title: The Practice of Midwifery in Rural US Hospitals.
abstract: BACKGROUND
  Workforce shortages limit access to care for pregnant women in rural and remote areas. The goal of this analysis was to describe the role of certified nurse-midwives (CNMs) in providing maternity care in rural US hospitals and to examine state-level variation in rural CNM practice.
  
  
  METHODS
  We identified 306 rural hospitals with at least 10 births in 2010 using discharge data from the Statewide Inpatient Databases for 9 US states. We conducted a telephone survey of hospital maternity unit managers (N = 244) from November 2013 to March 2014 to understand their maternity care workforce and practice models. We describe the presence of CNMs attending births by hospital and state characteristics. Using logistic multivariate regression, we examined whether CNMs attend births, adjusting for hospital characteristics, practice regulations, and state. We also analyzed the content of open-ended responses about staffing plans, challenges, and opportunities that unit managers identified, with a focus on midwifery practice.
  
  
  RESULTS
  CNMs attend births at one-third of rural maternity hospitals in 9 US states. Significant variability across states appears to be partially related to autonomous practice regulations: states allowing autonomous midwifery practice have a greater proportion of rural hospitals with midwives attending births (34% vs 28% without autonomous midwifery practice). In rural maternity hospitals, CNMs practice alongside obstetricians in 86%, and with family physicians in 44%, of hospitals. Fourteen percent of all respondents planned recruitment to increase the number of midwives at their hospital, although many, especially in smaller hospitals, noted challenges in doing so.
  
  
  CONCLUSIONS
  CNMs play a crucial role in the maternity care workforce in rural US hospitals. The participation of CNMs in birth attendance varies by hospital birth volume and across state settings. Interprofessional practice is common for CNMs attending births in rural hospitals, and administrators hope to increase the number of midwives in rural maternity practice.
authors.forename: Katy B
authors.initials: KB
authors.lastname: Kozhimannil
authors.forename: Carrie
authors.initials: C
authors.lastname: Henning-Smith
authors.forename: Peiyin
authors.initials: P
authors.lastname: Hung
mesh_terms: D005260:Female; D019538:Health Care Surveys; D006780:Hospitals, Rural / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D008427:Maternal Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D008880:Midwifery / Q000458:organization & administration* / Q000706:statistics & numerical data; D009721:Nurse Midwives / Q000458:organization & administration* / Q000706:statistics & numerical data; D024802:Nurse's Role; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D011247:Pregnancy; D019035:Rural Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D014481:United States
keywords: access; health policy; rural health; workforce