A bill wending its way through the Legislature seeks to improve birth outcomes, both for mothers and newborns, by establishing tighter, more succinct and permanent midwifery regulations and standards. This is good news for Hawaii, whose population continues to utilize midwifery services and, in many cases, adjacent Native Hawaiian/Pacific Islander cultural birthing practices. Unfortunately, the latest version of House Bill 1194 is weighed down by an overly broad set of provider stipulations and worrisome vague language. In short, it is self-defeating.
Hawaii’s regulation of midwifery dates back to 1931, when midwives were required to register with the state before practicing. From there, progressively stringent oversight called for certification and licensure, though state-level regulation was repealed in 1998 when nurse-midwives became the board of nursing’s responsibility. Midwifery continued and in 2019 legislators formulated a regulatory framework under Act 32. That act is now codified in Hawaii Revised Statutes, Chapter 457J, which is due to sunset on June 30.
HB 1194 is a vehicle to not only extend midwifery regulations, but make permanent any updates to existing law. It is important that lawmakers get this right, but the current draft passed Tuesday by the Senate committees on Commerce and Consumer Protection and on Judiciary does not foster an industry capable of supplying an adequate number of qualified professionals. There must be a balance of efficacious safety regulations and midwifery trade subsistence; both are necessary, as many residents seek out such services.
Under Chapter 457J, midwife practitioners, birth workers and family members who provide support during pregnancy and childbirth must be licensed. That stipulation is well-founded and must carry through to passage, though proposed amendments to HB 1194 muddy the water by introducing confusing clauses, vague language and legal inconsistencies.
Amendments attached by the Commerce and Consumer Protection Committee allow unlicensed attendants to take part in a home birth so long as they do not engage in midwifery duties, accept compensation or use the titles “midwife” or “licensed midwife.” That mix of provisos caused confusion among lawmakers during Tuesday’s public hearing. Kristie Duarte, chair of the Hawaii Home Birth Task Force, pointed out that the bill’s definitions of midwife practices were so broad that nearly anyone present at a home birth could conceivably be found in breach of the law. This language must be clarified, with specific and accurate descriptions of what practices are acceptable and by whom.
There is also some debate as to whether Hawaii should continue to accept certified professional midwife (CPM) credentials received through the North American Registry of Midwives (NARM) Portfolio Evaluation Process (PEP) apprenticeship pathway to licensure. In testimony, professional organizations claim exemptions for PEP pathway students should not be allowed, suggesting replacement with accredited routes to licensure to reduce consumer risk.
But according to ACLU testimony, the nonaccredited PEP pathway rightly leaves open the door for aspiring midwives who don’t have access to Midwifery Education Accreditation Council (MEAC) midwifery schools. This is particularly important to would-be CPMs, for whom the eight MEAC-accredited schools — all on the mainland — might be out of reach. An exemption for PEP students is necessary to expand Hawaii’s pool of practitioners.
Also important is explicit clarification that all Native Hawaiian traditional and cultural practices are exempt from regulating law, as protected under the state Constitution. This clause is vital to protect Native Hawaiians, who suffer troubling pregnancy-related health disparities compared to other demographics.
Without modification, HB 1194 does more to hinder midwifery in the islands and — more distressing — the people who rely on those vital services. It must be revised before passage.
