HONOLULU (KHON2) -- In 2019, a bill passed in the Hawaiʻi State Legislature that legalized midwifery services under a strict set of regulations. The law allowed midwives to legally assist with births. It was a move meant to ensure they could continue to provide care to mothers in rural areas of the state. Get Hawaii's latest morning news delivered to your inbox, sign up for News 2 You While the passing of the bill seemed like a victory for the midwifery community, the aftermath of its implementation revealed significant challenges. Rep. Amy Perruso, District 46, and Rep. Elle Cochran, District 14, have taken up the mantle to fix the fallout from the bill’s passing and ensure that midwives in Hawaiʻi can continue practicing without unnecessary hurdles. Both representatives are passionate about the importance of midwifery and women's health, and their discussions offer a glimpse into the complexities of legislating in Hawaiʻi. “I don’t think people really understand how important midwifery is here in Hawaiʻi,” Rep. Perruso said. “We have rural areas where doctors and nurses are few and far between, and midwives are providing an essential service. This is not just about a profession; it’s about a woman’s right to choose how and where she gives birth.” Rep. Perruso's words reflect a deeply personal commitment to protecting women’s reproductive rights. However, despite the 2019 bill, which aimed to regulate midwifery and ensure its safety, the reality has been more complicated. Choice is an empowering option: Midwifery in Hawaiʻi The law left many questions unanswered; and as midwives and healthcare professionals tried to implement it, confusion and frustration mounted. “The bill passed in 2019, but we didn’t anticipate the fallout that would come afterward,” Rep. Perruso explained. “There were loopholes. The regulatory structure was unclear. And worst of all, the midwives felt shut out from any real conversations about how to make the bill work.” Rep. Cochran, who has long supported midwifery, shared her initial experiences with the legislative process surrounding midwifery in Hawaiʻi. She remembers the first time she encountered midwives in the halls of the state Capitol. “I had no idea who they were or what they were advocating for, but I couldn’t ignore what was happening right in front of me," explained Rep. Cochran. "Women with babies were camped out in the hallway trying to get a meeting with the chair of the Finance Committee. I had to ask myself, ‘Why are they being treated like this?’” Hawaiʻi’s midwifery restrictions spark debate over reproductive autonomy, indigenous rights Rep. Cochran's story reveals the emotional impact that the issue had on her. After talking with midwives and learning about their struggle, she became deeply involved in their cause. “They just wanted to be heard. They wanted to meet with lawmakers and share their needs, their perspectives,” Rep. Cochran said. “But they weren’t being given the time of day. To me, it was about respect. These were mothers and caregivers trying to support other mothers.” Both Reps. Perruso and Cochran worked together to improve the law and ensure midwives had a voice in the process. However, they encountered significant resistance. In particular, some lawmakers refused to meet with midwives, and there was a lack of leadership on the issue, according to Rep. Cochran. “I’m still baffled by the response. It doesn’t make sense,” she said. “It became an issue of power and politics. But at the end of the day, it’s about women’s rights and the need for access to healthcare services.” Rep. Perruso said she voted for the bill in 2023 with the understanding that it would be revisited in 2023 to fix any problems that arose. Protecting choice, culture: The legal fight for birth equity in Hawaiʻi She believes any new legislation needs to make it easier for midwives in Hawaiʻi to operate while maintaining the necessary safety standards. However, it became politically impossible to address it in 2023. Despite the setbacks, Reps. Perruso and Cochran continue to push for reform. Rep. Perruso acknowledged the challenges but remains optimistic. “This is an issue that has been going on for years. But we can’t give up,” she said. “Midwifery is not just some fringe issue. It’s part of our cultural fabric. We need to protect midwives and ensure they can practice safely. But we also need to make sure that women have the freedom to choose how they want to give birth in a way that respects their health and their beliefs.” For Rep. Perruso, she was told that no one in Hawaiʻi uses midwifery or even cares about it. So, when she was approached by someone looking for legislator to listen to her, she decided to give them a forum. She was surprised by the overwhelming turnout at her "coffee talk" forum where she initially expected only about four people. "I thought it would be a small, intimate gathering," she recalled. "But when I walked in, there were about 60 people; and it was standing room only." The turnout reflected growing public interest in the midwifery bill and showcased the community's strong support for midwives and the need for legislative action. "It was clear to me the community cared deeply about midwifery in Hawaiʻi," she added. Rep. Cochran, too, emphasized the importance of midwifery in the context of Hawaii’s healthcare system. “Midwives