For the Maternal and Child Health Workforce Supportive Policy Index (“MCH Workforce Index”), is a composite score reflecting workforce policies for midwives and doulas, labor policies, and economic policies. Each state’s overall MCH Index score is based on an average of four sub-index scores. Each sub-index score (Midwifery Workforce, Doula Workforce, Labor, and Economic indices), in turn, is an average of the indicator scores within that sub-index. A more detailed description of each index is below, along with a chart providing detailed information regarding each indicator, its data source, and the scoring approach.

Midwifery workforce policies are defined as state policies that are intended to improve access to midwives, compensation, education and training, credentialing and licensing, and/or access to employment. Each of these policy indicators are equally weighted in the sub-index based on standardized scores.

Variable/Indicator 

Definition 

Data Source 

Year Used 

Index Scoring 

Scope of Practice 

Certified Nurse Midwives* 

CNM scope of practice varies by state and includes the following categories: Independent Practice and Privileges, Independent Practice, Hybrid, Collaborative Agreement, or Supervision required. 

 National Council of State Legislatures

2025

States scored 0 where there was a physician relationship or supervision required, a 50 where there was collaborative or hybrid practice or transitioning to independent practice, and 100 if CNMs are able to practice independently. 

Certified Midwife* 

CM scope of practice varies by state and is binary in that either the credential is recognized or it is not. 

American College of Nurse Midwives  

2023 

States that recognized the CM credential scored 100 and states that did not scored 0. 

Certified Professional Midwife* 

CPM scope of practice varies by state and is binary in that either the profession is regulated or it is not. 

Push For Midwives  

2024 

States that have regulated CPMs scored 100 and states that did not scored 0. 

Certified Nurse Midwife Prescriptive Authority* 

If a state has full prescriptive authority for CNMs, transitioning to independent prescriptive authority, and no prescriptive authority or requiring a collaborative agreement with physicians 

National Council of State Legislatures  

2025

States that have full prescriptive authority for CNMs scored 100, for those transitioning to independent scored a 50, and for those with no prescriptive authority scored 0. 

Certified Nurse Midwife Independent Authority to Admit Patients to Hospitals* 

State law may specifically regulate midwives’ authority to admit patients to a hospital and hospital medical staff privileges. 

Herndon A, Vanderlaan J. Associations Between State Practice Regulations and Access to Midwifery Care. Journal of Midwifery & Women’s Health. 2024;69(1):17-24. doi:10.1111/jmwh.13528. https://doi.org/10.1111/jmwh.13528  

2023 

States that allow for CNMs to admit patients to hospitals scored 100 and those that have not scored 0.  

Access to Education 

Access to Certified Nurse Midwifery Education* 

2022-23 academic year individual completions of CNM programs using the CIP (Classification of Instructional Programs) code for Nurse Midwife/Nursing Midwifery is 51.3807 or presence of an accredited program.  

Integrated Postsecondary Education Data System and The Accreditation Commission for Midwifery Education

2023 and 2025

If a state had one or more schools had at least one completion for the 2022-23 academic year or the presence of at least one accredited program, they scored 100. If a state did not meet these criteria, they scored 0. 

Access to Direct Entry Nurse Midwifery Education* 

2022-23 academic year individual completions of direct access midwifery programs using the CIP code for Direct Entry Midwifery is 51.3401. 

Integrated Postsecondary Education Data System  

2023  

If a state had one or more schools had at least one completion for the 2022-23 academic year, they scored 100. If a state did not have a school with any completions for the same academic year, they scored 0. 

Reimbursement  

Certified Nurse Midwife Medicaid Reimbursement* 

CNM Medicaid reimbursement rates are set at the state level and represented as percentages of physician reimbursement rates. 

National Academy for State Health Policy and American College of Nurse Midwives 

2023 (NASHP) and 2022 (ACNM)** 

States that provided CNM Medicaid reimbursement rates at less than 90% of the physician rate scored 0, those with 90-99% scored a 50, and those at 100% scored 100 

Certified Professional Midwife Reimbursement* 

CPM Medicaid reimbursement rates are set at the state level and use a binary value to determine if reimbursement is provided under Medicaid. 

