Autonomy and independence: a critical imperative for midwifery

Summary box.

• Midwifery autonomy and independence are distinct yet interdependent concepts that are both essential for high-quality maternal and neonatal care.

• Many health systems support autonomy in theory but fail to ensure midwives can practice independently in reality.

• Advancing midwifery requires system-wide structural investment in regulation, education, association, practice, research and leadership to support both autonomy and independence.

• Achieving midwifery autonomy and independence is a global imperative for equity, quality, and the advancement of evidence-informed policy and health system transformation.

Imagine being handed the tools to save lives but being told you need someone else’s permission to use them. This is the reality for many midwives around the world, who are recognised as the backbone of maternal and neonatal care¹ yet, they are often denied the professional recognition, independence and autonomy required to fully use their skills and knowledge.²

The conversation around midwifery autonomy is not new.³ For decades, midwives have fought for the right to self-govern, to define their own scope of practice and to lead care models grounded in extensive, high-quality, evidence-based research.^{4 5} Yet despite the frequent calls for autonomy,⁶ the equally vital concept of independence is often absent from the conversation. A fully realised professional identity requires both.⁷

Autonomy and independence are not interchangeable; they are distinct yet deeply interconnected. Autonomy refers to the right of a profession to self-govern, setting its own standards, scope of practice and educational frameworks based on evidence and professional consensus.⁸ Independence is the ability to act on that autonomy without external oversight or constraint.⁹ In midwifery, autonomy grants midwives the authority to define their professional standards and protocols.⁶ Independence enables midwives to translate professional standards into practice by acting as primary care providers, exercising clinical judgement and leading midwifery models of care.¹⁰ Without independence, autonomy remains theoretical; without autonomy, independence lacks foundation. Only when both are present can midwifery be fully realised as an autonomous, evidence-based and independent profession.

Midwifery is one of the most evidence-supported healthcare interventions for improving maternal and neonatal outcomes.^{4 10} Midwives have a broad scope of practice, defined by the WHO to include sexual, reproductive, maternal, neonatal and adolescent health (SRMNAH), and, when adequately supported, can meet up to 90% of essential healthcare needs across the women’s healthcare spectrum.¹⁰ Studies across low-income, middle-income and high-income countries consistently show that continuity of midwife care (CoMC) reduces maternal and neonatal morbidity and mortality, lowers healthcare costs, raises patient satisfaction and decreases unnecessary interventions.⁴ CoMC is defined as care provided autonomously and independently by a known midwife, or a small team of midwives, throughout pregnancy, birth and the postnatal period.¹⁰ A recent Lancet study found that if every woman had access to a midwife, 4.3 million lives could be saved.¹

Yet, this life-saving potential is too often obstructed by health policies that do not reflect or support the evidence.^{11 12} Many healthcare systems fail to recognise or support this dual foundation of autonomy and independence, leaving midwifery constrained by systemic barriers that undermine its potential.¹³ As a result, midwifery risks remaining a profession caught in limbo. Midwives are expected to deliver exceptional care, yet in many contexts, they are denied the structural support to do so effectively.¹⁴ The result is a profession that is celebrated in theory but constrained in practice. This dichotomy is not only a disservice to midwives but a failure to the individuals and families who depend on them.

This is not theoretical; the stakes are real. In countries where midwifery is well-integrated into healthcare systems, and midwives are recognised as autonomous and independent professionals with full scope of practice, maternal and neonatal outcomes are consistently better.^{5 15} They see fewer unnecessary interventions, higher satisfaction and lower rates of maternal and neonatal mortality.⁴ These successes are not incidental; they are the direct result of systems that empower midwives to lead, act and innovate. To truly practise independently, midwives must have the ability to diagnose, treat, prescribe medications and tests, refer to specialists, admit and discharge, and lead care models.¹⁶ They must also have the authority to order and interpret diagnostic tests and provide seamless continuity of care across the full SRMNAH continuum, including all phases of pregnancy, birth and the postnatal period, as fully independent and autonomous healthcare professionals.¹⁰

