When Sen. Josh Green, a Big Island family doctor who was chair of the Senate Health Committee, introduced a bill to regulate midwives in 2014, a hearing turned so contentious that Green said he broke a tooth from grinding his jaws.
The issue is so thorny that attempts to regulate people without nursing licenses who help deliver babies have failed repeatedly — in 1998, 2014, 2016 and earlier this year. Now, as the 2018 session approaches, there’s another push to regulate the practice of midwifery led by the Midwives Alliance of Hawaii.
Doctors who generally support regulation point to what they say are needless medical emergencies and even infant deaths. Midwives say planned home births are safer than planned hospital births and cite statistics showing women are more likely to undergo medical interventions like cesarean sections if they’re already in the hospital.
Midwives themselves don’t agree on whether the government should get involved, and if so, how.
Some want licensure to weed out incompetent peers. Others don’t want regulation at all, arguing birth is about reproductive freedom and shouldn’t be regulated by the state, especially when it comes to Native Hawaiian practitioners.
Even though the state already regulates professions as seemingly innocuous as bartenders and makeup artists, some say it’s practically an absolute that people who deliver babies for a fee should not be regulated.
“It should not be up to the state to regulate the how, with whom and where a woman should give birth,” Aubrey Aea wrote in testimony for a 2017 bill.
To many people, Green said, regulating non-nurse midwives becomes “an issue of autonomy and manifest destiny.”
Certified nurse midwives, or midwives who are also nurses, are already allowed to practice in all 50 states. They usually work in hospitals and are certified by the American Midwifery Certification Board.
The Midwives Alliance of Hawaii wants the state to create a mandatory licensing program for the two types of non-nurse midwives that are certified nationally: certified professional midwives and certified midwives.
CPMs take midwifery courses and/or complete an apprenticeship. They’re certified by the North American Registry of Midwives and are already regulated in 33 states.
CMs have a graduate degree in midwifery and an undergraduate degree in a health-related field other than nursing. They’re licensed in six states and are certified by the American Midwifery Certification Board.
Lay midwives would not be allowed to practice in the islands under the proposal, but an exception would be made for Native Hawaiian practitioners.
Cami Kanoa-Wong, a Native Hawaiian woman and aspiring midwife, birthed all three of her children at home in Manoa — the same valley where her great-great-great grandmother lived and died. Home birth made her feel like she was “going through a similar process that my ancestors went through.”
Birthing on kula iwi, or ancestral lands, is a significant part of Hawaiian birthing traditions, she said. Placentas are often buried in the yard — where families can cement them into the land or plant trees on top of them. Hospitals don’t always make it easy for a women to take their placenta home, she said.
By reading Hawaiian language newspapers and dictionaries and more, Kanoa-Wong discovered home birth was once so commonplace that men and families were trained to help. Some communities had a designated midwife.
Big Island CPM Dani Dougherty, formerly a licensed midwife in Idaho, said she supports a Hawaii licensing program because it could help CPMs gain credibility.
There’s a long history of apprenticeship as the main pathway to midwifery, Dougherty said, and she’s sensitive to concerns that requiring licensure takes something away from “the art of midwifery.”
“That’s what’s gotten emotional for everyone,” she said.
Under the MAH proposal, there would be other benefits of licensure, such as legal access to medication for use in emergencies. Dougherty admits she carries such medication and has had to use it on occasion — she said if her patient required a hospital transfer, doctors were grateful she had administered it for the patient’s safety.
Midwives would also be considered “care providers” and could communicate with doctors about a patient’s medical history, Dougherty said.
Oahu CPM Vanessa Jansen worries that licensure may limit midwives’ scope of practice, such as their ability to attend vaginal births after women had cesarean sections during prior births. Many hospitals prohibit the practice.
She describes herself as “very conservative” when it comes to home births and said, “if something doesn’t feel right, you shouldn’t be home.”
“I’m kind of mixed myself on whether (midwifery) should be (regulated), Jansen said. “But it would help families to get covered on their insurance so more low-income people could get home births and it’s safer for them.”
The Hawaii Regulatory Licensure Reform Act of 1977 allows the government to require certain professionals to obtain a license when government oversight is “reasonably necessary to protect the health, safety, or welfare of consumers.”
Manicurists, barbers and real estate agents are among the occupations regulated by the law.
Testimony submitted on bills in recent years — by midwives, doctors and the American College of Obstetricians and Gynecologists — shows the arguments likely to be made next year.
Last year, ACOG called mandatory licensure of midwives an internationally recognized “minimum standard for safe, high quality maternity care.”
Many midwives and physicians say regulation would improve patient safety. But many midwives have also been critical of bills introduced so far.
