Abstract

Background: Despite progressive maternal health policies, midwives globally continue to experience a gap between policy intentions and actual clinical practice. Professional autonomy remains constrained by regulatory, institutional, and sociocultural barriers. Objective: To systematically review evidence on factors contributing to the policy and practice gap in midwifery and to identify pathways that strengthen professional autonomy. Methods: A systematic review of qualitative, quantitative, and mixedmethod studies published between 2016 to 2025 was conducted. Databases searched included PubMed, Scopus, CINAHL, and Web of Science. Studies examining midwifery autonomy, scope of practice, regulatory frameworks, and implementation challenges were included. Results: Four major themes emerged: (1) Regulatory ambiguity, (2) Institutional hierarchy and medical dominance, (3) Educational and competency gaps, and (4) Organizational culture and leadership deficits. Pathways to autonomy included legal reform, midwife-led models of care, leadership training, and professional recognition. Conclusion: Bridging the policy and practice gap requires integrated reform across education, regulation, and health system governance. Sustainable autonomy improves maternal and neonatal outcomes.

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