National Academy for State Health Policy  

2023 

States that provided Medicaid reimbursement for CPMs scored 100 and those that did not scored 0.  

Certified Nurse Midwife Included in Global Maternity Payment* 

This variable uses a binary value to determine if global maternity payments includes CNM services under state Medicaid programs. 

National Academy for State Health Policy  

2023 

States that included CNM services under global maternity payments in Medicaid reimbursement scored 100 and those that did not scored 0. 

Certified Nurse Midwife Serve as Primary Care Provider Under Medicaid* 

Under state Medicaid programs, states can designate if CNMs qualify as primary care physicians. This is coded as a binary variable. 

National Academy for State Health Policy  

 2023 

States that allow for CNMs to serve as PCP in Medicaid scored 100 and those that did not scored 0. 

Mandated Certified Professional Midwife by Private Insurance* 

States may have laws or regulations requiring private insurance companies to reimburse for services provided by CPMs in their health insurance plans. 

Ijaz N, Carrie H (2023) Governing therapeutic pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the United States. PLOS Global Public Health 3(8): e0001996. https://doi.org/10.1371/journal.pgph.0001996  

 2023 

States that require private insurance reimbursement scored 100 and those that did not scored 0.  


* Data available on website and manually inserted
**The most recent data available was used for each state.
± Data manipulated by UW CHWS

 

Doula workforce policies are defined as state policies intended to improve access to doulas under Medicaid and private insurance programs, compensation, education and training, and credentialing and licensing. Each of these policy indicators are equally weighted in the sub-index based on standardized scores.

Variable/Indicator 

Definition 

Data Source 

Year Used 

Index Scoring 
Private Insurance Coverage of Doulas Mandated* States that have implemented doula coverage in private insurance. Birthing Advocacy Doula Trainings 2024 States that have implemented private insurance coverage for doula services scored 100 and those that did not scored 0.
Doula Medicaid Reimbursement* States that have implemented or are in the process of implementing legislative or administrative efforts related to Medicaid coverage for doula care. National Health Law Program’s Doula Medicaid Project 2025 States that have expanded access to doula services under Medicaid scored 100, states where implementation is progress scored 50, and states where there is no action on reimbursement scored 0.

Doula Credentialing 

 

 

 

 
Experience or Legacy Pathway* Experience or legacy pathways allow for doulas to attest to competency through previous experience.  National Health Law Program’s Doula Medicaid Project   2025 States that scored 100 allow for an experience pathway whereas those that do not have scored 0.  
Organizations for Core Competencies* States compile lists of credentialing organizations or have no organization requirements and/or have the option for core competency attestation. National Health Law Program’s Doula Medicaid Project 2025 States that included only DONA scored 0, states that included local or BIPOC-led options scored 50, and states that had no organizational requirement or core competency attestation scored 100.
Support Provided for Credentialing Process* States may grant funds or scholarships to support doula training and credentialing.

National Academy for State Health Policy, State Medicaid Approaches to Doula Service Benefits

 

Prenatal-to-3 Policy Impact Center

 2024 States that provide support for doula training and credentialing scored 100 and those that do not scored 0.
Flexible Credentialing Requirements* States may work with doulas to help with the enrollment and credentialing process, for example: waiving or minimizing application fees, funding and providing technical assistance, and flexible enrollment processes that enable doulas to enroll as an individual or with a group to allow for more doulas to go through the process.

Center for Health Care Strategies

 

National Health Law Program’s Doula Medicaid Project 

 2022 and 2025 States that have offered any flexibility in credentialing requirements scored 100 and those that have not scored 0.  
Fingerprinting and/or Background Check Required for Credential*

States may require doulas to submit to a background check or a fingerprint background check during the state certification process.

National Health Law Program’s Doula Medicaid Project 

 2025

States that do not require background checks or fingerprinting scored 100 and those that required a background check scored 0.

