Health Outcomes and Provider Choice under Independent Practice for Certified Nurse-Midwives

Hoehn‐Velasco, Lauren; Jolles, Diana; Silverio-Murillo, Adán; Plemmons, Alicia

doi:10.2139/ssrn.3878127

Cited by 4 publications

(20 citation statements)

References 42 publications

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“…8,9 Hoehn-Velasco et al conducted a sensitivity analysis that found controlling for midwives per capita weakened the main effect, but the main effect was small to negligible. 8 Measuring midwife density per capita, rather than per 1000 births, does not account for the variation in fertility rate between states. 25 Although both the Hoehn-Velasco and Markowitz studies reported more midwife-attended births after adopting independent midwifery practice, neither study found that independent midwifery practice resulted in an increase in midwife supply.…”

Section: Discussionmentioning

confidence: 99%

“…In terms of independent midwifery practice, a mediating relationship would mean independent practice improves pregnancy outcomes by increasing the number of midwives. Because prior studies find little or no change in outcomes with adoption of independent midwifery practice, even when the timeframe studied was 10 years, a mediating relationship is unlikely 1,8 . In contrast, a moderating relationship exists when the effect of one variable depends on the value of another variable.…”

Section: Introductionmentioning

confidence: 93%

“…17 Three variables were included to control for potential bias due to uneven distribution of characteristics; birthing person race, primary payer source, and birthing person risk. 8,18 Birthing person race and primary payer source were available in the State Inpatient Databases and were included to control for the inequities and disparities that exist within the health system and may, potentially, inflate or obscure the effects of midwife density. Birthing person race was included in the model as categorized in the State Inpatient Databases: Asian or Pacific Islander, Black, Hispanic, Native American, White, or other.…”

Section: Variables and Measurementmentioning

confidence: 99%

“…Markowitz et al examined the effect of independent practice on the total number of midwives but did not include control for the number of midwives in models to assess the relationship between independent practice and pregnancy outcomes 9 . Hoehn‐Velasco et al included control using the number of CNM‐attended births based on the birth certificate recording of birth attendant 8 . However, birth certificates only measure the number of vaginal births with a CNM as an attendant, which does not account for variations in the number of midwife‐attended births per midwife 1 .…”

Section: Introductionmentioning

confidence: 99%

“…7 However, the most rigorous studies comparing pregnancy outcomes before and after state adoption of independent midwifery practice have found ether minimal or no changes in preterm birth and cesarean birth rates. 8,9 ORCID Jennifer Vanderlaan https://orcid.org/0000-0002-2122-1537…”

Section: Introductionmentioning

confidence: 99%

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Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

Vanderlaan

2023

J Midwife Womens Health

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IntroductionStudies comparing pregnancy outcomes before and after state transition to independent midwifery practice have found little change in primary cesarean birth and preterm birth rates. One reason may be the failure to control for midwife density. The objective was to test if the local midwife density moderates the association between state independent midwifery practice and pregnancy outcomes.MethodsBirth records were abstracted from the State Inpatient Databases for 6 states. The Area Health Resource File provided county variables. Midwife density was operationalized as no midwives, low midwife density (<4.5 per 1000 births), and high midwife density (≥4.5 midwives per 1000 births). Multivariate logistic regression models compared primary cesarean birth and preterm birth, controlling for maternal and county characteristics. Moderation was tested by including an interaction term (independent practice × density) to the regression models. The magnitude of association for the interaction was measured by stratifying the models.ResultsThe study included 875,156 women; most (79.7%) resided in a county with low midwife density. Restricted midwifery practice was associated with increased odds of both primary cesarean birth and preterm birth. The interaction term was significant for both preterm birth and primary cesarean, indicating moderation. The largest magnitude of difference was the increased odds of preterm birth in counties with a high midwife density and restricted practice (odds ratio, 3.50; 95% CI, 2.43‐5.06) compared with those with high midwife density and independent practice.DiscussionMidwife density moderates the association between independent midwifery practice and primary cesarean birth and preterm birth. Moderation may explain why prior studies found small or no changes in outcomes when states adopted independent practice. Moderation models can improve testing for associations with independent practice. Both midwife independent practice and increasing midwifery workforce size can be strategies to improve state pregnancy outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 93%

Section: Variables and Measurementmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

Vanderlaan

2023

J Midwife Womens Health

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Relationship between midwifery density and midwifery regulatory environments in International Confederation of Midwives member countries

Clark,

LaNoue,

Clouse

et al. 2024

Preprint

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BackgroundMidwives are a cost-effective solution for reducing preventable maternal death, but barriers to their recruitment, training, deployment, and retention exist. Improved midwifery regulation is proposed to address these challenges through activities related to education and qualification, licensure, registration/re-licensure, and scope and conduct of practice. However, no quantitative analysis of the associations between midwifery regulation and workforce density in low- and middle-income countries has been conducted, limiting actionable insights for policymakers. The objective of this study was to evaluate the relationship between midwifery regulatory environments and midwifery workforce densities (midwives per 10,000 population) in International Confederation of Midwives member countries.MethodsThe study used secondary data from the 2019 Global Midwives’ Associations Map Survey to perform a cross-sectional analysis of 103 International Confederation of Midwives member countries. To operationalize the strength of a country’s midwifery regulatory environment, we used a previously developed Midwifery Regulatory Environment Index. We conducted multivariable linear regression analysis to evaluate the relationship between this index and country-level midwifery density, available from the National Health Workforce Accounts.ResultsMidwifery regulatory environments are significantly associated with midwifery workforce densities across countries. For every 1-point increase in the Midwifery Regulatory Environment Index (indicating activities in at least one additional regulatory domain), midwifery density increased by 0.66 midwives per 10,000 population (p = 0.011). This effect decreased to 0.41 midwives per 10,000 population yet remained significant even after controlling for country level income, per capita health spending, income inequality, and human development index (p = 0.04).ConclusionStronger regulatory environments are associated with higher densities of midwives, even when controlling for potential confounding factors such as country-level income and health spending. This relationship suggests that policymakers should invest in midwifery regulation to improve maternal health outcomes.

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Seeing is believing: The effects of optometrist scope of practice expansion

Bae,

Timmons,

Nandy

2024

Contemporary Economic Policy

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We examine how the emergence of optometrists as new “eye doctors” affected population eye health outcomes and optometrist earnings in the United States. Using the staggered adoption of optometrist prescription authority across states, we find suggestive evidence that optometrist scope of practice expansion reduced vision impairment and mitigated racial and ethnic disparities in eye health. We also find that the policy is associated with an increase in hourly wages among optometrists who are not self‐employed. These findings imply that allowing optometrists to use medications for eye treatments effectively expanded the primary eye care workforce and therefore improved public eye health.

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Health Outcomes and Provider Choice under Independent Practice for Certified Nurse-Midwives

Cited by 4 publications

References 42 publications

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

Midwifery Workforce Density Moderates the Association Between Independent Practice and Pregnancy Outcomes

Relationship between midwifery density and midwifery regulatory environments in International Confederation of Midwives member countries

Seeing is believing: The effects of optometrist scope of practice expansion

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