State Midwifery Full Practice Authority Policies and Midwife-Attended Births Among Rural and Urban U.S. Residents

Introduction: Midwives play an important and growing role in U.S. perinatal care. Several state-level policies regulate midwifery practice. We examined whether the adoption of one such policy—licensing midwives to practice without physician supervision (full practice authority)—changed the percentage of midwife-attended births for rural and urban residents. Methods: Using 2007–2023 Centers for Disease Control and Prevention's Wide-ranging ONline Data for Epidemiologic Research and state-level data on full practice authority policies collated by the American College of Nurse-Midwives, we estimated differences in the percentage of midwife-attended births before and after state adoption of these policies, examining rural and urban births separately. Results: In 2007, 13 states and the District of Columbia had full practice authority policies; an additional 20 states passed such policies between 2008 and 2023. The percentage of midwife-attended births increased between 2007 and 2023 among states without full practice authority policies (rural, from 9.9% to 14.8%; urban, from 9.6% to 14.4%), among states that passed policies in 2007 or earlier (rural, from 16.9% to 22.0%; urban, from 14.7% to 25.0%), and among states that passed policies during the study period (rural, from 14.3% to 20.2%; urban, from 9.5% to 16.3%). Difference-in-difference models show no change in midwife-attended births associated with full practice authority policy adoption relative to trends in states without such policies by 2023. Conclusion: Between 2007 and 2023, the percentage of midwife-attended births rose in both rural and urban settings and was higher in full practice authority states, although the trends did not change following the adoption of these policies.