The state auditor’s office, which is tasked with evaluating lapsing or potentially new regulatory programs, has determined in four reports over three decades that midwifery should be regulated.
Most people against regulation say that birth should not be regulated by the state.
And if licensure is established, some say, only midwives should serve on a governing board to oversee midwives because they’re the experts on home births. Some also believe licensure should be optional, as is the case in states like California and Utah.
Tara Compehos said it’s hard to pinpoint exactly when she became a midwife because the apprenticeship learning model is so organic. Compehos considers herself a birth attendant, or what many would call a traditional midwife. She said she studied for a decade under a “master midwife.”
She has been critical of past legislative proposals that would have only licensed nationally certified midwives. She says those programs favor the wealthy because many local women interested in midwifery have children and can’t afford classes, tests and licensing fees of mainland-based programs.
There’s a “wide diversity” of midwifery backgrounds in the state, but Compehos said bills in the past have offered “very, very limited models of how training should be done.” There are different kinds of experience and knowledge, she said.
For many women, giving birth in a hospital, surrounded by people with a medical background, feels safe. But other women feel the hospital setting is fear-based, and doctors and nurses operate on the assumption that anything could go wrong at any minute, Compehos said.
If a law is enacted, Compehos said there should be a grandmother clause written into it so the oldest, most experienced midwives can continue practicing.
In 2015, 339 babies born in Hawaii were born at home, according to a 2017 state auditor’s report. That’s almost 2 percent of about 18,000 babies born.
From 2004 to 2010, the number of American women choosing home birth rose by 41 percent, according to a 2014 study published in the Journal of Midwifery and Women’s Health.
The study also found 89 percent of the nearly 17,000 women surveyed who attempted home birth ultimately gave birth at home. Eighty-seven percent of women who tried to have a vaginal birth after a cesarean section were successful.
Several studies have shown that women who decide to give birth in hospitals experience more medical interventions such as cesarean sections, induced labor, and delivery using forceps or a vacuum, including a 2015 study from the New England Medical Journal that was cited by the American Congress of Obstetricians and Gynecologists.
Researchers noted the following differences between hospital and out-of-hospital births in Oregon from 2012-2013:
|Planned Out-of-Hospital Birth Events (per 1,000 births)||Planned Hospital Birth Events (per 1,000 births)|
|Operative vaginal delivery (using forceps/vacuum device)||10||35|
|Severe perineal lacerations (vaginal tears during birth)||9||13|
Source: American College of Obstetricians and Gynecologists
But perinatal death rates, or death rates around the time of birth, were almost twice as high in home births — one to two for every 1,000 births — compared to hospital births, according to that study. The study also found that seizures or “serious neurologic dysfunction” in newborns were three times as likely in home births.
Another study published this year in the Journal of Perinatal Medicine found midwife-attended home births had a higher rate of fatalities (almost 13 deaths per 10,000 births), compared to hospital deliveries by a doctor (six deaths per 10,000 births) and midwife-attended hospital births (3.5 deaths per 10,000 births).
Babies in that study were born full-term at a normal weight, but the deaths occurred within 27 days of delivery, Reuters reported.
At one time, Hawaii did regulate the profession. Only registered nurses were eligible for licensure as midwives until 1998, when nurse midwives became regulated separately as advanced practice registered nurses.
Leʻa Minton, nurse midwife and president of MAH, is working with board members to draft legislation to regulate non-nurse midwives. Physicians, state officials and legislators are also involved in the process, Minton said.
Rep. Della Au Belatti, House Majority Leader and former chair of the Committee on Health and Human Services, has worked with MAH on the draft. Belatti did not return a call Thursday requesting comment on whether she planned to introduce legislation next year to regulate midwives.
MAH has drafted legislation to create a licensing program for midwives twice before, Minton said.
While Minton isn’t confident a version of the bill will become law, she’s optimistic that the upcoming session will foster more productive discussion on the topic than in years past.
“Respecting women’s choices is what’s going to improve the safety of home birth in this state,” Minton said.
Under MAH’s proposal, the state may revoke licenses for midwives who are found to have injured patients, engaged in professional negligence or misconduct, or had a license revoked by another state with similar requirements.
Several states with licensing programs require midwives to notify patients whether or not they hold liability insurance. The leading provider of liability insurance for American midwives only accepts nationally certified midwives as clients.
Minton said MAH’s proposed legislation would not include a requirement for liability insurance.
MAH is negotiating the proposed scope of practice for midwives with the Department of Commerce and Consumer Affairs, Minton said.
“There’s a lack of respect and trust” that midwives will adhere to their scope of practice, she said, adding those concerns may not be entirely unfounded since non-nurse midwives have “kind of had a free-for-all” without state regulation.