Examining trends, outcomes and barriers to midwifery integration within Louisiana hospitals: a mixed-methods study protocol.

BACKGROUND: Childbirth in the USA, including Louisiana, has become increasingly medicalised, with high rates of obstetrical interventions even among clinically low-risk pregnancies. Midwifery-led care has been associated with fewer interventions and comparable or improved outcomes for low-risk births, but midwives remain under-represented in Louisiana hospitals. To improve perinatal outcomes in the Gulf South through increasing midwifery care, data are needed on barriers and facilitators to integrating midwifery care, trends in midwifery care utilisation and birth outcomes by provider type.

METHODS AND ANALYSIS: This sequential explanatory mixed-methods study includes two phases. Phase 1 is a retrospective cohort analysis of Louisiana Vital Records birth certificates from 2012 to 2024, limited to in-hospital births. We will (1) describe temporal trends in the proportion of births attended by certified nurse–midwives (CNMs) overall and within key sociodemographic and geographical subgroups and (2) compare maternal characteristics, obstetrical intervention patterns and selected birth outcomes between CNM-attended and obstetric-attended births to low-risk women with singleton term vertex pregnancies. Study outcomes include caesarean delivery, labour induction, epidural use (where available), 5-minute Apgar score and birth weight. Log-binomial regression (or Poisson regression with robust variance if convergence fails) will be used to estimate adjusted relative risks controlling for sociodemographic and clinical covariates. Phase 2 consists of semi-structured interviews with approximately 20–30 key stakeholders (CNMs, obstetrical clinicians, labour and delivery nurses, hospital administrators and health system or policy advocates) to explore barriers and facilitators to integrating midwifery care into hospital-based maternity care. Interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION: This study was approved by the Tulane University Institutional Review Board (Protocol #2026-008, approved 18 March 2026). Findings will be disseminated through peer-reviewed publication, the New Orleans Maternal and Child Health Coalition, Louisiana Perinatal Quality Collaborative and other state maternal health stakeholders.

TRIAL REGISTRATION NUMBER: Not applicable (observational and qualitative study protocol).