Hawaiian midwifery on trial: What’s at stake in this defining moment for indigenous rights and women’s health

By Annabel Rocha

Published on June 12, 2024

Today hearings begin in Kahoʻohanohano v. State of Hawaiʻi, a lawsuit challenging restrictions placed on the type of licensure midwives in Hawai’i need to legally practice. Native Hawaiian and Indigenous birth workers now face criminalization for serving their communities, and families are left with few options among a mounting U.S. maternal mortality crisis and for some, multiple barriers to accessing health care facilities.

The Center for Reproductive Rights represents nine plaintiffs, including six midwives and midwifery students suing the state of Hawai’i in response to a Midwifery Restriction Law which they say violates Native Hawaiian traditional birthing practices.

“We are going to court to ensure that every person in Hawai’i has the right to make their own decisions about their pregnancy care, including the decision to give birth at home with a traditional midwife,” said Nancy Northup, president and CEO at the Center for Reproductive Rights. “Right now in Hawai’i, skilled midwives are facing criminal prosecution for serving their communities in ways they have for generations.

While the Midwifery Restriction Law has been in place since 2019, its original exemption for birth attendants, or traditional Hawaiian midwives, expired in July 2023. Those practicing midwifery were then required to obtain a license including proof of certification as a Certified Professional Midwife or Certified Midwife from a Midwifery Education Accreditation Council-accredited (MEAC) program.

However, traditional midwives are typically unlicensed and learn how to assist in the birthing process through years of hands-on, generational training. Obtaining the type of licensure now required to practice costs thousands and requires years of study and practice, including clinical practice at an MEAC institution. According to Ms. Magazine in March, there are eight MEAC locations in the U.S., but none are in Hawai’i, forcing those who pursue accreditation to relocate. Without licensing, midwives risk a $2,000 fine and jail time for offering care or giving advice to pregnant women and families.

“We are not against licensure, we have never been against licensure, for those who want to pursue that path,” Kiʻinaniokalani Kahoʻohanohano, lead plaintiff and Native Hawaiian cultural practitioner told The Guardian in February. “But the wisdom of our elders defies settler logic, which sees our teachings and rituals as less than.”

Kahoʻohanohano has been practicing traditional midwifery for 20 years, but says she has now been forced to turn away families every week since the exception went into effect. She says that with this law in place her community is in danger of losing customary birthing practices, faces cultural erasure and mothers’ lives are at risk.

“This law is preventing me from passing along the life-changing and life-saving knowledge and traditions that I was gifted. It is robbing the next generation of Native Hawaiians of our own ancestral healing knowledge and power. Our communities are experiencing a maternal health crisis in hospitals, and cutting off our ability to care for our families with our own traditions and practices is medical colonialism,” she said.

Birthing in Hawai’i

As Reckon reported in November, families face multiple barriers to birthing on the island. Hawa’i faces a physician shortage, and some islands, like Lanai, do not have birthing hospitals or services like NICUs. Last year, the Honolulu Civil Beat reported that most pregnant women on Lanai and Molokai are flown to Oahu to give birth, which can be both expensive and lonely.

“They’re leaving their families behind,” said Jacquelyn Ingram, a lactation consultant and midwife on Oahu told the Honolulu Civil Beat in June 2023. “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 March of Dimes does not categorize Hawai’i as a maternity desert because of the distance to care in miles however, the layout of the land places additional challenges to accessing care, especially for those living in rural areas. Extreme weather conditions, like the 2023 Maui wildfires, tourism, and winding roads cause long travel times. About one-third of Native Hawaiians live in rural areas, according to the U.S. Census.

In November, Kahoʻohanohano said that Indigenous practitioners like her fill the void between medical facilities and the type of care that families need.

“We’re the ones that go inside of prenatal clinics in rural areas or meet them part way so they don’t have to drive three hours for prenatal visits. And then we spend hours with them… They’re missing that care and that connection and that support and that circle of sisterhood and love that they need,” said Kaho’ohanohano.

As Native Hawaiian face challenges in receiving care, data shows they are at greater risk for complications. In 2018, Native Hawaiian and Pacific Islanders (NHPI) had nearly twice the rate of infant mortality than white infants, and in 2019, NHPI mothers were 4.6 times more likely to receive late or no prenatal care, according to the U.S. Department of Health and Human Services.

An estimated 10 to 12 women die each year in Hawai’i due to pregnancy or pregnancy-related complications, according to the state Department of Health, who also says that at least half of those deaths are preventable.

Ezinne Dawson is a plaintiff in the case who does hold a state midwifery license, but says that the law limits women’s autonomy to choose options that better serve them.

“I went through three stressful and disempowering hospital births, so for my fourth child, I decided to do a home birth. It transformed my entire understanding of pregnancy and birth, which is why I decided to apprentice and become a midwife. My heart is breaking for every pregnant person in Hawai’i who is now unable to get the care that makes them feel most physically and emotionally safe because of this law,” Dawson said in a statement in February.

Kaho’ohanohano said the restrictions strip Native Hawaiians of their community and culture.

“I am known to my community as a resource, a person who can help our moms,” she said. “Why can’t I use the knowledge I have to help my own, my ohana?” Kaho’ohanohano told the Guardian.

Hearings in this case begin today at 9:00 a.m. HST (3:00 p.m. ET) and are scheduled through June 14.

This piece was republished from M Live.