Midwives: A Complete 2026 Career Guide

# Midwives Complete 2026 Career Guide

Role Overview

Midwives provide reproductive healthcare across the full spectrum, from prenatal care through labor and delivery to postpartum support and gynecological services. In the United States, most practicing midwives are Certified Nurse-Midwives (CNMs), who hold both nursing credentials and advanced midwifery training. A smaller number are Certified Midwives (CMs) or Certified Professional Midwives (CPMs), each with different educational pathways and scopes of practice.

The majority of midwife-attended births in the United States occur in hospitals, where CNMs work alongside obstetricians for low-risk deliveries. However, midwives also practice in birth centers and attend home births, with the scope of practice varying by state and practice setting. The model of care differs meaningfully from typical obstetric practice: midwives typically spend more time with patients during appointments, emphasize natural childbirth unless intervention is medically necessary, and prioritize patient education and shared decision-making.

Midwives serve a critical function in maternal healthcare at a time when the United States has one of the highest maternal mortality rates among developed nations. Access to midwifery care correlates with lower intervention rates, higher patient satisfaction, and improved outcomes for low-risk pregnancies. The role carries genuine responsibility. When something goes wrong during labor, you are the first responder before physician backup arrives. That reality shapes everything about the training and the work.

AI & Robotics Threat Level

[AI RISK: Low] Midwifery is fundamentally a relationship-based practice. The work requires real-time physical assessment (palpating the uterus, interpreting fetal heart rate patterns, detecting subtle behavioral cues from a laboring person), none of which current AI systems can replicate. AI tools can support documentation, suggest protocols, and flag anomalies in monitoring data. But the moment-to-moment clinical judgment during labor, the ability to read a room and know when to act, the trust relationship that allows someone to push through intense pain because you are beside them, that is not automatable. AI may gradually absorb more administrative and scheduling tasks, but the core clinical work remains firmly with the practitioner.

[ROBOTICS RISK: Low] Robotics has minimal relevance to midwifery. There is no mechanical system that can replace hands-on labor support, perineal repair, or the physical presence required during birth. Some aspects of fetal monitoring have become automated, but the interpretation and clinical decision-making remain with the midwife. Surgical or procedural aspects of obstetrics involve robotics, but those fall outside the midwifery scope of practice. This is not a field where automation will meaningfully displace practitioners.

Salary & Compensation

Salaries vary significantly between credential types and practice settings. The following reflects current market data for CNMs, who constitute the large majority of practicing midwives in the United States.

Certified Professional Midwives (CPMs) and those in home birth settings typically earn less, with entry-level compensation in the $60,000–$80,000 range and ceiling around $100,000 for established practices. This reflects differences in scope of practice, insurance reimbursement structures, and setting.

Geographic variation is substantial. Metropolitan areas on the coasts and in the Pacific Northwest tend to offer higher compensation, often $20,000–$40,000 above national averages. Rural areas may offer lower base salaries but often come with sign-on bonuses, loan repayment programs, or housing assistance given the acute shortage of maternal care providers outside urban centers.

The benefits package for hospital-employed CNMs is typically strong: health insurance, retirement matching, paid time off, and sometimes professional development stipends or malpractice coverage. Those in private practice or birth centers manage their own benefits but keep a larger share of earnings once established.

Source: BLS Occupational Employment Statistics (May 2024); AMCB Workforce Survey 2023; Pay.com 2025 Market Data

Job Outlook

The Bureau of Labor Statistics projects employment for nurse anesthetists and nurse specialists, which includes nurse-midwives, to grow 6% from 2023 to 2033, faster than the national average for all occupations. That translates to roughly 37,000 new job openings over the decade. The drivers are clear: an aging population requiring more healthcare services overall, growing recognition of midwifery as a cost-effective model for low-risk maternity care, and a persistent shortage of obstetricians willing to practice in rural and underserved areas.

The maternal health crisis in the United States has pushed policy makers and hospital administrators toward care models that maximize the workforce. Seventeen states and the District of Columbia have been designated as having maternity care deserts, where there are no hospitals offering obstetric care and no CNMs or OB-GYNs providing services. This is not a problem that will resolve without significant expansion of the midwife workforce.

