Midwives, Nurse Practitioners, and the Physicians Who (Still) Find Them Threatening

During the 2021 Louisiana legislative session, I took part in a campaign to eliminate an unnecessary law that has sexist, racist, and classist origins and effects. In doing so, I witnessed a striking contemporary iteration of the long patriarchal and racist history of medicine. Physicians organized a vehement response to what they viewed as a threat to their financial status and their professional and societal power.

The law in question, which exists in about half of US states, requires advanced practice registered nurses (APRNs – e.g., nurse practitioners and certified nurse-midwives) to sign a collaborative practice agreement (CPA) with a physician in order to practice in the state. No compelling scientific data suggests that this law produces better outcomes. Instead, evidence indicates that it hinders qualified professionals from filling gaping holes in Louisiana’s healthcare landscape and improving birth outcomes.^[1]

Thus, the New Orleans Maternal and Child Health Coalition, of which I am a co-convener, decided to join the fight, which was led by the Louisiana Association of Nurse Practitioners. The Coalition argued that since Governor John Bel Edwards had temporarily lifted the CPA to disencumber qualified healthcare professionals during the COVID-19 pandemic, the state legislature should permanently remove this requirement in light of the ongoing state of emergency represented by Louisiana’s unreasonably high rates of maternal and infant mortality (trends that long predate the pandemic). Removing this requirement, we illustrated, would increase access to high-quality prenatal and maternity care for Louisiana’s rural and marginalized residents. Indeed, most of the geographic area of the state exists in healthcare professional shortage areas, where 95% of the state’s population lives.

We lost. Despite our best efforts, the bill to eliminate the CPA failed, largely due to a well-organized and well-resourced resistance made up of physicians, who claimed that it would be unsafe to grant full practice authority to APRNs. Disregarding loads of data, physicians wielded anecdotes about APRNs’ incompetence, stating that doctors must remain at the helm of healthcare to save lives.

Many of us are familiar with how OB/GYNs professionalized themselves through the marginalization and elimination of midwifery care and the ways these processes particularly affected Black midwives.^[2] Nonetheless, I was shocked by the force with which these doctors eschewed scientific evidence and organized against their fellow healthcare providers, denigrating them to protect their own perceived economic and professional status.

The professionalization of certified nurse-midwives has its own white supremacist history, as does the history of nursing in general. The CPA requirement is arguably a technology of racism and classism that erects financial and bureaucratic hurdles that only the most privileged APRNs can overcome. This means fewer low-cost, high-quality healthcare and birthing options for impoverished or uninsured families. And it means that the APRNs who do succeed in establishing themselves in the state may be less likely to come from or resemble the communities they serve, including Black residents who make up 32% of Louisiana’s population but 50.1% of Louisiana’s impoverished (an important reason the state should be working to attract and retain more Black physicians as well).

Throughout the debates about eliminating the CPA, physicians argued that APRNs receive less training than them and thus need supervision by a doctor, something that the CPA requirement does not even stipulate (rather, it requires that a contract be on file, regardless of how much collaboration, consultation, or supervision actually occurs). They claimed that the law would expand APRNs’ scope of practice beyond their training, despite the fact that the bill makes no such changes, and that APRNs are trained to consult with physicians when necessary, regardless of whether a CPA is on file. They also claimed that eliminating the CPA would result in fewer patients for physicians, but cited no evidence for this claim from any of the 23 states that have full practice authority for nurse practitioners or the 29 states with full practice authority for certified nurse-midwives.

In response to evidence-based claims about APRNs’ good (and sometimes better) health outcomes, one physician wrote, “I witnessed numerous cases of patients seeing me after being grossly misdiagnosed by nurse practitioners having failed to get their supervising physicians involved. Often numerous medications were used inappropriately; try one, if it does not work, blindly try another. Maybe they will get it right.”

While personal experience is certainly a valid form of knowledge, it is ironic that those in a profession regarded for its adherence to scientific rigor relied upon their already-high cultural and social capital to sidestep the weight of evidence. In this case, anecdotes from deeply paternalistic viewpoints and tinged with sexist tropes about nurses’ incompetence and irrationality were paired with powerful lobbyists to preserve the status quo and keep APRNs financially and symbolically subjugated.

The battle over the CPA requirement in Louisiana – one which is by no means over – is an extension of medicine’s long history of racism and hostility toward midwifery and woman-dominated medical professions. The tendency of many physicians to promote their own perceived interests above the health and wellbeing of their patients extends back to the dawn of gynecology, when, as Deirdre Cooper Owens has illustrated, J. Marion Sims experimented on the bodies of enslaved women.^[3] It continues through the overuse of the Cesarean section.^[4] This reality is surely a factor in this nation’s, and especially Louisiana’s, poor reproductive health.

Moving forward, we need more physicians to be brave, to stand up against the inertia of their profession’s history (as well as significant pressure from their peers), and to act in the interests of public health. We need them to ally themselves on the side of the evidence and support full practice authority for advanced practice registered nurses, so that more Louisianans can access high-quality affordable healthcare.

Clare Daniel

Clare Daniel is an administrative assistant professor at Newcomb Institute of Tulane University and a co-convener of the New Orleans Maternal and Child Health Coalition. She is the author of Mediating Morality: The Politics of Teen Pregnancy in the Post-Welfare Era and a member of the Scholars Strategy Network.

This author does not have any more posts.