Kill Senate Bill No. 2569 and protect Midwife Care in Hawaii
- por: Amber Seber
- destinatário: Senate Committee on Commerce and Consumer Protection, Senate Committee on Health, Senate Committee on Judiciary and Labor, and The Senate Committee on Ways and Means
A Petition to Kill S. B. No. 2569 in Hawaii
S. B. No. 2569 which has recently been introduced and concerns regulation and licensure of home birth midwives contains dangerously incorrect information and is a health and safety hazard to mothers and babies as well as a transgression on mothers' medical, religious and constitutional rights. It is harmful to women and their families, creates a monopoly in healthcare and will eradicate the safe practice of home birth and midwifery in Hawaii.
S. B. No. 2569 would all but make midwifery and home birth illegal in the state of Hawaii, forcing mothers who choose to home birth to potentially go underground in finding illegal care providers which may pose a risk to herself and her baby. The bill also infringes on patients' rights and violates their right to medical privacy.
To begin, S. B. No. 2569 specifically states "The legislature also finds that national data reports a two to three fold increased risk of neonatal mortality with planned home birth versus hospital birth." (Section 1, paragraph 2) In fact, it is well and widely known that international data supports the fact that planned home birth has similar if not better outcomes than planned hospital births.
This wildly incorrect assumption that home birth has a threefold increase in neonatal mortality is based entirely off of a single study entitled Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis (Joseph R. Wax, MD. et al) which, since its publication, has been well and widely discredited due to its incorrect data and substandard data analysis.
An article by Carl A. Michal, PhD, Patricia A. Janssen, PhD, Saraswathi Vedam, SciD, Eileen K. Hutton, PhD, Ank de Jonge, PhD entitled "Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong" and published on MedScape reads:
"The highly charged debate over the safety of home birth was inflamed by the publication of a meta-analysis by Joseph R. Wax and coworkers, which concluded that "less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate." The statistical analysis upon which this conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research." (http://www.medscape.com/viewarticle/739987)
Yet another statement issued by Gill Gyte, Trainer in Research Methodology, NCT; Mary Newburn, Head of Research and Information, NCT; Alison Macfarlane, Professor of Perinatal Health, Department of Midwifery and Child Health, City University London entitled "Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home" states:
"In summary, NCT has found that this study has serious methodological limitations, including:
•Insufficient detail about the assessment of the quality of the primary research papers identified by the authors and their specific reasons for inclusion or exclusion of each study.
- Lack of information about the included studies, and the specific data contributed by each one to the outcomes under investigation. Scrutiny of the primary research papers has led to somewhat different numbers being identified. (A ‘forest plot’ should have been included.)
•Lack of clarity and consistency about the definition of neonatal mortality in each of the included studies, including whether stillbirth data were included.
•The small size of the sub-group contributing to the calculation of comparative risk of neonatal death for planned home birth and planned hospital birth. It has been suggested that 200-400 adverse events are needed in order to be confident of avoiding a systematic error of insufficient data, but there were just 64 neonatal deaths reported by Wax for all neonatal mortality and 37 for non-analogous neonatal mortality.
- A number of the non-randomised studies included in the meta-analysis were not matched for confounding risk factors nor had adjustments been made to data afterwards, and some included women at increased risk of complications.