Birth center attendance has grown at a rate of approximately 6–8% annually, driven by patient preference and policy support. Several states have enacted legislation expanding practice authority for midwives, removing former barriers to independent practice. That trend is likely to continue, which would further expand job options for newly credentialed midwives.

The picture is not uniform. Hospital-based CNM positions remain the largest single employer, but growth is strongest in birth centers, group practices, and hybrid models that blend telehealth prenatal care with in-person delivery coverage.

Source: BLS Occupational Outlook Handbook (2024); March of Dimes Maternity Care Deserts Report 2024; American College of Nurse-Midwives Membership Survey 2024

Education, Training & Certification

The path to becoming a Certified Nurse-Midwife (CNM) requires a multi-step process that typically spans six to eight years from start to practice-ready credential.

Step 1: Nursing Education (2–4 years)

You must first become a registered nurse (RN). This can happen through an associate degree in nursing (ADN, typically 2 years) or a bachelor of science in nursing (BSN, typically 4 years). Most CNM programs require or prefer a BSN, so the four-year route is more efficient in the long run. Accelerated BSN programs exist for those who hold a bachelor's in another field.

Step 2: Clinical Experience (1–2 years recommended)

Most midwifery programs prefer applicants with at least one to two years of labor and delivery or maternal-child nursing experience. Working as an RN on a labor and delivery unit provides critical clinical context that makes midwifery training far more meaningful. This is not strictly required by all programs but is considered essential by most faculty and clinical preceptors.

Step 3: Graduate Midwifery Education (2–3 years)

CNM programs award a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) with a specialization in nurse-midwifery. Accreditation requires programs to include substantial clinical hours: at least 700–1,000 births attended under supervision before graduation. Programs are offered by nursing schools across the country, with online didactic portions allowing students to remain employed while completing course work.

The American Midwifery Certification Board (AMCB) is the certifying body. After completing an accredited program, graduates must pass the certifying exam, which covers antepartum, intrapartum, postpartum, newborn, and gynecologic care across the full scope of midwifery practice.

Step 4: State Licensure

Licensing requirements vary by state. Most states license CNMs through the board of nursing, with requirements that mirror the national certification. Some states have independent practice authority, while others require a collaborative agreement with a physician. The legal scope of practice differs enough that it is worth investigating your state specifically before committing to this path.

Continuing Education and Renewal

Certification must be renewed every five years through the AMCB, requiring 75 hours of continuing education and either re-examination or a maintenance certification program. Most employers require ongoing competency demonstrations and may have additional requirements for privileges at their facility.

Realistic timeline: Plan on six to eight years minimum from starting your first nursing prerequisite to being an employed, credentialed CNM. The fastest path (ADN to accelerated BSN to CNM program) can compress to five years with intense focus, but most people take longer given the clinical experience recommendation.

For Certified Professional Midwives (CPMs), the route is different. The North American Registry of Midwives (NARM) manages certification for CPMs, which focuses on out-of-hospital birth. This route typically involves attending a program accredited by the Midwife Education and Accreditation Council (MEAC), which includes a combination of didactic education and apprenticeship clinical training. The total path is generally shorter and less expensive than the CNM route, but CPMs have a narrower scope of practice and fewer insurance reimbursement pathways in most states.

Career Progression

A typical career arc for a hospital-employed CNM over ten years looks like this:

Years 1–3: Orientation and Building Competence

New CNMs spend the first one to two years in a structured orientation program, working under senior preceptor supervision. During this period, you build confidence in managing labor, handling emergencies, and developing your own clinical style within the safety net of close oversight. By the end of year three, most CNMs have attended 100–200 births and are functioning with independent decision-making authority for routine cases, with backup available for complex situations.

Years 4–7: Established Practitioner

You develop a reputation for clinical competence and reliability. Some practitioners begin taking on additional responsibilities: precepting new CNMs, serving on quality improvement committees, developing specialized skills in areas like vaginal birth after cesarean (VBAC) support, twin births, or external cephalic version. Compensation typically increases 20–30% over this period, and you gain access to better shift schedules and call arrangements.

Years 8–12: Senior Clinician or Leadership Track

At this point, practitioners typically choose between remaining at the bedside as a senior clinician with difficult-case expertise and higher compensation, or moving into leadership roles. Clinical leadership options include becoming a lead midwife for a practice group, director of a birth center, or clinical educator for a midwifery program. Some CNMs transition into administrative roles, managing a team of midwives, negotiating hospital contracts, or building an independent practice.