Yet in practice, levels of autonomy and independence for midwives vary significantly across countries, reflecting major differences in legal frameworks, regulation and systemic support. In New Zealand, for example, midwives are fully recognised as autonomous and independent practitioners and often lead models of care.¹⁷ Similarly, countries such as the UK and the Netherlands have well-established and integrated midwifery systems, where midwives practise with a high degree of professional autonomy.^{18 19} In contrast, countries such as India, Iran, Jordan and parts of sub-Saharan Africa, midwifery is often highly regulated and restricted by overmedicalised and risk-oriented models, limiting both autonomy and independent practice.¹⁵ In some contexts, midwives are not even recognised as a distinct professional category or are required to work under the direct supervision of physicians regardless of their training.² Significant variation also exists within countries themselves. In the USA, for instance, the scope of midwifery practice differs widely between states, some recognising midwives as autonomous primary care providers, while others impose restrictive regulations.²⁰ In many countries, midwives’ ability to practice independently also varies depending on the setting: autonomy may be supported in birth centres or home settings but restricted within hospitals.^{3 21} Such inconsistencies point to the necessity of global recognition of midwifery as an autonomous and independent profession, with standardised scope and authority across all settings and contexts.

This interplay between autonomy and independence is not confined to clinical practice; it extends across every aspect of the midwifery model,¹⁰ including research, education, regulation and association. The International Confederation of Midwives (ICM) Professional Framework for Midwifery²² underscores the need for midwives to lead their profession at all levels, from governance to advocacy. Without autonomy and independence, the framework itself risks being undermined, as midwives are left unable to fully implement its principles or achieve its goals.

Realising the full potential of this framework requires more than acknowledgement; it demands deliberate investment in the systems that make autonomy and independence possible.³ Education must encompass all stakeholders, from midwives in training to the highest levels of healthcare leadership, fostering mutual understanding and respect across disciplines.²³ Evidence shows that when midwives are educated to international standards, such as those outlined in the ICM Essential Competencies for Midwifery Practice²⁴ and the ICM Global Standards for Midwifery Education,²⁵ they are fully equipped to function as autonomous, independent practitioners across the full spectrum of SRMNAH care.^{10 15} However, the quality of education and regulation remains highly variable across settings, with midwifery education often underfunded and inconsistent, with gaps in hands-on clinical experience, assessment and competency development.²⁶ To address this, ICM has developed a comprehensive competency mapping tool,²⁷ aimed at harmonising quality standards while allowing for contextual adaptation. These tools offer a blueprint for ensuring that midwifery autonomy and independence are paired with rigorous education, reliable assessment and effective self-regulation. Investment in midwifery-led research is also essential to provide the evidence base for policy changes and to demonstrate the benefits of autonomous and independent midwifery care.²⁸ Equally important is the development of infrastructure that supports midwifery models of care, including equitable funding, dedicated facilities and multidisciplinary collaboration.^{1 29} Strengthening midwifery leadership is also essential to drive these changes forward; strong leaders play a pivotal role in advancing autonomy, influencing policy and fostering systems that enable midwives to practise independently.³⁰

With the necessary tools and frameworks in place, the challenge now lies not in deciding whether midwives should be autonomous and independent, but how to achieve it. This requires coordinated action from healthcare systems, policy-makers, professional bodies and midwives themselves, working in partnership to create the conditions where independence and autonomy can thrive. The time has come to redefine the narrative. Autonomy and independence must be recognised as equally essential components of midwifery practice. This is not merely a debate over semantics or terminology; it is a call to action to rethink, reimagine and globally standardise midwifery models of care. With the right policies, infrastructure and collaborative support, midwifery can transcend systemic barriers, delivering equitable, evidence-based care that transforms maternal and neonatal health outcomes and strengthens healthcare systems worldwide.

Data availability statement

No new data were generated or analysed for this study. This commentary draws on previously published sources, which are cited throughout the manuscript.