Loneliness can be a struggle for expecting mothers in rural Hawaii who are advised to relocate to Honolulu in the weeks before giving birth due to a shortage of maternity care on some neighbor islands. 

On Lanai, where there are roughly 50 births a year, the island’s labor and delivery ward has been defunct since Dole phased out its pineapple operations in the early 1990s.

Molokai’s only hospital delivers about 30 babies a year through a midwifery program available only to women with low-risk pregnancies who sign up for an unmedicated birth. Another 70 pregnant women per year don’t qualify for the program or opt out.

As a result, most pregnant women on Molokai, and virtually all expecting mothers on Lanai, board a plane to Oahu to bring their child into the world.

Often this means leaving family and other support systems behind. It can also be a financial burden when the cost of lodging is not reimbursed by insurance.

“It is a lonely process,” said Pennie Bumrungsiri, program director of Healthy Mothers Healthy Babies Hawaii. “For some women, it can also be expensive.”

On the more populous neighbor islands, women with complicated pregnancies also travel to Honolulu to reach specialty care.

In one example, Bumrungsiri said an expecting mother from Maui who suffered a stroke shortly after she became pregnant last year followed a doctor’s recommendation that she relocate to a Honolulu hotel room five months into her pregnancy.

The move allowed the mother to maintain fast access to a higher level of hospital care than she could get on Maui. But it came at a price: social isolation.

“She felt very lonely because she had a 7-year-old daughter and a partner and mother who lived back home on Maui,” Bumrungsiri said. “Her family was divided. Occasionally she had her mother and partner come over, but otherwise she had no community there.”

But even uncomplicated pregnancies can require a temporary move to the state’s medical hub for women on Lanai and Molokai. Doctors typically advise expectant mothers from these islands to relocate to Honolulu three or four weeks before the baby’s due date.

“They’re leaving their families behind,” said Jacquelyn Ingram, a lactation consultant and midwife on Oahu. “Often when moms come, they might have four other kids at home. It’s a long time to be away from your children. And who’s going to be watching them, caretaking them, feeding them and getting them ready for school?”

The cost of these temporary relocations for child delivery are sometimes borne by the patient. For example, lodging during the weeks before childbirth is not a reimbursable expense for patients covered by HMSA PPO, the most popular health insurance plan on Lanai. 

Clinicians at Lanai Community Health Center encourage patients in this situation to apply for dual coverage from Medicaid, which typically funds the cost of ground transportation and a hotel stay. But for women who earn too much to qualify for Medicaid, the cost of lodging tends to fall on their shoulders.

“I had some patients who had to book an Airbnb for as long as three weeks,” said Jared Medeiros, associate medical director at Lanai Community Health Center. “When you add that up, it’s a lot. And for them it wasn’t covered. So we really try to start that conversation as early as we can so they can try to get feelers out there to see if they know anyone who can provide them with lodging — or start saving.”

Established in July 1985, Molokai General Hospital’s midwifery program does not perform cesarean sections and it prohibits vaginal births for mothers with a prior history of C-sections. Women who give birth at the 15-bed hospital sign up for an unmedicated delivery with little access to medical interventions if things go sideways. 

Strict criteria determine who can safely deliver a child through the program. Disqualifying criteria includes a history of preeclampsia, chronic hypertension or severe diabetes.

The hospital has occasionally been approached by family physicians who’ve wanted to expand its childbirth services. But it would take more than a couple of ob-gyns for the facility to offer more comprehensive care.

“You need a neonatologist,” said Hilton Raethel, president and CEO of Healthcare Association of Hawaii. “You need nurses that are trained in obstetrics. You need a birthing room. So it’s the cost of all the additional infrastructure and staffing that makes it very challenging to set these things up unless you’ve got a sufficient population base.”

Decades ago, maternity care on Molokai was more robust. A handful of primary care doctors in the island’s main town of Kaunakakai started delivering babies in the 1940s, partnering with a fly-in obstetrician-gynecologist from Honolulu to provide care to women with riskier pregnancies. 

The doctors abandoned child birth services in January 1985, however, when malpractice insurance premiums shot up higher than their incomes.

A subsequent government investigation revealed that between 1984 and 1987, premiums paid by the average ob-gyn in America rose more than 70%. Family doctors who delivered babies paid almost twice as much for insurance as their colleagues who opted out.

The loss of on-island child delivery on the island that year meant that expectant mothers who wished to give birth with a doctor in the room had little choice but to fly to Honolulu, a journey that remains common practice today.

“I happened to be pregnant during that time and I’m going to tell you that it was a crapshoot,” said Molokai General Hospital President Jan Kalanihuia. “People delivered in the parking lot. People delivered at home. People delivered in the emergency room, which I can tell you the last thing an emergency doc wants is a delivery. It was just a mess.”

After six months of chaos, the hospital launched a midwifery program in July 1985. The program allowed Kalanihuia to give birth to her second child without leaving the island.

“It’s the love of my life,” Kalanihuia said of the hospital’s Women’s Health Center, which today has two certified nurse midwives, clinical support staff and a patient navigator.

For many women on Molokai and Lanai, boarding a plane to give birth is an accepted way of life. The state’s most remote places struggle to attract and keep health professionals, making it harder for residents there to get health care.

People in Hawaii’s most rural outposts rely on airline travel to access emergency and even routine medical care. Lanai residents, for example, must fly for colonoscopies, mammograms, any kind of surgery — even an ankle fracture. 

When it comes to child birth, there’s little disputing that the added element of an airplane trip can make planning for labor more difficult.

“Taking early maternity leave or unpaid time off from work before the baby comes, lining up a place to stay, these are the conversations we have with our patients from the time they find out they’re pregnant,” Medeiros said. “It’s never too early to prepare.”

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

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.