* Data available on website and manually inserted

± Data manipulated by UW CHWS

Labor policies are defined as state policies intended to support the ability of all workers to access health insurance, take paid time off, achieve greater economic stability, and access and maintain employment without discrimination. Each of these policy indicators are equally weighted in the sub-index based on standardized scores.

Variable/Indicator 

Definition 

Data Source 

Year Used 

Index Scoring 

Medicaid Expansion* 

States have the option to access additional federal funding to expand Medicaid eligibility for all adults to 138% of the federal poverty level under the Affordable Care Act. 

Kaiser Family Foundation  

2025 

States where Medicaid has been expanded scored 100 and states without expansion scored 0. 

Paid Family and Medical Leave* 

States have either enacted mandatory paid family leave systems, voluntary systems that provide leave through private insurance, or do not have any systems implemented.  

Bipartisan Policy Center  

2024 

States with mandatory paid family leave scored 100, those with voluntary paid family leave scored 50, and those that have not taken action scored 0.  

Protections for LGBTQ+ Workers* 

States may offer a variety of protections for LGBTQ+ workers, including: the Equal Employment Opportunity Commission accepting complaints of sexual orientation and gender identity discrimination in employment based on Title VII’s prohibition against sex discrimination, laws explicitly prohibiting discrimination based on sexual orientation and gender identity, prohibition of discrimination based on sexual orientation only, or no statutory or enforcement authority protections.  

Human Rights Campaign  

2024 

States with any sort of enforcement or protections for LGBTQ+ workers scored 100, whereas those with no statutory of enforcement authority protections scored 0.  

State-based Earned Income Tax Credit (EITC)* 

State earned income tax credits provide an additional benefit to the federal credit for low-income taxpayers by reducing their state income tax liability. A refundable EITC can result in a tax refund if the credit exceeds the taxes owed, while a non-refundable EITC can only reduce the tax owed to zero but cannot generate a refund. 

Tax Policy Center (TPC)  

2024 

States with no EITC programs scored 0, whereas states with non-refundable EITC scored 50, and those with refundable EITC scored 100.  

* Data available on website and manually inserted

± Data manipulated by UW CHWS

The economic index includes data on federal maternal health funding and information on wage competitiveness and sufficiency to meet the cost of living in that state. Each of these policy indicators are equally weighted in the sub-index based on standardized scores.

Variable/Indicator 

Definition 

Data Source 

Year Used 

Index Scoring 

MOMNIBUS Funding 

The Momnibus Money Tracker is a record of “federal maternal health funding streams” that have been enacted by Congress, collected by staff of the U.S. House of Representatives’ Black Maternal Health Caucus leaders, Rep. Alma Adams & Rep. Lauren Underwood. Data can be sorted by the federal, state or local program receiving the funds, the year of the funding, the sponsor, the funding amount, etc. 

U.S. House of Representatives Black Maternal Health Caucus Momnibus Money Tracker  

 

 

2024

States were scored based on the amount of money received as of 2024:

  • 25=< $2mil
  • 50=$2mil-$3mil
  • 75 = $3mil-$5mil
  • 100=$5mil plus

CNM Wage Competitiveness 

This compares average hourly wages for certified nurse midwives and nurse practitioners in 2023, with data retrieved from the Occupational Employment and Wage Statistics (OEWS) database.

Occupational Employment and Wage Statistics

2023

States were scored based on the following criteria:

  • 0=CNM hourly wage $10 or more below NP wage
  • 25=CNM hourly wage between $3 and $10 below NP hourly wage.
  • 50=CNM hourly wage up to $3 below NP hourly wage.
  • 75= CNM hourly wage equal to up to $3 above NP hourly wage
  • 100= CNM hourly wage greater than $3 above NP hourly wage

Doula Reimbursement Adequate for Cost of Living± 

Based on the Doula Medicaid Project’s dashboard of maximum reimbursement rates per birth for doulas under state Medicaid programs, we estimated a full-time workload to be 3 births per month per doula. We then took that amount and used the living wage calculator provided by MIT.  

