The Rural and Urban Texas Midwifery Workforce: A Comparative Cross‐Sectional Survey

INTRODUCTION: Texas faces a critical shortage of maternity care clinicians in its rural communities, where nearly half of rural counties are maternity care deserts. This study aimed to characterize and compare rural and urban midwives across several domains and identify workforce and health care policy strategies to strengthen Texas's rural maternity workforce. METHODS: We conducted a secondary, comparative, cross-sectional analysis using 2 parallel web-based surveys in 2025 among rural and urban licensed midwives (LMs), certified professional midwives (CPMs), and certified nurse-midwives (CNMs) practicing in Texas. Harmonized items across instruments allowed pooled comparisons of rural and urban participants. We used descriptive statistics and bivariate analyses to assess differences. RESULTS: Among practicing midwives (LMs/CPMs and CNMs) in Texas, 228 completed the survey and were eligible for the study. Compared with urban midwives (n = 184), rural midwives (n = 44) were more often self-employed, reported lower incomes, were less likely to have liability insurance, and reported more barriers to physician consultation. Rural midwives were also less likely to offer the option for a vaginal birth after cesarean but reported greater physiologic birth support and legislative engagement. Among CNMs, prescriptive authority was significantly less common in rural areas. DISCUSSION: Despite workforce and practice barriers, rural Texas midwives demonstrate a strong commitment to physiologic birth and policy advocacy. Strengthening the integration of rural midwives into the health care systems through consultation and liability support as well as policy reform is essential to sustaining and expanding the Texas midwifery workforce.