Regulators want to standardize practices, but some people fear mandatory licensure could hurt rural and Native Hawaiian communities.

By the time Ki‘i Kaho‘ohanohano picked up the phone, the mother on the other end of the line had called almost every midwife she could find on Maui. 

Maui County locator map

The woman was expecting her third child and dreamed of giving birth in Kipahulu, her ancestral land. But so far, everyone else said they couldn’t help her. The rural East Maui community is a 54-mile drive away from the only hospital that delivered babies and a two-hour journey for most midwives living on island.

Kaho‘ohanohano, a mother of five who had her two youngest children on her family’s land in remote Kahakuloa, agreed to help. She is a trained Native Hawaiian healer, who, after the birth of her first child, started her journey to become a pale keiki — a traditional Hawaiian midwife.

Kaho‘ohanohano, 46, trained under an experienced Maui midwife for 13 years, and long practiced without a license. Unlike most other states, Hawaii for two decades hasn’t required midwives without nursing degrees to be licensed.

Ki‘i Kaho‘ohanohano cares for a family welcoming their child into the world. (Courtesy of Ki‘i Kaho‘ohanohano)

That could change with a new provision in a law set to take effect July 1, renewing a debate over who should be able to use the label midwife and whether a license to practice should be required.

Kaho‘ohanohano views birth as a sacred ceremony, a rite of passage that can help families reconnect with the practices of their ancestors. She fears the changes will hurt traditional providers like her and anyone who might decide to pursue the pathway in the future.

“This is not just midwifery or a baby coming, this is reclaiming who we are in such bigger ways and healing each other in the process,” Kaho‘ohanohano said.

The law requiring licenses for midwives was passed in 2019 but included a grace period that expires after June 30. Under that law, midwives must attend certain accredited schools to qualify for a license; providers who don’t meet those requirements have temporarily been able to serve as “birth attendants” as long as they make clients sign consent forms and don’t advertise as midwives. Starting this summer, the law will bar any unlicensed providers from practicing.

A permanent exemption for Native Hawaiian cultural practitioners was carved into the law, but some fear they may be excluded since there’s no official consensus on the line between cultural practices and unlicensed midwifery care.

Ki‘i Kaho‘ohanohano poses with a group of Native Hawaiian birth workers. (Courtesy of Ki‘i Kaho‘ohanohano)

The issue is complicated in Hawaii, where many women living on neighboring islands have scarce access to hospitals and giving birth at home is more common. For aspiring midwives, the cost to attend accredited schools can also be prohibitive.

On one side, state regulators and medical professionals say it’s a straightforward consumer protection issue; the surest way to protect patient safety is through regulation and minimum training requirements.

On the other side, many mothers and birth workers see it as a fight to preserve generational knowledge and protect the right to choose how to give birth.

“Women have, for all of millennia, sought to deliver where they want to deliver, with whom they want to deliver,” said Sara Edwards, a nurse midwife who recently moved to Maui and has delivered more than 3,000 babies over the course of her career.

Turbulent History

For decades, Hawaii only recognized midwives who were also nurses, known today as certified nurse midwives who can practice in hospitals, clinics, free-standing birth centers or in patients’ homes. That changed in 1998, when new state laws paved the way for midwives without nursing degrees, commonly called direct-entry midwives, to practice without any sort of regulation.

In the 25 years since, fights over licensing have unfolded numerous times in the Hawaii Legislature, including in 2014, 2016, 2019 and again this year.

All states recognize nurse midwives, who are the only providers allowed to practice in some places. More than 35 states also allow direct-entry midwives to practice, although laws vary widely.

This year, Hawaii Rep. Natalia Hussey-Burdick introduced House Bill 955 in a bid to extend the exemption and to make it easier for some midwives to meet educational requirements by allowing an apprenticeship pathway. Right now, Hawaii’s law recognizes only certain accredited midwifery schools, none of which are in the islands and can cost tens of thousands of dollars in tuition. Hussey-Burdick said there are several states that allow midwives to practice without licensure, and she's working to identify the exact number.

Update: This story has been modified to clarify the number of states that don't require licensure.

Oregon is one of the states that allows traditional midwives to practice without a license -- similar to how Hawaii currently treats what it calls birth attendants -- as long as the provider doesn't advertise and discloses to clients that risks may be higher because the state hasn't reviewed their education and they aren't allowed to administer potentially life-saving medications.

Hawaii regulators have for years said that midwives should be among professionals who must be licensed because what they do clearly affects health and safety.

Proponents say setting standard training requirements and maintaining oversight boards helps ensure that midwives know what to do when something goes wrong. Those supporting tighter regulation include the Midwives Alliance of Hawaii, Ahahui O Na Kauka, a group of Native Hawaiian physicians, and the Hawaii chapter of American College of Obstetricians and Gynecologists, which represents more than 200 OB-GYNs.

"This is not just midwifery or a baby coming, this is reclaiming who we are in such bigger ways and healing each other in the process.”

Ki‘i Kaho‘ohanohano, traditional healer

Licensure, some say, is also an important step toward integrating midwifery care into Hawaii’s health care system.