MIT Living Wage Calculator  

2025 

States were scored based on the following reimbursement amount equivalent to an annual wage:

  • 0 = < -$9,000
  • 25 = > -$9,000 & < $0
  • 50 = > $0 & < $16,000
  • 75 = > $16,000 & <$40,000
  • 100 = > $40,000

* Data available on website and manually inserted

± Data manipulated by UW CHWS

The MCH Worker Supportive Policy index offers a state-level, data-driven picture of the experience of the maternal and child health workforce. This interactive tool is meant to offer opportunities to examine specific experiences for 2 groups within the MCH workforce – midwives and doulas – as well as how economic and labor policies may be affecting this workforce. The tool allows for state-by-state comparisons and for an in-depth look within a particular state, with the goal of helping decision-makers prioritize potential areas for improvement.

While there has been increasing interest in understanding and supporting the MCH workforce, greater investment is needed to ensure access to and availability of this workforce for comprehensive obstetric services. The MCH Worker Supportive Policy Index provides information for states, policymakers, and other decision-makers on where states excel in supporting this workforce, how states compare to each other, and opportunities for additional state policies targeted towards MCH workforce development and support.

We chose to focus on midwives and doulas for the initial iteration of this index as research demonstrates the importance of these two workforce groups for supporting better perinatal health outcomes and the need for more targeted workforce support for both midwives and doulas. There are a range of other important workforce groups who contribute to maternal and child health, including physicians, nurses, lactation consultants, physical, occupational, and speech therapists, community health workers, and behavioral health professionals. Future iterations of this index may work to include these as well.

For this study, we used the following definitions to define the midwifery and doula workforce:

  • Certified Nurse-Midwives (CNMs) are advanced practice registered nurses who receive graduate-level training in midwifery and are certified by the American Midwifery Certification Board. They provide comprehensive reproductive and primary care—including pregnancy, birth, postpartum, and gynecologic services—and are licensed in all 50 states.
  • Certified Midwives (CMs) are healthcare providers educated in midwifery at the graduate level without first becoming nurses, and they are also certified by the American Midwifery Certification Board. Their scope of practice is similar to CNMs, but they are licensed in fewer states and typically practice in hospital or birth center settings.
  • Certified Professional Midwives (CPMs) are trained specifically in out-of-hospital birth and earn certification through the North American Registry of Midwives. They provide prenatal, birth, and postpartum care primarily in home or birth center settings, focusing on low-risk pregnancies and physiologic birth.
  • Birth doulas are non-medical professionals who provide emotional, physical, and informational support during pregnancy, labor, and the postpartum period. They do not perform clinical tasks or deliver babies, but instead support the birthing person’s comfort, decision-making, and overall experience.

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $481,001 with zero percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, please visit HRSA.gov.

Researchers, policymakers, health workforce planners, and other decisionmakers will likely be interested in the findings presented in these indices. The information is intended to improve understanding of the support available for the maternal and child health workforce at a state level, specifically support for midwives and doulas.

All variables included within the overall index and each sub-index are created sourcing publicly available data. Detailed information on how each index is defined, along with the variables within each index, can be found in the methods table. 

We used the most recent data available as of August 2025. Unfortunately, not all data is updated annually. For indicators which have more than one dataset and year listed, we used the most recent data available for each state.

Scoring of this index used existing indices as initial guides for building the index, including PHI’s Direct Care Workforce State Index and the Midwifery Integration Scoring System (MISS) by Vedam et al. (2018).

We are not able to capture all the information about every state and acknowledge the state-specific complexity that may exist which is not represented here. This dashboard is meant to provide some insight into areas which may benefit from more focus, but the information provided is limited to what is data is publicly available.

This index was launched in October 2025.

This index was last updated September 2025. Further updates are dependent on funding.

Please contact us with any questions (uwchws@uw.edu).

Recommended citation: Kett PM, Guenther G, Dunlap B, Frogner BK. (2025) Maternal and Child Health Worker Supportive Policy Index. University of Washington Center for Health Workforce Studies.