“It’s not my profession. It never has been. This is a kuleana,” said Kiʻinaniokalani Kahoʻohanohano, a pale keiki — a traditional Hawaiian midwife — who has practiced for decades on Maui.
“It’s not just pregnancy,” she emphasized. “This is a heightened state of wellness, and we want to add to that wellness. We want to build strong babies and strong mamas.”
Kahoʻohanohano works with Pacific Birth Collective, a nonprofit launched in 2016 by a group of Maui midwives, doulas, childbirth educators and birth advocates. With roots on Maui, they now encompass a statewide network of birth workers and supporters.
The wāhine-led organization was born from an identified need in the community. Operating with a model of decentralized leadership inspired by other collaborative care organizations allows for a deft community response.
Sonya Niess, the board president of the birth collective, said they responded to “the need for connection … for networking between birth professionals … birth workers, anyone really who lays hands, or eyes or gives support (or) heart to women going through pregnancy, birth, postpartum — really any part of reproduction.”
Maui wildfires exacerbate access issues
Like so many local organizations, PBC sprang to action after the August fires. They were preparing for a September launch of their Haʻikū hub when the fires catapulted the team into action.
“When it came … to answering that kāhea of, 'There is devastation, there is a strong need on the west side, and we’ve got to figure out how to get there and how to service our community in whatever way we can,' it was difficult for everybody,” Niess said.
“But mothers have grit … we're holding each other’s babies while we’re on the computer getting that next donation order in. We’re out on the west side with our keiki in tow … everybody is a part of it.”
Kahoʻohanohano, who lives in Kahakuloa on Maui’s west side, spent nearly 24 hours a day at the Puʻuhōnua Honokōwai community hub for months after the fires. Survivors lined up to access medical care including birth kits created by PBC, mental health services, food and water, supplies and much-needed connection.
“I'm a healer in my community,” Kahoʻohanohano explained. “This is what I do. It’s natural for me to want to go out there and, for lack of a better word, save people. But literally, at this point, that’s what we needed. So I wasn’t coming in as a birth worker alone, I was coming in as a cultural practitioner, with knowledge of lomi lomi, lāʻau lapaʻau, hoʻoponopono — which has been huge for…dealing with trauma, and getting more to the source.”
Navigating legislative roadblocks to practicing traditional Hawaiian midwifery, Kahoʻohanohano began serving her community as what one family called “a generational trauma healer.”
Concurrently, midwives from other islands flew in to help.
But with many pregnant fire survivors sheltering in hotels, and some even living in their cars or in tents on the beach, Kahoʻohanohano soon began receiving calls about babies.
“The first couple of weeks of the fire, so much mamas thought they lost their babies,” she said. “I went to a handful of houses where I got called to from Honokōwai just to listen to heart tones and clarify whether or not they had lost their babies.”
Once, leaving one emergency and being told there were no ambulances available in West Maui, Kahoʻohanohano responded to a call about a birth from a first-time mother in a hotel in Kahana.
“I gather whatever I had in my bag. And I’m not equipped nor planning to go to birth, especially because I was made illegal when that exemption was expiring, July 1, 2023. I’ve been treading very lightly in that way.”
Because of the wildfire emergency proclamation and knowing emergency responders likely wouldn’t make it to the mother in time, she rushed out.
“No prior contact, no preparation, no nothing. I walk in, all I have is my hands and my heart and my kūpuna,” Kahoʻohanohano recounted.
“I’m going to put it in a nutshell: Mom would have died. I saved her life. Baby would have died. I saved his life.”
Maternal care faces business and legal constraints
In 2019, Hawaiʻi lawmakers passed legislation requiring a specific state license for midwives to practice. Starting in July 2023, unlicensed birth workers were deemed illegal — and subject to fines and imprisonment.
That included Kahoʻohanohano, who has chosen a path of Native Hawaiian midwifery, though she also supports licensure. After a decade-long legislative battle to increase access to care, she is part of a lawsuit filed by the Center for Reproductive Rights against the State of Hawaiʻi.
Even before the August fires, maternal care on Maui had sharply declined as multiple providers dropped obstetrics services.
Last March, Maui Lani Physicians and Surgeons — one of only three clinics offering pregnancy and delivery services on Maui, alongside Kaiser Permanente and Mālama i ke Ola — announced that they would no longer be offering obstetrical care as of October 2023.
PBC Board President Niess said the limited access to OB-GYN care in Maui County had reached crisis level.
“Mamas are falling through the cracks,” Niess said. “Things weren’t being followed through, lab results weren’t being called in, moms had to be their own advocate in a whole new level and way.”
Kahoʻohanohano asserted that PBC’s efforts are to ultimately ensure access to the care each individual wants and needs.
“You hear very often, ‘It’s about safety. We want safety,’” she said. “But what does that mean, when we’re looking at a nation here in Hawaiʻi, that (is) 50th in the 50 states in prenatal care? We know all too well.”
“Most people walking around in Hawaiʻi have no idea what a maternal health care desert means. And they definitely don’t know that they’re walking around in one.”
The data backs this up. The Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System reported that Native Hawaiians and Pacific Islanders have the highest pregnancy-related mortality rate in the United States, as of 2019.
Ensuring maternal health resources for the next generation
PBC is working hard to ensure the maternal health care desert on Maui doesn’t get drier.
The organization now has a mobile program to deliver supplies and services, and continues to accept donations for families in need while offering classes and events at their hub in Haʻikū. Residents with a West Maui address can register with PBC for free supplies and services.
Kahoʻohanohano also leads a cultural practice internship and a mālama ‘āina program, supported by Kupu Hawaiʻi.
“It goes back to cultural competency … and connection,” she said. “Our people feel safer in the hands of our people.”
Kahoʻohanohano and PBC are nurturing the next generation of culturally informed birth workers.
“Too often, reproductive justice is just associated with abortion,” Kahoʻohanohano noted. “But especially in … places with Indigenous cultures that have been colonized and assimilated and essentially erased from their own homeland, it’s very pertinent to incorporate all practitioners.”
“And really, as much as culture or religious freedom is important, it’s about bodily autonomy and choice for wāhine — to not feel uncomfortable.”
PBC aims to bring that birth sovereignty to women throughout Maui Nui and beyond.
Lily Diamond is a bestselling author, educator, and advocate from Maui, Hawaiʻi, working to redefine narratives of interdependence and resilience in our earth and human communities. Her work has been featured in the New York Times, VICE, Women’s Review of Books, Vogue, and more.