"The majority of births occur without major complications, whether they occurred in the hospital or out of the hospital. However, we do know that complications occur,” Dr. Angel Willey, the chair of the Hawaii ACOG, wrote to lawmakers. “It is critical that when they occur, the providers attending the birth are trained and competent to recognize it.”

But many residents and care providers say the requirement could limit access to care, especially for rural communities.

Seeking An Extension

More than 1,200 individuals and organizations — including mothers, fathers, midwives, local government officials, the Hawaii State Commission on the Status of Women, Hawaii Homebirth Collective, Chamber of Sustainable Commerce, Pacific Birth Collective and Kalauokekahuli, a Maui nonprofit that provides care to Native Hawaiian and Pacific Islander families — recently wrote to lawmakers to urge them to approve the bill.

Even Maui’s usually divided County Council unanimously passed a resolution in support of the proposal after dozens of people packed council chambers, spending hours giving emotional and sometimes tearful testimony.

"Indigenous people and people of color have been robbed of our traditional cultural practices for far too long," council member Keani Rawlins-Fernandez, who introduced the resolution, said during the meeting.

Many people fear the looming requirements could pose barriers to Hawaii residents who might want to become midwives in the future. For decades, the main pathway into the practice was studying under experienced community midwives, especially in Hawaii's rural areas. 

"You can’t eliminate that by just saying, ‘Well, these people aren’t considered legal,’" Edwards said. “What happens is that things go underground, and it never serves the women; it never serves whoever is providing the care.”

In her view, the best way forward is to require more dialogue to ensure that everyone within the islands’ health care system — from hospitals to physicians to nurse midwives to traditional midwives — are able to collaborate to provide patients the best care.

Barriers To Midwifery Care

A number of studies have shown that integrating midwifery care into health systems can lead to fewer interventions, lower costs and improved experiences for mothers. Typically, midwives might spend 30 to 90 minutes during a prenatal visit with a patient, focusing not only on physical health but well being as a whole — for example, making sure they have friends to prepare and deliver meals in the weeks after birth.

But progress has been slow in many places, including Hawaii, because of a number of factors, ranging from insurance companies’ lack of coverage to low reimbursement rates for obstetric care.

"The majority of births occur without major complications, whether they occurred in the hospital or out of the hospital. However, we do know that complications occur.”

Dr. Angel Willey

In the view of some medical professionals, mandating that midwives are licensed could help standardize practices and clear confusion for patients and other providers.

Le‘a Minton, a certified nurse midwife and president of the Midwives Alliance of Hawaii, has been pushing for years for mandatory licensure. Right now, patients wanting to give birth at home must navigate a wide array of providers, ranging from licensed midwives to unlicensed birth attendants to naturopaths offering childbirth services without midwifery licenses.

Minton said since the law changed in 2019, at least 28 people in Hawaii received midwifery licenses. She says that proves that it’s possible for Hawaii residents to meet the current education requirements to get licensed. Although there aren’t any accredited schools in Hawaii, a few of programs are available online, she said.

By her count, only a handful of existing unlicensed birth attendants might be barred from practicing if the licensure law takes full effect this summer.

“We do not believe cultural practices currently exist within five unlicensed birth attendants,” Minton said. “We believe that families and communities practice their culture within their daily lives and incorporate what they wish within their births.”

Others say the figure might be higher, and that many of the licensed midwives practicing in Hawaii moved from other states, after completing the arduous and often expensive midwifery education process thousands of miles away. Today, it’s impossible to know how many traditional midwives there are in the islands, because many of them have for years operated by word of mouth. Some were trained by community midwives who began practicing when it was illegal for anyone to practice midwifery who wasn't a nurse.

One of them was the late Tina Garzero, or Tina the Midwife as she was widely known. Garzero began her career in California and moved her practice to Maui in the late 1970s, even though her work was illegal until the law changed in 1998.

TIna Garzero after giving birth in her home, surrounded by her own children and others from the neighborhood. (Courtesy of Nara Boone/1982)

"Not only was she an outlaw doing what needed to be done for the community, she also felt women deserved to be given the birth experience they desired -- one that empowered them and their families," said Nara Boone, one of Garzero’s daughters.

Garzero worked for nearly 40 years as a midwife on Maui. She was so well known that families in rural East Maui would circulate maps to her home in Haiku, in case they couldn’t make the two hour-journey to the hospital in Kahului. She was celebrated as an advocate for Maui's families and mentored many revered midwives. After her death, more than 1,500 people came to the celebration of her life.

Kaho‘ohanohano attended hundreds of births under Garzero's guidance. None of them, Kaho‘ohanohano said, ever ended up with a mother in an emergency situation. Garzero taught her students what signs to look for so they could help support a mother to work closely with her obstetrician or plan a birth in the hospital instead.  

For years, Kaho‘ohanohano grappled with whether to pursue a formal midwifery credential, something she could’ve received as an apprentice to Garzero. But she believed it went against her own sovereignty as a Native Hawaiian woman.

“There is a really big difference, just in the way we see the world,” said Kaho‘ohanohano. “​​Even if they handed me a scholarship, airplane tickets and came and took care of my kids, it doesn’t mean that I fit into that box.”

Civil Beat’s coverage of Maui County is supported in part by grants from the Nuestro Futuro Foundation and the Fred Baldwin Memorial Foundation.

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