Cross-Over Paths

Midwives with experience and additional training sometimes move into roles in reproductive health (fertility nursing, abortion care), public health (maternal-child health programs), academia (teaching and research), or healthcare policy (working for state health departments or advocacy organizations). The clinical foundation of midwifery translates well to these adjacent spaces, and advanced degrees (DNP, PhD) open further doors.

A Day in the Life

A hospital-based CNM working on a labor and delivery unit might have a schedule that looks like this:

6:45 AM: Handoff and Chart Review

You arrive early to receive handoff from the outgoing shift. Review the status of patients currently in labor, check triage notes for anyone who came in overnight, identify the patients you will be following today. Labor and delivery is one of the few places in medicine where you genuinely cannot predict the day, but chart review gives you a baseline.

7:00 AM: Rounding on Antepartum Patients

Before active labor work begins, you see patients admitted for observation: those with preterm labor symptoms, hypertension, gestational diabetes. You review orders, adjust care plans, communicate with the physician group for higher-risk patients, and document thoroughly.

8:00 AM – 12:00 PM: Active Labor Coverage

This is the core of the work. You are assigned two to four patients in various stages of labor. You assess cervical dilation, fetal heart rate patterns, and maternal vital signs regularly. When a patient is complete and ready to push, you manage the second stage, attend the delivery, repair any lacerations, and manage the immediate postpartum period. In a teaching hospital, you may work with residents or medical students, which adds a layer of teaching and supervision.

The physical reality of the work is significant. Labor support involves standing, walking, repositioning patients, and sometimes physically supporting someone through a contraction. Deliveries require kneeling, squatting, or leaning over a bed for extended periods. Shifts that last 12 or 24 hours mean that endurance matters as much as skill.

12:00 PM – 1:00 PM: Documentation and Communication

After the morning's deliveries, you handle documentation, update birth logs, communicate with pediatric teams for newborn assessments, and call families with updates. This administrative chunk is often where the day feels most compressed.

1:00 PM – 5:00 PM: Continued Coverage and Postpartum

Afternoon includes postpartum rounding on patients who delivered, managing new admissions from triage, and potentially catching a second delivery. The rhythm is unpredictable, but the constant thread is continuous assessment: fetal monitoring, maternal status, emotional state, progress.

5:00 PM – 7:00 PM: Handoff

End-of-shift handoff to the incoming CNM. A good handoff is precise and includes not just clinical status but the emotional narrative: who is anxious, who is progressing faster than expected, who needs extra support. Labor care depends heavily on continuity of information.

In birth centers and home birth practices, the rhythm differs. Prenatal visits take 30–60 minutes each, allowing for far more patient education than hospital schedules permit. Attending a birth involves being on call, traveling to the birth location, and managing the full spectrum of care from home. Postpartum visits in the days following birth are conducted in the patient's home, which is logistically demanding but clinically rewarding.

Skills That Matter

Technical Skills:

Fetal heart rate interpretation recognizing patterns that indicate wellness versus distress and responding appropriatelyIntrapartum assessment cervical exam technique, labor progress evaluation, and decision-making about intervention timingPerineal repair suturing skills for tears and episiotomies that require precision and knowledge of pelvic anatomyPharmacological management familiarity with labor pain management options, induction agents, antihypertensives, and postpartum hemorrhage protocolsNewborn assessment Apgar scoring, initial resuscitation, screening for anomalies, and stabilization before pediatric handover

Soft Skills:

Crisis composure the ability to think clearly and act decisively when something goes wrong, without freezing or panickingCommunication under pressure conveying serious information clearly and calmly, especially when decisions involve immediate riskPatience with unpredictable timelines labor does not respect scheduled breaks, lunch hours, or shift changes; managing fatigue is a real skillContinuous calibration reading a patient's emotional state, adjusting your approach to fit their needs rather than your habitsAdvocacy particularly in systems where physician oversight creates tension, knowing when and how to advocate for your patient's preferences

Tools & Technology

Midwives regularly work with the following tools and systems:

