California’s Midwives: How Scope of Practice Laws Impact Care


Connie Kwong, Margot Brooks, Kim Q. Dau, and Joanne Spetz

October 16, 2019

California and the United States face shortages of qualified clinicians to provide prenatal, labor, and postpartum care, as well as women’s health services.There has been no growth in the number of obstetricians nationwide since 1980 despite increases in the number of women of childbearing age and the number of births. To ensure that women’s health care needs are met, national organizations recommend that the midwifery workforce increase and that midwives work within a system of care that fosters collaboration among licensed, independent providers.

What Is Midwifery?

Historically, midwifery has been a profession that focuses on care for mothers and infants during prenatal, labor, and postpartum periods. The word “midwife” means “with woman,” and the midwife model of care is, fundamentally, woman-centered. Midwifery recognizes pregnancy and childbearing as normal physiological processes and seeks to deliver care that empowers women to assume responsibility for their health and their families’ health. Increasingly, midwifery practice — especially that of nurse-midwives — has expanded its focus to include primary care and sexual and reproductive health.

Practice Requirements

Across the United States, midwives practice subject to each state’s licensing and regulatory environments. In California, midwives may practice either as nurse midwives (NMs) or licensed midwives (LMs). These are officially two distinct professions with different education requirements, certifying organizations, enabling statues, regulatory bodies, licensing policies, and often different practice environments. Consequently, the two professions’ respective scopes of practice differ as well. In 2019 there were 386 LMs licensed in California (PDF), and in October 2019 there were 753 NMs in California. The number of births in California attended by LMs and NMs between 2007 and 2017 rose, while the number attended by doctors of medicine declined. In 2017, LMs attended 0.6% of births, with 21% of these occurring in freestanding birth centers and 74% occurring in residences; in that year, NMs attended 10.5% of births in California, with more than 97% occurring in hospitals.

Role of Midwives Around the World

Midwives are common providers for prenatal care and birth in many countries, including most European countries, Canada, and Australia.5 It has been reported that 50% to 75% of births are attended by midwives in other developed countries. Midwifery has been described as a healing or holistic model of care in comparison with the medical model of care that physicians practice. Direct comparisons between midwives and physicians can be challenging because the philosophies of these models of care are different. Nevertheless, a large body of research (discussed in this paper) finds that midwife care results in comparable or improved health outcomes for low- and moderate-risk mothers and infants compared with physician care. Additionally, the literature suggests that midwives help improve access to care for underserved communities and can help achieve health care expenditure savings. The research also finds that restrictions on midwives’ scope of practice may limit their supply and, consequently, the utilization of midwives.

This paper provides information on the different professional licensures, regulatory schemes, and scopes of practice for midwives in California and briefly reviews how midwifery regulations differ across other states. Additionally, the paper summarizes recent research on how these laws impact health care access, quality, productivity, and costs.