provide a critical service, especially in rural areas,” she said. “Hawaiʻi has a shortage of healthcare workers, and many women in remote areas don’t have easy access to doctors or hospitals. Midwives are an essential part of the healthcare landscape here.” However, both lawmakers expressed concern over how the midwifery issue has been politicized. “I believe there’s a financial element at play,” Rep. Cochran explained. “Some people don’t want midwifery to succeed because it could disrupt the established medical system. If we’re being honest, it’s about money and power. It’s not just about what’s best for the women of Hawaiʻi.” The issue of licensing for midwives has also been a point of contention. According to Rep. Perruso, some lawmakers were uncomfortable with the idea of midwives practicing without the formal certification required by more traditional healthcare professions. “Some people just don’t understand that traditional cultural knowledge is valuable,” Rep. Perruso said. “The fact that midwives have been practicing for generations using skills passed down through families and communities, doesn’t seem to matter to some people. They want everything to be certified and regulated, but we need to recognize the value in our cultural practices.” House Finance Chair, Rep. Yamashita had this to say about the controversies surrounding midwifery in the Hawaii State Legislature. "Unfortunately, there have been misunderstandings regarding this issue and events from last year. Efforts are currently underway to reach a compromise," explained Rep. Yamashita. "Several legislators are collaborating with stakeholders on a bill slated for introduction this year. We eagerly anticipate reviewing the legislation in the upcoming session to ensure safe practices for birth attendants and the delivery of babies in our state." Despite the political hurdles, both Reps. Perruso and Cochran remain committed to ensuring midwives are treated with the respect and dignity they deserve. “At the end of the day, it’s about the people,” Rep. Cochran said. “It’s about the mothers and the families who need these services. Midwifery isn’t some side issue or political pawn. It’s a crucial part of our healthcare system.” Rep. Perruso echoed her sentiments and emphasized that the issue of midwifery goes beyond politics. “This is about women’s rights. It’s about ensuring women have choices when it comes to their own health and their own bodies,” she said. “We need to stop making this about politics and start making it about what’s best for the people of Hawaiʻi.” Rep. Perruso also emphasized the need for diverse pathways to certification that respect both modern and indigenous practices. "There are many ways to certify midwives," she said. "We have to recognize the value of indigenous knowledge and the mentoring that’s passed down through generations. And we have to figure out how to incorporate those practices into a system that makes sense." She proposed creating a system that acknowledges both formal training and traditional mentoring, advocating for "a holistic approach" to certification that rely not only on written tests, but also includes cultural competence and hands-on experience. As both lawmakers continue to navigate the complex political landscape surrounding midwifery, they remain hopeful that the voices of midwives and their supporters will be heard. “We’re not giving up,” Rep. Cochran said firmly. “The fight is far from over. We will keep pushing, and we will keep advocating until midwives have the support they deserve.” For Rep. Perruso, the fight is personal. “I have spoken to so many women who have had their lives impacted by the lack of midwifery support in Hawaiʻi,” she said. “I have seen firsthand the value of what midwives bring to our communities. And I will continue to fight to make sure they can practice freely and safely in our state.” She also discussed the unique challenges faced by her rural constituents, especially after the closure of the Wahiawa General Hospital. "When you lose access to healthcare in rural areas, you really lose a lifeline," she explained. "Midwives play a critical role in filling that gap. They’re part of a system of care that’s more accessible to people who are often underserved." She emphasized the importance of midwives in providing essential healthcare where traditional services are lacking or unavailable. Vice Speaker Linda Ichiyama told KHON2.com that she is working on a bill to address the midwifery licensure statute and intends to introduce it as soon as it is finalized. As the 2025 legislative session approaches, both representatives are prepared to keep pushing for change. Whether through new bills or continued advocacy, they remain steadfast in their commitment to ensuring that midwifery has a secure and supportive place in Hawaiʻi’s healthcare system. Their work is far from over, but they are determined to see it through. As Rep. Perruso put it, “This is not just about legislation. This is about people’s lives. And that’s what we’re fighting for.” You can click here to find a midwife in your area. Click here to learn more about the women’s fight for reproductive choices. Get news on the go with KHON 2GO, KHON's morning podcast, every morning at 8 KHON2.com has reached out to Speaker Nakamura for a statement. This article will be updated to reflect any responses.