When asked what I do for work, my reply is often prefaced by a big sigh. Same with the question, “How are you?”

I am a midwife and community health advocate. The roots of choosing this profession began during the aftermath of 9/11. I was living in New York City, 40 weeks pregnant, and preparing for a home birth.

The experience of having a dedicated and confident midwife for my family changed the trajectory of my life. It was empowering and we were spared the chaos of hospitals during a disaster. The cost was covered by insurance, a biller negotiating out-of-network coverage, $15,000 for nine months of care and delivery.

The morning after the delivery, I asked my midwife, “Does everyone want to be a midwife after that?”

Having already been in the field for a few decades, she hesitated. Unfortunately, this care is not well known nor easy to secure in the U.S.

Lack Of Understanding

Over the years, what I’ve encountered is a general lack of understanding of the value of midwifery and community-based care. Midwives believe we are the solution to the reproductive health crisis. Midwifery is based on preventative care.

Many midwives believe we contribute to the healing process of generational trauma. We strive to provide a culturally adept service to our communities and work for the advancement of our professions.

In 2019, Act 32 was passed with a purpose to expand access to licensed midwives and regulate vocations associated with midwifery. Impacted practitioners include Certified Midwives, Certified Professional Midwives, and exempt birth attendants.

Since its implementation, the statute has been challenged annually. For the CM, scope of practice and prescriptive privileges remain restricted.

For the unlicensed, a lawsuit filed against the state of Hawaii last week claims a family’s right to choose where and with whom they receive care has suffered as the “Law threatens a network of traditional and apprenticeship-trained midwives and cuts off culturally-informed maternal care.”

Records at the Department of Commerce and Consumer Affairs reveal that since the beginning of the Midwives Program established through Act 32, 36 CPMs have applied for a license and one CM. According to a survey conducted last year by the Hawaii Affiliate of the American College of Nurse-Midwives, midwives per capita are very low and only a portion provide full-scope care.

Approximately 40 CNMs work throughout the islands. Outside of Kaiser and Tripler hospitals, only a few attend deliveries in the Queen’s Health System, and none are in other hospitals. Many only work in clinics.

Per 2023 data from Hawaii State Vital Records, there were 14,271 babies born at a rate of 42 births a day. Most of these births were on Oahu. On the more rural islands of Hawaii and Kauai, there were 1,807 and 674 births, respectively. Vital Records does not publish statistics for Lanai, Molokai and Niihau.

Numbers are lower on the more rural islands not only because of population difference but also due to lack of providers. Many, many families are forced to travel to Oahu to receive care. On Hawaii island, live births per midwife total more than 250 annually, 337 on Kauai. Those are impossible numbers, considering private-practice licensed midwives generally manage 15-40 deliveries annually, and hospital-based only twice that.

Hawaii is not alone in facing challenges in determining statutes and regulatory bodies for the profession and vocation of midwifery. States have had varying degrees of success in authorizing practice for midwives to the fullest extent of their training.

By addressing shortcomings in Act 32, Hawaii could stand as a precedent for other states. An amendment to the law has the potential to expand the scope of the CM credential and the pathway for CPM licensing, as well as clarify the exemption status for unlicensed birth attendants. Act 32 sunsets June 2025. Now is a vital time to consider how Hawaii is going to integrate midwifery care providers to address the maternal health crisis.

There is support for progressive policy from both the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, and Centers for Medicare & Medicaid Services. In May 2023 the ACNM published a workforce study data brief titled, “Is there an association between state policies regarding midwifery practice and the density of midwives?”

The conclusion: “States can potentially increase the growth of the midwifery workforce by adopting independent practice, right to medical staff privileges, and Medicaid reimbursement parity.”

Though views on home birth differ, a joint statement by ACNM and the ACOG from 2011 that has been annually and was reaffirmed through 2018: “ACOG and ACNM believe health care is most effective when it occurs in a system that facilitates communication across care settings and among clinicians.”

They “recognize the importance of options and preferences of women in their health care.”

Last week, CMS presented details of a new program — Transforming Maternal Health — to engage a “whole-person approach,” address disparities in access and treatment, and recognize the need to expand midwifery care in all settings.

It’s a time for communities to reach out to legislators, health care systems, and insurance providers in support of midwifery. Though it’s a long time coming, I feel encouraged.