in large urban areas, and care most often for Hispanic/Latino women, a typically underserved and vulnerable population in Texas. Additionally, in an aging generation of midwives, most report working at their full capacity - caring for 20 clinic patients a day and working 40-60 hours a week though close to one-third felt they were able to see more patients. CNMs often felt unable to support women in a range of issues impacting physiologic birth; over three-quarters believed a Midwifery Board should regulate practice separate from the existing Texas Board of Nursing. Among the top legislative priorities were: need for independent prescriptive authority, hospital admitting privileges, and elimination of physician supervisory language in hospital bylaws. Finally, subsets of 8 CNMs were individually interviewed to gain a better understanding of the barriers and incentives to midwifery practice. Open coding analysis revealed themes related to most midwives feeling mostly satisfied with their work. However, many expressed frustration regarding physician-midwife relationships, and many felt a physician-focused medical culture fails to appreciate the larger contributions midwives could make. Midwifery issues found in this study reflect current trends experienced by other countries that also face border issues and healthcare systems where resources are often stretched perilously thin.