Fetal heart rate monitoring equipment (external and internal monitors) central to labor assessment. Learning to interpret patterns correctly takes time and is one of the most important clinical skills in the specialty.Electronic health records (EHR) systems like Epic, Cerner, or MEDITECH manage documentation, orders, and clinical communication. The learning curve is typically two to four weeks for basic proficiency.Ultrasound machines used for point-of-care assessment in some practices, particularly for estimating gestational age, checking fetal presentation, and identifying multiple gestations. Formal sonography is performed by radiology or dedicated ultrasound techs.IV pumps and medication administration systems standard for pitocin inductions, magnesium sulfate protocols, and postpartum hemorrhage management.Blood pressure monitoring and point-of-care testing for conditions like preeclampsia or postpartum hemorrhage requiring rapid lab values.Communication systems securing messaging platforms for handoffs, triage communication, and physician consultation.

The learning curve for most equipment is reasonable. The skill that takes longest to develop is fetal heart rate interpretation, which requires seeing many patterns over time and receiving quality feedback from experienced preceptors.

Work Environment

The practice setting defines the work environment more than any other factor. Three common settings:

Hospital Labor and Delivery Units

The most common setting for CNMs in the United States. Shifts are typically 12 or 24 hours. Coverage is around the clock, which means weekends, holidays, night shifts, and being on call are all part of the career. The unit is fast-paced, physically demanding, and emotionally intense. You work alongside nurses, obstetricians, anesthesiologists, and pediatric teams. The pace is unpredictable; you can have a quiet shift or back-to-back deliveries with complications in the same day.

Birth Centers

Freestanding birth centers operate with a midwifery-led model and transfer to hospitals if complications arise. Birth center practices typically schedule prenatal visits during business hours, with practitioners rotating on-call duties for births. The model generally produces more predictable schedules than hospital L&D, though on-call obligations remain. Birth centers are more common in some regions than others; access varies significantly by state.

Home Birth Practices

Practicing midwives in home birth attend deliveries in patients' homes. This requires travel, carrying equipment, and managing the full scope of care in an uncontrolled environment. Transfers to hospitals are necessary in a minority of cases, and managing that transition smoothly is a core skill. Home birth midwives typically work in small group practices to manage call schedules.

Travel and Schedule Considerations

Hospital CNMs may have schedules that rotate between days and nights, while birth centers and home birth practices typically operate on call rotations. Travel between practice sites is uncommon except for CNMs working at multiple clinic locations or those in rural locum tenens roles. Union representation exists in some hospital settings but is not universal.

Challenges & Drawbacks

Be honest about what makes this work hard.

Unpredictability and exhaustion. Birth does not happen on a schedule. If you work in a hospital setting with 24-hour shifts, you will be awake all night and then expected to function safely the following day. Even in shifts that nominally end at a set time, births that are in progress do not stop at the end of a shift. Coverage gaps mean CNMs frequently work beyond their scheduled time. Chronic sleep deprivation is a real issue in this specialty, and the ability to recover and be safe on subsequent shifts is not always supported by staffing structures.

High-stakes decision-making with incomplete information. When a laboring patient's fetal heart rate drops, you have seconds to decide whether this is a temporary deceleration that will resolve or an emergency requiring immediate intervention. You make that call without the certainty of imaging or labs, based on pattern recognition and clinical experience. The stakes are as high as any in medicine, and the pace is relentless.

Emotional intensity that does not end when you leave. Birth trauma, infant loss, maternal hemorrhage, emergency cesarean sections. These experiences stay with you. Not all births are joyful, and even joyful births can be traumatic. The emotional weight accumulates in ways that are not always acknowledged or supported in workplace cultures. Burnout rates in obstetrics are significant, and midwifery is not immune.

Liability exposure. Malpractice insurance is a real cost and concern. Birth is a high-litigation area regardless of provider skill or quality of care. Even when not at fault, CNMs may face legal action, and the emotional and financial cost of defending a malpractice claim is substantial.

Systemic disrespect and scope battles. Midwives have fought for decades for recognition and practice authority, and in many settings that fight continues. Some physicians view midwifery as an infringement on their territory, and hospital politics can undermine midwifery autonomy in ways that are professionally demoralizing. Scope of practice battles, particularly around home birth and out-of-hospital transfer agreements, create ongoing friction.

Physical toll. Standing through long labors, holding positions during deliveries, assisting with resuscitation. The physical demands are significant and increase with age. Many experienced CNMs find that the physical requirements of L&D become harder to meet over time, pushing them toward lower-acuity settings or administrative roles.

