Editor’s note: As part of Reckon’s coverage of Native American Heritage Month, we are focusing our reproductive justice reporting on the courageous work of indigenous midwives, and the barriers they face in providing care to their communities

In the United States, high maternal mortality rates among people of color reveal the systemic racism that pregnant people face when trying to access care. For indigenous pregnant people, whose rates of pregnancy-related death are twice as high as those of white women, one proven solution has been found within their own communities: culturally competent Indigenous midwives.

Yet despite the proven successes of the holistic services offered by indigenous midwives to their own communities, Indigenous pregnant people and midwives alike face high barriers both to access and provide care.

These struggles are particularly pronounced in Hawaii, where the compounding effects of climate change, and lack of healthcare providers in rural areas exacerbate the ways in which pregnant people and their families experience birth.

This summer, a law that advocates say allowed Indigenous midwives–who are legally referred to as birth attendants– to practice without state licensure ended, putting many at risk of legal challenges if they continue to practice.

Navigating maternal care on the island

Hawai’i, like many rural communities across the US, faces a shortage of physicians, which means that pregnant people are forced to travel long distances to reach a maternity ward or birthing center. For Indigenous people and others pursuing midwifery, increased restrictions in obtaining licensure is creating additional barriers to practice.

“We’re generational family healers,” said Ki’i Kaho’ohanohano, a pale keiki, or Native Hawaiian traditional midwife, and founder of Mālama Nā Pua o Haumea. “We are the ones who fill in those gaps.”

The three-year exemption period of Act 32 ended in July, requiring those using the midwife title to obtain a license including proof of certification as a CPM or CM from a Midwifery Education Accreditation Council-accredited (MEAC) program. Birth attendants, or traditional midwives, are usually unlicensed, learning how to assist in the birthing process through years of hands-on, generational training.

Kaho’ohanohano trained for 13 years under an experienced Maui midwife, and says that the new legislation threatens the preservation of traditional birth attendants in communities which already have few options to accessing reproductive healthcare.

This, she says, is a disservice to her people.

“We’re the ones that go inside of prenatal clinics in rural areas or meet them part way so they don’t have to drive three hours for prenatal visits. And then we spend hours with them… They’re missing that care and that connection and that support and that circle of sisterhood and love that they need,” said Kaho’ohanohano.

An October 2023 Obstetrics & Gynecology study found that patients with language barriers experienced xenophobia and racism, leading to lower gynecologic cancer screenings, more unscheduled c-sections and even forced sterilization.

Kiana Rowley, co-founder of Pacific Birth Collective, has witnessed these barriers. She says white physicians often treat Native Hawaiians, whose primary language is often Pidgin, a Hawaiian creole which combines the indigenous language of Hawai’i with English, Japanese, Chinese, and Portuguese.

“The providers primarily who have been able to access the licensure and get the training and the education are not from Hawaii so they don’t understand… I think especially for Native Hawaiians unfortunately because of colonization a lot of them can kind of switch on and off their Pidgen and communicate, but the language barrier between medical terminology that these practitioners use, the way that they speak to people with these really big words and make things sound very complicated,” said Rowley, adding that white doctors have difficulty communicating with a local person who’s in pain during labor.

“There’s a communication and a cultural disconnect that happens where they just kind of get run through a system and it’s just this perpetuating, compounding trauma that keeps getting replayed over and over again,” she said.

A compounding crisis

In August 2023, a surge of wildfires devastated Maui, killing at least 114, displacing thousands, and damaging around 2,200 buildings on Lahaina, a small town at the western end of the island. The disaster exacerbated pre existing barriers to prenatal and maternal care. Though parts of the area reopened two months after the fires, Rowley says that locals are still recovering and continue to face challenges with internet connection and only having two access roads to reach services.

“The level of isolation that people are dealing with just to be able to receive basic care, I think it’s hard for people to really comprehend,” said Rowley.

Access to care differs depending on which of the eight major islands of Hawai’i locals live on. For example, Moloka’i only has one emergency department, and two nurse midwives according to Rowley. Lanai has no maternal unit, so residents who need specialized care on either of these islands must fly out, which has become increasingly difficult since two of the airlines that service these islands shut down during the pandemic.

“There’s very few care providers who are willing to drive to the rural communities which means the majority of our rural moms literally drive on windy, treacherous roads just for a five minute care appointment,” said Rowley.

Barriers to midwifery licensure

To become a licensed midwife, Hawaiians must have attended a Midwifery Education Accreditation Council (MEAC) school. Rowley is currently training to be a midwife on Maui. She says that the cost of midwifery education ranges from $50,000 to $100,000, depending on whether your path is CPM or CNM.

Already four years in in her licensure journey, she still needs to complete 8 months of clinical in which she’ll have to leave the island for.

“I’m hoping that I’m going to have a placement on O’ahu where I have family and a place to stay. If I didn’t have connections, with places to stay [obtaining a license] would be pretty much impossible for me.

Despite these barriers, some Indigenous midwives continue to provide care using cultural practices that have long served their community.

Though Kaho’ohanohano stopped accepting births a year ago, she was recently called in to assist in a home birth.

“Literally if I didn’t show up to this birth two minutes down the road the baby would have died,” she said during a panel about colonization and midwifery held by Changing Woman Initiative on Nov. 5.

“I play a pretty important role in my community and whether they acknowledge that or not, we’re here,” said Kaho’ohanohano.