Midwifery licensing laws up for debate at state Legislature
After seeing her mother give birth with the assistance of a midwife, 12-year-old Sovereign Duarte decided she wanted to become a traditionally trained midwife.
“I want to train under a religious midwife who's been practicing for 40 to 50 years,” Sovereign said.
But that’s not so easy to do, and a pathway to reach that may not be clear. Current Hawaiʻi laws differentiate between a midwife and a traditionally trained birth attendant. For the latter, if a law doesn’t get past this legislative session, what Sovereign wants to study may be illegal come July.
“In the law, midwife means a person licensed, they wouldn't let us use a word that's been passed down for thousands of years, so we went with birth attendants,” Hawaiʻi Homebirth Collective President Kristie Duarte, Sovereign’s mother, said.
Kristie Duarte, in 2019, chaired the state’s Home Birth Task Force that was born out of another state Legislature attempt to figure out licensing with Act 32.
That 2019 law also gave the state until June 30, 2023, to determine licensing for birth attendants, or, as the law states, "incorporate all birth practitioners and allow them to practice to the fullest extent under the law."
Now, that time has come, and House Bill 955, nicknamed Sovereign’s Law, seeks to define the state’s midwifery licensure laws and exemptions this legislative session.
But it’s not just Sovereign who in the future would be affected. Come July, if nothing gets sorted, the work of some traditional birth attendants will be outlawed.
What would happen if HB 955 passes?
According to the state’s 2017 report, from 1991 through 1996, the state saw about 170 home births annually. In 2015, the number of home births had risen to 339. Though it's a small portion of the population, the number of active midwives isn't enough to provide care.
There are 28 licensed midwives in the state, Duarte said, and of those, only two were fully trained in Hawai'i.
“Those two could be the only two that were given the practices of Hawai'i to pass on,” Duarte said.
One of them is Rachel Curnel Struempf on Hawaiʻi Island. She was the state’s first licensed midwife, but she received all of her training traditionally.
“After July, if this bill doesn't pass, they will be illegal to practice midwifery and all of the families that they have served for all of the years that they've been in practice will no longer have access to their wisdom and knowledge,” Curnel Struempf said.
This time around, the law comes down to licensure.
One method would be to use the Portfolio Evaluation Process, known as PEP. The other option is to attend a Midwifery Education Accreditation Council-accredited school. HB955 would allow the PEP license or an exemption to attend births without a license.
“The midwife who gets their credentialing through the Portfolio Evaluation Process are not eligible for a Hawaiʻi state license,” Curnel Struempf explained. “However, they are nationally and internationally recognized by all of the same organizations, they take the same credentialing medical exam, they have all of the same requirements as people who attend a MEAC school.”
Fifteen of the 28 licensed midwives in the state came to Hawaiʻi with certification in hand, Duarte said. Without a Hawaiʻi option for somebody locally to get a MEAC-endorsed license, somebody interested in becoming a certified midwife would need to seek schooling on the continent.
“Both routes at the end of the day, take the same exam, pass the exam, get the same certification,” Duarte said. “We want our local people to be able to have access to licensure, if they want it, and be able to stay home.”
Testimony for and against HB 955
Supporters of House Bill 955 say enforcing the singular MEAC licensure can mean losing a traditional practice. It could mean that future midwives and birth attendants would be required to seek out-of-state learning or they may leave the profession altogether.
“Women who have been midwives for 40-plus years now have to be demoted to a traditional birth attendant because the state won't allow them to use the title midwife,” Curnel Struempf said. “It's just so disrespectful to our kūpuna.”
Opponents to the bill include the Hawaiʻi Section of the American College of Obstetricians and Gynecologists.
“Licensure of midwives was critical to making community (or out of hospital) births in Hawaiʻi safer,” ACOG Hawaiʻi Section Chair Angel M. Willey said in written testimony. “Licensure of midwives was also important for future efforts at promoting a more integrated maternal health care system, similar to those seen in western Europe where maternal and neonatal outcomes exceed those in the U.S.”
Willey cited a 2022 study from the Journal of Midwifery and Women's Health which looked at neonatal intensive care unit records at Kapiʻolani Medical Center on Oʻahu.
"The newborns in the neonatal ICU with this brain injury (hypoxic ischemic encephalopathy) were three times more likely to have been planned home births compared to the normal neonates,” Willey said. “This emphasizes that complications during birth occur, and it is critical to have trained, licensed healthcare providers capable of recognizing and managing these complications wherever that birth is occurring."
State representatives debate HB 955
On the House floor last week, Rep. Lisa Marten of Oʻahu was the only "no" vote on the bill’s second hearing.
“I think that everybody should be licensed when providing this kind of very important health care and that standard should be met,” Marten said. “I understand that three years ago when the deadline was given, that was a time period to resolve some of the issues and agree on a path forward. I'd hate to just keep kicking the can down the road, while people are still practicing taking money for a service in our state, without any set of standards.”
Marten cited her time in Guatemala, when she ran a child and infant nutrition program, as first-hand experience.
“There, in very traditional Mayan villages, almost everybody was attended by traditional midwives with no particular certification,” Marten said. “The only people that were not were the people that could afford to go to the hospital. We did have relatively high maternal mortality, and I saw the consequences of that among the children that I cared for when they were orphaned.”
Rep. Natalia Hussey-Burdick of Oʻahu authored the bill. In that same floor session, she shared her personal story.
“I was born at home to a traditionally trained midwife, and at the time that that happened, that choice to choose a traditionally trained midwife was illegal because the year before my birth, the Legislature had passed a law requiring only certified nurse midwives can practice,” Hussey-Burdick said in an interview last week. “So it's basically an advanced practice nursing degree and it doesn't honor the culture and traditions of any of our host culture or any other culture that's in the melting pot of Hawaii.”
Hussey-Burdick said there’s been large support for the bill from residents on neighbor islands.
“We have very rural areas on neighbor islands where they don't have access to hospitals, and with so few licensed midwives currently practicing their only option, if we don't pass this bill, is to give birth unassisted,” Hussey-Burdick said.
County-level support for HB 955
The Maui County Council passed a resolution through Councilmember Keani Rawlins-Fernandez from Molokaʻi supporting the bill.
Hawaiʻi County Councilmember Jenn Kagiwada represents Hilo. Later this month, she will co-introduce a resolution in support.
“We don't have what we need as far as health care in general on our islands, but then you look at places like Kaʻū or Puna, or even Hāwī, some of these places, they're just much farther away from any access to general health care,” Kagiwada said Monday. “Think of being in a vulnerable position of being pregnant and not knowing how long you have before you're actually going to give birth and the thought of having to, travel and not know that you'll get there in time.”
The distance Kagiwada described is a reality for Curnel Struempf.
“It really matters to the outer islands and to the rural communities, because we are the ones that are underserved,” she said. “We have such a desperate need for rural community midwives.”
Sovereign’s Law is scheduled for a hearing Wednesday in front of the House Committee on Consumer Protection and Commerce. But if it doesn’t get passed, Sovereign said she’d still like to pursue the profession.
“I'm not sure how I would do it, because I'm just hoping that this will be passed,” Sovereign said.