Legislation to regulate midwives in Hawaii has underscored a divide among home-birth advocates.

Senate Bill 1033, approved Friday by the Legislature and moved to the governor, licenses midwives and make it illegal for cultural and traditional practitioners to provide midwifery services after 2023.

Midwives act as primary- care providers during childbirth, taking the mother’s vital signs and monitoring contractions, heart rates and the position of babies in the womb. They also do cervical exams; assess potential abnormalities during the birthing process; conduct breast exams, Pap smears and screening for sexually transmitted diseases; and even treat women who aren’t pregnant — all without any oversight.

Of the roughly 18,000 children born in Hawaii in 2015, 1.8% — 339 — were home births, according to a 2017 state auditor’s report recommending that midwives be regulated.

Proponents of SB 1033, who include midwives with formal training who are certified, say they want to create a path for licensure to ensure safe home births. Advanced practice registered nurses who specialize in midwifery and can prescribe medications are the only ones currently licensed by the state Department of Commerce and Consumer Affairs.

Some midwives with professional certification do not view cultural and traditional practitioners as their peers because many are self-trained and have not completed any formal education or apprenticeship programs, said Le‘a Minton, board president of the Midwives Alliance of Hawaii.

“It comes down to the fact that because we have not regulated this profession for the last 20 years, currently anybody can call themselves a midwife and advertise that they are providing midwifery services,” she said. “Part of the issue is essentially who we believe is a midwife. Anyone who’s not currently certified is not a midwife.”

Cultural and traditional practitioners say that even though they did not undergo Western training, they follow traditional, cultural childbirth practices.

Alohi Ae‘a, who used cultural midwives to deliver two of her three children, called SB 1033 an infringement on women’s civil rights.

“Traditional and cultural midwives need to be protected and allowed to practice,” she said, “and women need to be able to choose who is with them in their most vulnerable and precious moments as they are bringing babies into the world.

“Women choose to birth at home for various reasons, and many of the midwives who serve this community have obtained their training and experience through ways other than the American medical model,” Ae‘a said.

The situation is made more difficult because there are no midwifery schools in Hawaii, she said.

Laine Hamamura, who gave birth to three of her four children at home, agreed. “The legislation would take away women’s rights, eliminate their choices and criminalize midwives who are already attending to Hawaii families,” she said.

Jaymie Lewis, a traditional midwife who began practicing under an apprenticeship with a naturopathic doctor in 2010, said not everyone wants a “medicalized birth.”

“Not everyone views it as a medical event,” said Lewis, whose two children were born in her Kailua home with the help of a midwife. “I don’t necessarily think that everybody’s opposed to licensure per se. It was intended to give some recognition to midwives … because over many decades, centuries, midwives have kind of been shunned and even persecuted for what they do.

“There’s many types of midwives who are loved, cherished, highly respected, have great outcomes … (who) would not be included in this.”

Similar legislation was introduced but failed during the 2014, 2016, 2017 and 2018 sessions.

The legislation exempts Native Hawaiian healers, who are protected under the state Constitution, and temporarily exempts birth attendants from licensure requirements until 2023. It also establishes a task force to study the issue and appropriates $146,000 in the first year and $73,000 in the second year to regulate the industry.

Minton said there are at least three midwives practicing here after their licenses were revoked on the mainland, underscoring the need for licensing.

“Without regulation the public doesn’t have the ability to know whether the state has determined if a person has met minimum competencies and education to practice in their profession,” she said.

State Rep. Chris Lee (D, Kailua-Waimanalo), who spoke in support of the bill on the House floor, noted the potential detrimental outcomes that can arise when using an unlicensed midwife. He said people expect doctors and other medical specialists to be licensed and adequately trained, and that should be the standard for midwives, too.

“The state licenses and regulates all sorts of different things — from the folks cutting your hair to doing much less risky procedures. It’s amazing that in this day and age, this particular area in which life-and-death decisions depend on the expertise of someone in this position is unregulated.”