A civil complaint being heard this week in Circuit Court has drawn a critical eye toward Hawaii laws governing midwifery, an important facet of pregnancy care for Native Hawaiians and Pacific Islanders, in particular. The increased scrutiny is for good reason.

As of 2019, midwife practitioners, birth workers and family members who provide support during pregnancy and childbirth must be licensed, a process that requires training through a program accredited by the Midwifery Education Accreditation Council (MEAC). An alternate path to becoming a certified professional midwife involves procurement of a bridge certificate from the North American Registry of Midwives, though this route applies only to practitioners who obtained certification before 2020 or have a valid license in a state that does not require accredited education.

There are just eight MEAC-accredited schools in the U.S., all on the mainland, meaning unlicensed midwife practitioners and student midwives seeking certified professional midwife credentials must cover travel, education and lodging expenses. Hillary Schneller, an attorney for the Center for Reproductive Rights, told the Honolulu Star-Advertiser that she is not aware of any initiatives to implement MEAC-approved programs in Hawaii. That’s a problem.

Hawaii’s restrictions and their enforcement through monetary fines border on the extreme, and in many ways serve to hinder much-needed access to culturally sensitive services in a state that cannot afford to lose more ground on health care. By some measures, Hawaii ranks at or near the bottom of the scale when it comes to prenatal care, and ethnicities native to or living in this state are at much higher risk of death due to pregnancy-related complications.

According to recent Centers for Disease Control and Prevention (CDC) statistics, Native Hawaiian and Pacific Islanders have among the worst maternal mortality rates of any ethnicity in the U.S. Between 2017 and 2019, pregnancy-related death rates for Native Hawaiian/Pacific Islanders were 450% higher than white mothers and 60% higher than Black mothers. Infant mortality rates are similarly outsized at nearly twice that of non-Hispanic whites.

In 2022, the Native Hawaiian/Pacific Islander demographic was the least likely to initiate prenatal care in the first trimester and led the country in receiving late or no prenatal care, according to the CDC. Much more must be done to address these disparities — and removing existing practitioners from the care continuum, with no concrete options for replacement, is not a tenable solution. Time is ticking after a three-year license exemption window closed in July 2023.

While 2019’s Act 32 included what was designed to be a carve-out for “traditional Hawaiian healers” conducting “traditional healing practices of prenatal, maternal, and child care,” that affordance is predicated on recognition by kupuna councils convened by Papa Ola Lokahi. Unfortunately, such exemptions never materialized. Papa Ola Lokahi limits council approval to those affiliated with a nationally recognized health center and, more prohibitively, can only recognize practitioners of four cultural practices including laau lapaau and lomilomi — insufficient to fulfill a comprehensive range of prenatal, continuing pregnancy, birth and postpartum care.

House Bill 955 introduced in the 2023 state Legislature would have extended exceptions for Native Hawaiian practitioners and created an informed consent form whereby mothers would be granted rights to opt for a midwife or practitioner. But the bill did not survive committee, nor did it go far enough to address the need for more accessible practical health services.

For many, pregnancy and birth are intensely personal, cultural and spiritual experiences. Hawaii has a duty to provide its mothers with safe, effective care that promotes cultural considerations, not diminishes them.