Who Thrives

You might thrive in this role if:

You are genuinely drawn to birth as a profound human experience, not just as a clinical challengeYou can function under pressure without freezing and can make decisions with incomplete informationYou are comfortable with sustained physical presence during long labors, sometimes without a breakYou value building relationships with patients over efficiency and throughputYou can set emotional boundaries while remaining genuinely present for patientsYou are resilient enough to process difficult outcomes without becoming cynical or disconnectedYou are comfortable in a role that has historically required fighting for recognition and respectYou want a career where the work is inherently meaningful and rarely feels routine

The field attracts people who care deeply about the experience of birth, who want to be present for one of life's most pivotal moments, and who find that meaning worth the physical and emotional costs. If that resonates with you, the career can be deeply rewarding despite the difficulties.

How to Break In

Breaking into midwifery requires patience and deliberate planning. Here is how to approach it:

Step 1: Get nursing experience in labor and delivery first. Before committing to midwifery education, work as an RN on a labor and delivery unit for at least one to two years. This gives you the clinical context to understand whether you truly want to pursue the graduate-level training, and it makes you a far stronger midwifery school applicant. It also establishes relationships that will become your professional network.

Step 2: Choose your credential path. Decide whether CNM (nurse-midwife route) or CPM (direct-entry route) makes more sense for your situation. CNM is more expensive and longer but leads to hospital privileges and broader insurance reimbursement. CPM is shorter and cheaper but with more limited practice settings. Most people who pursue the CNM route have more career flexibility in the long run.

Step 3: Apply to accredited programs strategically. Look at programs with strong clinical placement networks in your target region. Accreditation by ACNM or MEAC is essential. Consider online programs if you need to continue working while studying, but evaluate their clinical placement support carefully. Programs with limited clinical placement networks will leave you responsible for finding your own preceptors, which is a significant burden.

Step 4: Build your network before you graduate. Attend ACNM chapter meetings in your state. Introduce yourself to practicing CNMs. Ask them about their career paths and what they wish they had known. This is not just about finding a job after graduation; it is about understanding how the professional community actually works and what the unwritten rules are.

Step 5: Plan for your first position strategically. Your first job does not have to be your forever job. Look for a practice that will support your development as a new graduate, with adequate preceptor oversight and reasonable patient volumes. Large hospital-based practices with multiple CNMs tend to have better onboarding infrastructure than small solo practices. Once you have one to two years of experience and demonstrated competence, you have far more leverage to choose your next position.

Common mistakes to avoid:

Rushing into midwifery education without working in maternal health first. The training is expensive and demanding. Knowing what you are getting into matters.Ignoring state licensing requirements when evaluating programs. Not all programs prepare you for the specific licensing exam in your state.Underestimating the financial cost. Graduate education is expensive; plan for the full duration of training, not just the application period.Choosing a program based on convenience rather than clinical quality. The clinical preceptorships are where you actually learn the work.

Realistic timeline from first college class to employed CNM: seven to nine years for most people.

Related Career Alternatives

The career path with the most direct overlap is labor and delivery nursing, which is often where prospective midwives discover their interest. If you are not certain about graduate-level midwifery education, working as an L&D nurse for two years is a legitimate way to explore the field before committing.

Self-Assessment Questions

Ask yourself:

Am I genuinely fascinated by the process of birth, or am I attracted to the idea of being a midwife more than the daily reality of the work?Can I function on little sleep and remain clinically sound? The shifts are long and often go past their scheduled end.Can I make decisions quickly and confidently when information is incomplete? Labor does not allow for consultations and second opinions in real time the way other specialties do.Am I prepared for the emotional weight of this work, including outcomes that are not positive?Can I set boundaries with patients and families while remaining compassionate? The line between support and overextension is real.Am I comfortable navigating a professional role that has historically been contested and requires ongoing self-advocacy?Am I willing to invest seven or more years in education and training before earning the salary I want?Do I understand that the physical demands of this work are significant and may not be sustainable for a full career?

If you answered yes to most of these, midwifery may be a strong fit. If you hesitated on the first question in particular, spend more time in a clinical setting before committing.

