Some midwives seek to uphold Native Hawaiian birth traditions. Would a state law put them at risk?

HONOLULU– Ki’inaniokalani Kaho’ohanohano longed for a deeper connection with her Native Hawaiian ancestors and culture as she prepared to give birth to her first child at home on Maui’s North Shore in 2003.

But generations of colonialist suppression had eroded many Hawaiian traditions, and it was difficult to find information about how the islands’ indigenous people honored pregnancy or childbirth. She also was unable to find a Native Hawaiian midwife.

That experience led Kaho’ohanohano — now a mother of five — to become a Native Hawaiian midwife, a role in which she spent years helping to deliver up to three babies a month, receiving them in a traditional cloth made from tree bark and pronouncing sacred words, trembling chants as she welcomed them into the world.

Her quest to preserve the tradition also took her to a courtroom in downtown Honolulu this week, where she and others are trying to block a state law that they say jeopardizes their ability to continue serving pregnant women awaiting such customary births. of native Hawaiians.

“Being able to have our babies in the places and ways of our kupuna, our ancestors, is very vital,” she testified. “For me, the goal of what we do is to be able to give birth back to these places.”

Legislators enacted a midwife licensing law in 2019, concluding that “inadequate midwifery practice poses a significant risk of harm to the mother or newborn and may result in death.” Violations are punishable by up to one year in prison, as well as thousands of dollars in criminal and civil fines.

The measure requires anyone who provides “evaluation, monitoring and care” during pregnancy, labor, delivery and postpartum to be licensed. The women’s lawsuit says this would include a wide range of people, including midwives, doulas, lactation consultants and even family and friends of the new mother.

Until last summer, the law provided an exception for “birth attendants,” which allowed Kaho’ohanohano to continue practicing Native Hawaiian birth customs. With that exemption now expired, however, she and others face licensing requirements — which they say include expensive programs available only out of state or online that don’t align with Hawaiian culture and beliefs.

As of 2022, the average cost of an accredited midwifery program is $6,200 to $6,900 per year, according to court documents filed by the state.

Lawyers for the state argued in a court filing that the law “undoubtedly serves a compelling interest in protecting pregnant people from receiving bad advice from untrained individuals.”

State Assistant Attorney General Isaac Ickes told Judge Shirley Kawamura that the law does not prohibit midwifery or home births for Native Hawaiians, but that requiring a license reduces the risk of harm or death.

The dispute is the latest in a long history of debate over how and whether Hawaii should regulate the practice of traditional healing arts, which dates back long before the islands became the 50th state in 1959. These arts have been banned or severely restricted during much of the 20th century. century, but the Native Hawaiian rights movement of the 1970s renewed interest in customary forms.

Hawaii eventually adopted a system in which boards versed in native Hawaiian healing certify traditional practitioners, although those suing say their efforts to form such a board for midwifery failed.

However, practicing midwifery without a license was prohibited until 1998 – when, according to lawmakers, they inadvertently decriminalized it by changing the regulation of nurse midwives, something the 2019 law sought to remedy.

Among the nine plaintiffs are women seeking traditional births who argue that the new licensing requirement violates their right to privacy and reproductive autonomy under the Hawaii Constitution. They are represented by the Center for Reproductive Rights and the Native Hawaiian Legal Corporation.

“For pregnant women whose own family no longer holds knowledge of the ceremonial and sacred aspects of birth, a midwife trained in the traditional and customary birthing practices of Native Hawaiians can be an invaluable and culturally informed health care provider,” the lawsuit states. .

When Kaho’ohanohano was unable to find a Native Hawaiian midwife to attend the birth of her first child, she turned to a Native American midwife, who was open to incorporating traditional Hawaiian aspects that Kaho’ohanohano learned from her elders.

She surrounded herself with practitioners of Hawaiian culture with a focus on pule, or prayer, and lomilomi, a traditional massage with physical and spiritual elements. All of this helped ease her three days of labor, she said. And then, “two pushes and a stick” — that’s it — the boy was born.

The birth of her five children in various Maui communities, Kaho’ohanohano said, were her “greatest teachers” in becoming one of the few midwives who knows the birthing practices of Native Hawaiians.

She is believed to be the first person in a century to give birth on her husband’s ancestral land in Kahakuloa, a remote valley in West Maui inhabited mainly by Native Hawaiians, where their daughter was born in 2015. The community is at least 40 minutes along winding roads. to the only hospital on the island.

Kahoʻohanohano testified about helping low-risk pregnant women and identifying instances in which he transferred someone to receive care at the hospital, but said he never experienced any emergency situations.

Other plaintiffs include midwives she helped train and women she helped during childbirth. Makalani Franco-Francis testified that she learned about customary birth practices in Kaho’ohanohano, including how to receive a newborn in kapa, or traditional cloth, and cultural protocols for a placenta, including taking it to the ocean or burying it to connect a newborn to their ancestral lands.

The law disrupted his education, Franco-Francis said. She testified that she is not interested in resuming her midwifery studies through out-of-state or online programs.

“It is not aligned with our cultural practices and is also a financial obligation,” she said.

The judge heard testimony throughout the week. It is unclear when a decision might come.

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Johnson reported from Seattle.