On the basis of these limitations, it is completely unjustifiable to claim that ‘Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate’. On the basis of the poor quality data of their data, the authors should not have reached this conclusion. Furthermore, the editors of the American Journal of Obstetrics and Gynecology should not have accepted the paper for publication without major modifications." (http://www.scribd.com/doc/34065092/Critique-of-a-meta-analysis-by-Wax)
And an article published in Birth (Volume 30, Issue 1, pages 57-63, March 2003) entitled "Home Birth versus Hospital Birth: Questioning the Quality of the Evidence on Safety also discusses the flaws with the study, saying:
"In contrast, the Midwives Association of Washington State press release stated that 'Childbearing women and health policy makers should be made aware that the study contains numerous flaws and limitations...this study alone should not be used to make decisions that could restrict women's choice of birth place or access to birth attendants with expertise in home birth'" (http://onlinelibrary.wiley.com/doi/10.1046/j.1523-536X.2003.00218.x/abstract)
Other reviews of this study include the following:
"Study validity questioned" in The American Journal of Obstetrics & Gynecology (volume 204, Issue 4, page e14, April 2011) (http://ajog.org/article/S0002-9378(10)01107-5/fulltext)
Home birth metaanalysis: does it meet AJOG's reporting requirements? (http://ajog.org/article/S0002-9378(11)00074-3/fulltext)
International data demonstrate home birth safety. (http://www.ncbi.nlm.nih.gov/pubmed/21458614)
“Home birth triples the neonatal death rate”: public communication of bad science? (http://www.ajog.org/article/S0002-9378(11)00075-5/abstract)
In truth, there is no study that can correctly claim that home birth is any greater risk than hospital birth. This study has consistently been used as ACOG's last line of defense for political gain in the face of rising rates of home birth and other studies which show that home birth results in equal if not better outcomes than hospital birth and with less intervention and neonatal and maternal morbidity.
http://www.ncbi.nlm.nih.gov/pubmed/23769011
http://www.bmj.com/content/330/7505/1416
" There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system." (http://www.bmj.com/content/346/bmj.f3263)
In Hilo, obstetricians are notoriously anti-homebirth and they will never allow any patient to seek birth outside of the hospital. I can personally attest to this as I have experienced the hostility towards women and home birth first hand. After being admitted to the hospital after the birth of my second child, I was specifically denied present and future medical care by all obstetricians in the area because I had had a home birth. One would not even come to the hospital to treat me.
This is the care that you will be subjecting women to if S.B. 2569 is passed. Women have no choice of obstetrician in an area where OBs are extremely limited and who, by reason of geographical location, have no other options available to them. Hawaii is unique in the fact that the state is a series of islands and women cannot, therefore, easily travel outside of their area to seek other medical care or care providers who are willing to consider their choice to home birth.
This bill gives the false idea that it will be improving midwifery care for home birthing mothers by allowing the medical board to regulate them. The truth is that it puts women in a dangerous position. The number of midwives able to practice will be drastically reduced to fewer than five in the entire state, nowhere near enough to handle the load of over 450 (461 according to the CDC's report for the state of Hawaii in 2010: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_11.PDF ) women who choose practitioners outside of a hospital each year.
In states where midwifery is illegal, women still choose midwife care in secret and do not report their midwives as having attended their births. This fear of the law may cause harm to women and babies in cases where illegally practicing midwives fear to transport their clients to the hospital in a timely manner for fear of being found out. Parents may also be less inclined to seek medical attention in hospital when necessary because of fear of legal retaliation for having seen a midwife. Home birthing women will be forced underground and will be put in danger by being made to feel as though they must deal with higher risk situations alone because of fear of persecution if they transport.
And if the legislative body finds home birth without a midwife is more risky than home birth with a midwife (and I do not agree that it is) then it is pertinent to reason that this bill will endanger women who refuse obstetric care on any grounds by forcing them to birth at home alone and with no care provider at all. As one who is a member of several groups of women who choose to birth without an attendant, I can attest to the fact that many women who choose to give birth with no doctor or midwife are driven to do so specifically because midwives are illegal in their area. We have already seen increasing numbers of women seeking vaginal births after cesarean at home because there is a ban on VBAC at our hospital. This bill will push more women to leave obstetric care for situations which obstetricians would themselves consider to be risky (whether or not they truly are).
Mothers who choose home birth are not looking for a standard medical practice modeled on obstetric care. They desire to exercise their right to choose a care provider who will be open to the level of intervention that they choose. S.B. 2569 violates the rights of women who choose home birth because they desire less interventive care than is used in hospital and it takes away a woman's choice to birth safely where and how she likes.
