The state requires barbers, plumbers, massage therapists, electricians, auto mechanics, pest control operators, dental hygienists, physicians, and a host of other professional and vocational job holders to meet minimum standards before they can get licenses to serve customers.
But Hawaii has no such requirements for those who help women give birth at home.
Unlike the majority of other states, Hawaii does not have minimum qualifications for licensing or certifying midwives and others who perform home deliveries.
That means providers with a wide range of training — including little at all — can tap into what has been a growing demand for home-birthing services in the islands, though the actual number of cases still is relatively small.
For each of the past six years, home births have increased in Hawaii, hitting a peak of 345 in 2012, up 64 percent since 2007, state data show.
The 345 cases represented less than 2 percent of overall births statewide in 2012.
Even as the home-birth trend shows signs of slowing this year, with the total expected to decline for the first time since 2007, a key state legislator is drafting a bill he plans to introduce in the upcoming session that would bring state oversight to the home-birth setting.
Sen. Josh Green, who heads the Senate Health Committee, said Hawaii’s current lack of standards is "totally unacceptable." His bill will establish minimum requirements for midwives and others who perform such deliveries.
"I trust trained midwives," said Green, an emergency room physician. "But I don’t trust those who put up a shingle," have virtually no training or experience yet describe themselves as midwives, he added.
Lay midwives or birth attendants who overstate or misrepresent their qualifications are becoming more of a concern as the demand for home birthing grows, according to supporters of state oversight.
Green envisions the bill establishing minimum qualifications for obtaining a state license or certification. He also wants to limit home deliveries to low-risk cases and ensure that the provider has a backup medical plan in case something goes awry.
"This is what I would expect of myself or any provider taking on a pregnancy," Green said.
Hawaii is one of 23 states that do not regulate midwives, according to 2013 data from the Midwives Alliance of North America and the North American Registry of Midwives. Midwivery is the health care field that focuses on pregnant women.
The move to bring Hawaii in line with the majority of other states comes in the wake of some tragic cases involving home births around the state, including some fatalities, physicians say.
The lack of state oversight was raised publicly earlier this year when a mother who had given birth at her Oahu home sued the naturopathic physician who delivered the baby, alleging that the physician’s negligence contributed to her baby suffering severe brain damage.
The physician denied the allegations. The lawsuit is pending.
Some women prefer giving birth in the comfort of their home and under the supervision of a qualified provider. Proponents cite data indicating that home births result in fewer medical interventions for mothers and fewer instances of premature and low-birth-weight babies.
But others cite studies showing higher infant mortality rates linked to home births.
The local section of the American Congress of Obstetricians and Gynecologists is among those calling for state oversight.
"We are very concerned about home birth safety in Hawaii," Dr. Lori Kamemoto, chairwoman of the local section, said in an email to the Honolulu Star-Advertiser. "Deaths of newborns associated with a planned home birth in Hawaii appear to be on the rise. Nationally, when compared with hospital births, planned home births are associated with a twofold to threefold increase in newborn deaths."
While hospitals are the safest setting for birth, Kamemoto said the OB/GYN organization respects the right of a woman to make a medically informed decision about delivery.
But to avoid preventable deaths or harm, mothers who plan a home birth need to be aware that this should not be considered for high-risk pregnancies and that a certified nurse midwife or certified midwife be at the home to ensure the safety of the woman and newborn, according to Kamemoto. The two types of midwives Kamemoto referred to receive formal obstetrics training under the auspices of the American Midwifery Certification Board.
She also said there should be ready access to medical consultation and a way to safely and quickly transport the mother and baby to a hospital if necessary.
"Home birth safety regulations are needed to ensure the safety of Hawaii’s mothers and newborns," Kamemoto added.
Annette Manant, a certified nurse midwife and secretary for the Hawaii affiliate of the American College of Nurse Midwives, said establishing out-of-hospital standards is a good idea.
A state license will elevate the status of certified professional midwives in Hawaii and enable them to become eligible for liability insurance and to bill insurers, according to Manant, who works at Waimea Women’s Center at North Hawaii Community Hospital on Hawaii island.
But she said she would not want the legislation to prevent pregnant mothers from being able to use lay birth attendants — those without formal midwife training — if the mothers are comfortable with the attendants and the attendant’s qualifications are made clear to the family, Manant said.
While physicians who treat pregnant women and newborns told the Star-Advertiser that anecdotally they are seeing a rise in deaths and complications associated with home births, no reliable statistics are available to give a comprehensive picture of what’s happening.
Local infant mortality statistics are considered unreliable by some physicians, who contend the number of home births and associated deaths is underreported in Hawaii.
The Health Department, for instance, reported no deaths within three months of birth among the 345 home deliveries recorded statewide in 2012.
The city medical examiner’s office reported only three Oahu infants born at home from 2004 through 2012 died within three months of birth. All three involved stillbirths.
Yet several physicians told the Star-Advertiser they know of cases that belied such statistics.
Green’s bill is expected to address the issue of getting more reliable data on home births.
Rich Turbin, the attorney who represents Margaret Drake, who sued the naturopathic doctor who delivered her baby, contends state oversight of home births is long overdue, given the consequences when an unqualified provider makes a mistake.
"You’re wrecking people’s lives," Turbin said.
In 2011, Drake gave birth at home to her son, Makaio, who suffered brain damage because of a lack of oxygen, according to her March lawsuit.
The lawsuit accused the doctor, Lori Kimata, and Sacred Healing Arts Center, where Kimata worked, of providing negligent care that led to Makaio’s injury.
Kimata and Sacred Healing denied the allegations, saying she did nothing improper or incorrect, according to court documents.
Hawaii island resident Derek Kirbow, whose spouse is a midwife, said state oversight will not only enable the public to know who has met minimum standards to legally practice here but should help address a lack of health care providers for women in underserved areas.
"There have been challenges in having home births in Hawaii, but almost all of these have been due to midwives (who) have not been under the auspices of any governing body nor have had any oversight," Kirbow wrote in an email.
Dr. Sheree Kuo, a neonatalogist at Kapiolani Medical Center for Women and Children, said she hopes Green’s bill will help to better educate the public.
"I don’t know if most people realize that there are people out there who advertise their midwifery expertise but have little or no medical training," Kuo said.
Regardless of where a mother chooses to deliver, she added, the main goal should always be the same: a healthy, happy mom and baby.
