Thirty-one years ago, Native Hawaiian cultural practitioner Laulani Teale gave birth alone in a sacred plot of land in Halawa Valley.
For her hanau — the Hawaiian tradition in which mothers determine their birthing process — Teale wanted to keep the experience between herself, her baby and her ancestors. The licensed midwife who monitored the birth and the cultural practitioners who assisted in the hanau supported Teale by giving her privacy.
Afterward, friends and family, including kupuna, trekked into the valley bringing papaya for her sustenance and blankets for her newborn.
Despite the logistical and physical challenges, Teale now reflects on that hanau as pivotal to her experiences as a Native Hawaiian woman.
“You have to be able to navigate your way through the unknown, and in order to do that in a way that is healthy and reflects in the rest of life, you need to be able to birth in whatever way your ancestors and the land tells you to do it,” Teale said.
But the concept of “your body, your choice” has not always been present in Hawaii’s laws related to childbirth. Hawaii first began regulating midwives in 1931. The regulation of midwives was repealed in 1998 when nurse-midwives were placed under the purview of the state Board of Nursing.
Teale gave birth during a resurgence of hanau in the late ’90s when midwifery and Native Hawaiian birthing practitioners, or pale keiki, were not state-regulated. Now, midwifery and the Native Hawaiian cultural practices that blur the boundaries of statutory definitions are again at the center of a fierce legislative debate that harkens back to the 2019 legislative session, when lawmakers passed what became Act 32 in recognition of “the potential for harm to public health and safety posed by the unregulated practice of midwifery.”
The law established a regulatory framework for the licensure of midwives and defined the roles of midwives and birth attendants. Many in the Native Hawaiian community complained the law did not adequately protect the rights of traditional birthing practitioners trained through nonaccredited apprenticeships.
The law subjected birth attendants who engage in midwifery practices to potential fines of up to $2,000 and/or a year in prison. However, it also set a four-year exemption for birth attendants to engage in home births without facing criminal penalties if they disclosed their lack of license to the state.
Since enactment of Act 32, approximately 41 midwives have been licensed, according to the Legislature.
The regulations are set to “sunset” June 30 unless further action is taken. House Bill 1194 was introduced during the current legislative session to make permanent the state law regulating midwives and the practice of midwifery.
The current draft of the bill provides that individuals practicing Native Hawaiian traditional and customary practices are protected under Article XII, Section 7 of the Hawaii State Constitution and are not required to obtain a midwife license from the state Department of Commerce and Consumer Affairs.
The measure was amended Thursday before passing third reading in a 20-4 Senate vote to prevent any criminal penalties for birth attendants “who engage in the practice of midwifery,” but civil fines would remain.
With HB 1194 still in limbo as the Legislature heads into its home stretch before adjournment May 2, Native Hawaiian cultural practitioners and the women who seek their guidance are bracing for what additional amendments could mean for pale keiki attending to childbirths at home or on ancestral lands.
While state Department of Health data shows that home births accounted for only 2% of Hawaii births from 2015 to 2024, it is widely recognized they hold cultural importance to the Native Hawaiian community and are sometimes a necessity in rural areas of the state.
However, there is disagreement among lawmakers, cultural practitioners, health care professionals and licensed midwives on how best to ensure safe home births for mothers and their newborn infants.
Enforcement threat
DCCA spokesperson William Nhieu said in an email that the department had received six anonymous online complaints under Act 32 since 2019. One matter is pending, he said, but DCCA had yet to impose any disciplinary or enforcement actions.
Native Hawaiian midwives and birthing attendants say the risk of penalties has increased since the birthing attendant exemption expired in June 2023. The Center for Reproductive Rights and their partners filed suit on behalf of nine plaintiffs who say that since the exemption expired, Act 32 “prevent(s) pregnant people from receiving pregnancy and birth care from trusted, skilled midwives.”
The plaintiffs argue the definition of midwifery under Act 32, which includes providing “advice and information regarding the progress of childbirth and care for newborns and infants” and “supervising the conduct of labor,” is too broad and encompasses some of what traditional cultural practices might entail.
Currently, pale keiki who assist in the delivery of a baby in the Hawaiian tradition are, under state definition, considered birth attendants rather than midwives. According to Kristie Duarte, chair of Hawaii Home Birth Collective, none of the state-licensed midwives are Native Hawaiian or engage in traditional birthing practices.
Ki‘inaniokalani Kaho‘ohanohano, who has 20 years of birthing experience as a pale keiki in rural Maui, said she has assisted mothers in their hanau through hooponopono conflict resolution and lomi lomi massage during delivery and the traditional planting of the newborn’s umbilical cord afterward.
Kaho‘ohanohano said pale keiki also serve a critical need in rural areas of the state, especially in low-income communities. In 2023, she delivered babies in areas of West Maui ambulances could not reach after the Lahaina wildfire that killed 102 people.
The state granted a preliminary injunction in July that keeps individuals who practice, teach and learn only Native Hawaiian traditional birthing practices safe from penalties under Act 32. But uncertainty remains, and that’s why Kaho‘ohanohano and her student Makalani Franco-Francis say that since the 2023 expiration of the birthing attendant exemption, they have turned away families and mothers seeking their birthing services.
“I started to take on a few families and I just was not able to give them what they need,” Kaho‘ohanohano said, holding back tears. “I found myself canceling appointments for prenatal (care) and a class I was going to host for a few couples, and it’s heartbreaking. One of (the mothers) isn’t even speaking to me right now. She’s so disappointed, but she just doesn’t understand what level of demand we are under.”
A mother’s choice
Six mothers who birthed at home told the Honolulu Star-Advertiser they found their midwives independently, relying mainly on referrals, face-to-face interviews and an intersection of belief and cultural systems. They said they did not consider licensing as the most important factor in their decision.
Carrie Ann Shirota, policy director for the American Civil Liberties Union of Hawaii, said Act 32 and HB 1194 seek to regulate those who engage in midwifery practices but that the greatest impact is on mothers, especially those of Native Hawaiian descent, who are at risk of no longer being able to choose who gets to attend the birth of their child.
“Removing the birth attendant exemption is very paternalistic to assume that pregnant and birthing people cannot make informed decisions for themselves,” Shirota said.
The Hawaii Home Birth Collective’s Duarte said that since 2023, a nonaccredited midwife who delivered two of Duarte’s three children at home has been considered unlicensed under the state despite having 40 years of experience with exemplary outcomes.
“That’s terrified me,” Duarte said. “I’ve wanted another (baby) but the thought that the person I would choose (as a midwife) is someone who is not legal, and the amount of fear that I would be bringing into that birth because the government has told me what I’m doing could lead to criminalization (of her) — it doesn’t feel good.”
But Le‘a Minton, Midwives Alliance of Hawaii president and certified nurse midwife, said regulating midwifery licensure does not equate to removal of a mother’s choice or autonomy.
“For the law, when we license a professional, at no point does it remove an individual’s choice to choose who their provider is,” Minton said. “It’s just that if the individual they choose practices midwifery without a license, then that provider is at risk for receiving fines.”
Teale said the midwifery duties of pale keiki are ones that have existed since “time immemorial.”
With a final version of HB 1194 yet to emerge from legislative conference, Teale is imploring lawmakers, midwives and practitioners to remember that Native Hawaiian cultural practices cannot exist in isolation.
“A cultural practice relies on non-native people to keep it going and to support people in a lot of different roles,” she said. “You can’t just protect Hawaiians and protect the practice, because Hawaiians rely on community — that’s how these practices work.”