The bill, if introduced, will also infringe on the rights of women who have been sexually assaulted to refuse certain care by an OB which exposes them to further emotional abuse.
Doctors are not required to (and do not) inform women of the dangers of giving birth in hospital or of the risks of any medical procedure which may be performed necessarily or unnecessarily during her pregnancy or her birth. (Hospital birth is associated with higher risk of intervention, higher risk of cesarean section, higher risk of maternal mortality and higher risk of fetal and maternal morbidity than is associated with home birth.)1 Why, then, is it logical to insist that women be forced to sign a form stating that they have been informed of the risks of home birth? This bill violates not only a woman's right to make her own medical decisions but also violates her right to informed consent as it unnecessarily places heavy bias against home birth and will, by choice of obstetrician, criminalize a woman's decision to birth out of hospital.
1. ("Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician." - Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician by Patricia A. Janssen, PhD et al. CMAJ. 2009 September; 181(6-7): 377–383. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/ )
Giving control of home birth to obstetricians is akin to giving Monsanto control and regulation of the organic food industry. It entirely defeats the purpose of home birth which is to have the choice of being independent of obstetrics except in case of emergency.
In another letter regarding S.B. 2569, it was said that the bill will "Violate women’s medical privacy by requiring home birth providers to report a woman’s 'intent to give birth at home' to the State Department of Health, potentially endangering women by exposing their private medical information to partners or family members who don’t agree with their birth choices."
Many mothers choose home birth for religious reasons. It is unconstitutional to deny women their right to choose a religious midwife for home birth for religious reasons as it goes against the first amendment which states "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof..."
The California College of Midwives states: " Women have a constitutional right to have an experienced, non-medical helper of their choice present in their home during the normal spontaneous events of physiological childbearing...Home-birth parents and home-based practitioners must persistently and consistently challenge this unconstitutional monopoly of normal maternity care. The history of a 100 Years war against midwifery is most recently evidenced in exclusive supervisory language that continues to criminalize both traditional and nurse-midwifery practice without obstetrician supervision while legally permitting physicians to withhold this statutorily-mandated participation with immunity. Domiciliary maternity care depends upon establishing the constitutional right of us as childbearing families to utilize an experienced (non-medical) helper of our choice. It may be necessary to legally establish that prosecution of non-medical midwives is an unconstitutional restraint of trade and an unfair business practice.
" Since our incorporation as a United States territory up to this present time, childbirth has been and remains to this day statutorily neutral — NO LAWS constrain the manner, the place or the persons able to provide non-medical assistance to childbearing women. The Medical Practices Act does NOT identify normal childbirth as a medical, pathological, abnormal or risky condition, no statute mandates that childbirth be attended by medically-trained persons OR that attendance at childbirth by non-medical persons is a criminal offense. [No] valid statute forbids parents from choosing an experienced helper of their choice NOR does any statute restrict non-medical birth assistance to state certified medical care providers."
It is insulting to imply that home birth mothers are ignorant and/or do not care for the welfare of their child and that no mother is capable of making healthcare decisions either for herself or her baby. In a society where hospital birth is the norm and fear of death in childbirth is universally taught, it is irrational to expect that mothers who choose to birth at home with the care provider of their choice do so out of laziness or lack of education. On the contrary, hospital birth is the norm and home birth the choice of mothers who have invested time and thought and made a decision based on a far superior level of research than a mother who simply chooses a hospital birth by default.
The decision should be left in the hands of mothers who have heavily weighed their options and act in the interest of themselves and their child as opposed to obstetricians who act in the best interest of their business
A Petition to Kill S. B. No. 2569 in Hawaii
S. B. No. 2569 which has recently been introduced and concerns regulation and licensure of home birth midwives contains dangerously incorrect information and is a health and safety hazard to mothers and babies as well as a transgression on mothers' medical, religious and constitutional rights. It is harmful to women and their families, creates a monopoly in healthcare and will eradicate the safe practice of home birth and midwifery in Hawaii.
