New Research: Legal and Regulatory Frameworks Are Undermining Midwifery Models of Care

New legal research reveals that gaps and restrictions in national laws and regulations are obstructing the effective integration of midwifery care into health systems, undermining access to quality, respectful, and community-centered maternal health care.

Context

At the Center for Reproductive Rights, we uphold that every pregnant person has the right to quality, dignified, and respectful maternal health care.

Midwifery models of care, centering trained, competent, licensed, and regulated midwives, are internationally recognized as a critical approach to delivering such care. These models emphasize continuous, person-centered, holistic care throughout pregnancy, childbirth, and the postpartum period.

The WHO recognizes that midwives are capable of providing up to 90% of essential sexual, reproductive, maternal, newborn, and adolescent health interventions across the life course. Research consistently shows that well-integrated midwifery services significantly reduce maternal and neonatal mortality, stillbirths, and unnecessary medical interventions, while improving overall health outcomes and respectful care experiences.

Despite this compelling evidence and clear global guidance, many countries have yet to establish legal and regulatory frameworks that fully integrate midwifery models of care into their health systems. This is not just a policy gap—it is a human rights concern.

International and regional human rights bodies have recognized maternal health as a core component of the right to health and have affirmed states’ obligations to ensure access to quality maternal health care free from discrimination. In particular, individuals have the right to access skilled birth attendants, such as midwives, and states are obligated to ensure adequate training, resourcing, and integration of providers into the health care system, in order to ensure equitable access to maternal health care.

About the Report

While global support for midwifery continues to grow, few studies have mapped the legal and regulatory barriers to implementing midwifery models of care.

To help address this gap, the Center conducted an in-depth legal analysis of six jurisdictions: Colombia, India, Kenya, Nigeria, Romania, and the state of Hawai’i in the United States.

These regions were chosen for their geographic diversity and the Center’s strategic partnerships in these regions.

Key Findings

1. Inconsistent Legal Recognition, Routes of Entry, and Regulation

Legal recognition and regulation are fundamental to ensuring that only trained and competent professionals provide midwifery care and that these professionals are effectively integrated into health systems. International standards call for clear legal definitions of who may use the title “midwife,” consistent and accessible routes of entry into the profession, and robust oversight mechanisms.

While most countries studied have some regulatory framework in place, challenges remain. These include multiple and confusing routes of entry and qualifications, lack of legal clarity on who qualifies as a midwife, and use of the title by individuals without full midwifery competencies (Kenya, India). In Colombia, midwifery is not legally recognized at all, leaving care providers outside the formal health system and unable to access essential resources or referrals. These gaps limit the integration of midwifery models of care into national health systems and thereby obstruct access to equitable maternal health care.

2. Gaps in Licensure and Registration

Licensure or registration grants midwives the legal right to practice and is essential for ensuring competence and public trust.

While most countries surveyed require licensure and maintain public registers, important gaps persist. In Colombia, the absence of legal recognition means midwives cannot be formally licensed. In other settings, licensure systems impose restrictive or unworkable standards that exclude traditional or community-based providers (Hawai’i).

Such gaps disproportionately affect marginalized and underserved populations who rely on community-based care.

3. Lack of Representation on Oversight Bodies 

Effective regulation of midwifery requires oversight bodies that recognize midwifery as a distinct and autonomous profession. The International Confederation of Midwives recommends that midwifery be regulated separately from nursing and that oversight bodies be composed primarily of midwives.

However, in many countries, midwifery remains subsumed under nursing regulation, consistently conflating the two professions (Kenya, India, Nigeria, Romania). This also means that midwives often lack adequate representation on governing bodies that make important decisions around education, regulation, and oversight, thereby diluting midwifery’s autonomy.

4. Autonomy and Scope of Practice

International standards emphasize that midwives must have autonomy to provide comprehensive care throughout pregnancy, birth, and the postpartum period. This includes making independent clinical decisions and practicing within a broad scope that covers preventive care, emergency interventions, contraception, abortion care, and newborn support, while collaborating in an interdisciplinary team with other health professionals when needed.

Many countries, however, impose restrictive regulations requiring midwives to practice under physician supervision, limiting their scope and reinforcing a medicalized model of care. For example, India mandates obstetrician oversight with rigid exclusions from midwifery practice that are not evidence-based. Other countries limit midwives’ autonomy based on facility level, granting more independence in primary care settings but imposing strict physician supervision in hospitals (Kenya, Nigeria). Romania bans homebirths entirely and prohibits independent midwives from prescribing medication or attending births without physician presence.

Such restrictions prevent midwives from fully utilizing their skills, limit access to respectful, person-centered care, and undermine the benefits of midwifery models of care.

Key Recommendations

Based on these findings, the Center for Reproductive Rights recommends states to:

• Establish legal and regulatory frameworks that formally recognize midwifery as an autonomous and distinct profession, integrate midwives into health care systems, and allow them to practice independently without requiring supervision or authorization from other medical personnel. 
• Create accessible pathways for training, development, and continuous practice for midwives.
• Establish regulatory bodies that are composed of or meaningfully include midwives.
• Enable midwives to practice to the full extent of their competencies and remove legal provisions that prevent individuals from seeking care from a midwife.
• Recognize the legitimacy of midwifery care across diverse settings, including homes, communities, hospitals, and health clinics.
• Repeal punitive measures against midwives who assist with home births.