Key Threats to Watch

Scope of practice restrictions. In some states, CNMs are still required to have a collaborative agreement with a physician to practice or prescribe. These restrictions limit practice flexibility and create vulnerability if physician relationships change. The trend has been toward independent practice authority, but the transition is uneven. Political engagement with state-level scope of practice reform is an ongoing need.

Malpractice climate. Birth is a high-risk specialty for litigation regardless of care quality. Rising malpractice insurance costs push some physicians out of obstetrics entirely, which paradoxically increases demand for CNMs but also creates pressure on hospital practices to reduce liability exposure through protocols that may limit midwifery autonomy.

Workforce burnout and attrition. The combination of physical demands, emotional weight, unpredictable schedules, and systemic disrespect has driven significant attrition from the field. Estimates suggest that up to 30% of CNMs leave clinical practice within ten years of initial certification. This creates demand signals but also means that new practitioners may inherit environments where veteran colleagues have already left.

Insurance reimbursement inequity. While Medicare covers CNM services, reimbursement rates from private insurers vary widely. Some payers reimburse CNMs at 80–100% of physician rates for the same service, while others pay significantly less. This disparity affects practice viability and salary levels in settings where revenue is tied to reimbursement.

Hospital system consolidation. As hospitals acquire independent practices and birth centers, the employment model for midwives shifts. Independent birth centers may be absorbed into hospital systems, changing practice culture and potentially reducing midwifery autonomy. Keeping track of system changes in your region matters for career planning.

Resources & Next Steps

American College of Nurse-Midwives (ACNM) membership organization, career center, state chapter directoryAmerican Midwifery Certification Board (AMCB) certifying body for CNMs and CMs; exam information and maintenance requirementsNorth American Registry of Midwives (NARM) certification for CPMsMidwife Education Accreditation Council (MEAC) accreditation information for direct-entry programsBLS Occupational Outlook Handbook: Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners salary and job growth dataMarch of Dimes maternal health data, policy updates, and desert reportsEvidence Based Birth free research summaries for both practitioners and patients

Frequently Asked Questions

Q: Is midwifery a good career for someone who wants work-life balance?

A: It depends heavily on the setting. Birth centers and home birth practices generally offer better schedule predictability than hospital L&D units, which require 24-hour coverage. Hospital-based midwifery typically involves shift work, nights, weekends, and on-call obligations. If absolute schedule predictability is the priority, this career has limitations.

Q: Can midwives work independently or do they always work under physician supervision?

A: It varies by state. Twenty-three states currently grant full practice authority to CNMs, allowing independent practice without a collaborative agreement. Other states require physician oversight to varying degrees. The legal landscape has been expanding toward independent practice, but you should verify the requirements in your state before planning a practice.

Q: How long does it take to become a CNM?

A: Most people need seven to nine years total: two to four years for RN training, one to two years of L&D experience, and two to three years of graduate midwifery education. Accelerated programs can compress this, but the experience requirement generally cannot be bypassed.

Q: Is the salary worth the educational investment?

A: For CNMs, yes, in most cases. The graduate education costs $40,000 to $80,000 depending on the program, but the typical salary range of $95,000 to $165,000 makes that investment recoverable within three to five years of practice for most graduates. CPMs have a shorter training path but lower earning potential, so the calculus is different.

Q: What is the difference between a CNM, CM, and CPM?

A: CNMs (Certified Nurse-Midwives) are registered nurses with graduate-level midwifery education and hospital privileges in all 50 states. CMs (Certified Midwives) have graduate-level midwifery education but are not necessarily nurses; they are certified by AMCB and licensed in fewer states. CPMs (Certified Professional Midwives) are certified by NARM with a focus on out-of-hospital birth; their scope is narrower and state recognition varies more widely.

Q: Do midwives only attend births, or is there more to the job?

A: The scope of practice for CNMs includes prenatal care, gynecologic exams, family planning, postpartum care, and newborn care for the first 28 days. Birth attendance is a significant portion of the work, but well-person care, contraception, and health education are built into most practices as well.

Q: Is there a shortage of midwives that makes this a good time to enter the field?

A: Yes. Maternal care deserts are a recognized national problem, and policy makers are actively working to expand the midwifery workforce. Hospital systems have increased CNM hiring as one response to physician shortages in obstetrics. The demand picture is strong and likely to remain so given demographic trends.