To begin, S. B. No. 2569 specifically states "The legislature also finds that national data reports a two to three fold increased risk of neonatal mortality with planned home birth versus hospital birth." (Section 1, paragraph 2) In fact, it is well and widely known that international data supports the fact that planned home birth has similar if not better outcomes than planned hospital births.
This wildly incorrect assumption that home birth has a threefold increase in neonatal mortality is based entirely off of a single study entitled Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis (Joseph R. Wax, MD. et al) which, since its publication, has been well and widely discredited due to its incorrect data and substandard data analysis.
An article by Carl A. Michal, PhD, Patricia A. Janssen, PhD, Saraswathi Vedam, SciD, Eileen K. Hutton, PhD, Ank de Jonge, PhD entitled "Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong" and published on MedScape reads:
"The highly charged debate over the safety of home birth was inflamed by the publication of a meta-analysis by Joseph R. Wax and coworkers, which concluded that "less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate." The statistical analysis upon which this conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research." (http://www.medscape.com/viewarticle/739987)
Yet another statement issued by Gill Gyte, Trainer in Research Methodology, NCT; Mary Newburn, Head of Research and Information, NCT; Alison Macfarlane, Professor of Perinatal Health, Department of Midwifery and Child Health, City University London entitled "Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home" states:
"In summary, NCT has found that this study has serious methodological limitations, including:
•Insufficient detail about the assessment of the quality of the primary research papers identified by the authors and their specific reasons for inclusion or exclusion of each study.
- Lack of information about the included studies, and the specific data contributed by each one to the outcomes under investigation. Scrutiny of the primary research papers has led to somewhat different numbers being identified. (A ‘forest plot’ should have been included.)
•Lack of clarity and consistency about the definition of neonatal mortality in each of the included studies, including whether stillbirth data were included.
•The small size of the sub-group contributing to the calculation of comparative risk of neonatal death for planned home birth and planned hospital birth. It has been suggested that 200-400 adverse events are needed in order to be confident of avoiding a systematic error of insufficient data, but there were just 64 neonatal deaths reported by Wax for all neonatal mortality and 37 for non-analogous neonatal mortality.
- A number of the non-randomised studies included in the meta-analysis were not matched for confounding risk factors nor had adjustments been made to data afterwards, and some included women at increased risk of complications.
On the basis of these limitations, it is completely unjustifiable to claim that ‘Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate’. On the basis of the poor quality data of their data, the authors should not have reached this conclusion. Furthermore, the editors of the American Journal of Obstetrics and Gynecology should not have accepted the paper for publication without major modifications." (http://www.scribd.com/doc/34065092/Critique-of-a-meta-analysis-by-Wax)
And an article published in Birth (Volume 30, Issue 1, pages 57-63, March 2003) entitled "Home Birth versus Hospital Birth: Questioning the Quality of the Evidence on Safety also discusses the flaws with the study, saying:
"In contrast, the Midwives Association of Washington State press release stated that 'Childbearing women and health policy makers should be made aware that the study contains numerous flaws and limitations...this study alone should not be used to make decisions that could restrict women's choice of birth place or access to birth attendants with expertise in home birth'" (http://onlinelibrary.wiley.com/doi/10.1046/j.1523-536X.2003.00218.x/abstract)
Other reviews of this study include the following:
"Study validity questioned" in The American Journal of Obstetrics & Gynecology (volume 204, Issue 4, page e14, April 2011) (http://ajog.org/article/S0002-9378(10)01107-5/fulltext)
Home birth metaanalysis: does it meet AJOG's reporting requirements? (http://ajog.org/article/S0002-9378(11)00074-3/fulltext)
International data demonstrate home birth safety. (http://www.ncbi.nlm.nih.gov/pubmed/21458614)
“Home birth triples the neonatal death rate”: public communication of bad science? (http://www.ajog.org/article/S0002-9378(11)00075-5/abstract)
In truth, there is no study that can correctly claim that home birth is any greater risk than hospital birth. This study has consistently been used as ACOG's last line of defense for political gain in the face of rising rates of home birth and other studies which show that home birth results in equal if not better outcomes than hospital birth and with less intervention and neonatal and maternal morbidity.
http://www.ncbi.nlm.nih.gov/pubmed/23769011
http://www.bmj.com/content/330/7505/1416
" There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system." (http://www.bmj.com/content/346/bmj.f3263)
In Hilo, obstetricians are notoriously anti-homebirth and they will never allow any patient to seek birth outside of the hospital. I can personally attest to this as I have experienced the hostility towards women and home birth first hand. After being admitted to the hospital after the birth of my second child, I was specifically denied present and future medical care by all obstetricians in the area because I had had a home birth. One would not even come to the hospital to treat me.
This is the care that you will be subjecting women to if S.B. 2569 is passed. Women have no choice of obstetrician in an area where OBs are extremely limited and who, by reason of geographical location, have no other options available to them. Hawaii is unique in the fact that the state is a series of islands and women cannot, therefore, easily travel outside of their area to seek other medical care or care providers who are willing to consider their choice to home birth.
This bill gives the false idea that it will be improving midwifery care for home birthing mothers by allowing the medical board to regulate them. The truth is that it puts women in a dangerous position. The number of midwives able to practice will be drastically reduced to fewer than five in the entire state, nowhere near enough to handle the load of over 450 (461 according to the CDC's report for the state of Hawaii in 2010: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_11.PDF ) women who choose practitioners outside of a hospital each year.
In states where midwifery is illegal, women still choose midwife care in secret and do not report their midwives as having attended their births. This fear of the law may cause harm to women and babies in cases where illegally practicing midwives fear to transport their clients to the hospital in a timely manner for fear of being found out. Parents may also be less inclined to seek medical attention in hospital when necessary because of fear of legal retaliation for having seen a midwife. Home birthing women will be forced underground and will be put in danger by being made to feel as though they must deal with higher risk situations alone because of fear of persecution if they transport.
And if the legislative body finds home birth without a midwife is more risky than home birth with a midwife (and I do not agree that it is) then it is pertinent to reason that this bill will endanger women who refuse obstetric care on any grounds by forcing them to birth at home alone and with no care provider at all. As one who is a member of several groups of women who choose to birth without an attendant, I can attest to the fact that many women who choose to give birth with no doctor or midwife are driven to do so specifically because midwives are illegal in their area. We have already seen increasing numbers of women seeking vaginal births after cesarean at home because there is a ban on VBAC at our hospital. This bill will push more women to leave obstetric care for situations which obstetricians would themselves consider to be risky (whether or not they truly are).
Mothers who choose home birth are not looking for a standard medical practice modeled on obstetric care. They desire to exercise their right to choose a care provider who will be open to the level of intervention that they choose. S.B. 2569 violates the rights of women who choose home birth because they desire less interventive care than is used in hospital and it takes away a woman's choice to birth safely where and how she likes.
The bill, if introduced, will also infringe on the rights of women who have been sexually assaulted to refuse certain care by an OB which exposes them to further emotional abuse.
Doctors are not required to (and do not) inform women of the dangers of giving birth in hospital or of the risks of any medical procedure which may be performed necessarily or unnecessarily during her pregnancy or her birth. (Hospital birth is associated with higher risk of intervention, higher risk of cesarean section, higher risk of maternal mortality and higher risk of fetal and maternal morbidity than is associated with home birth.)1 Why, then, is it logical to insist that women be forced to sign a form stating that they have been informed of the risks of home birth? This bill violates not only a woman's right to make her own medical decisions but also violates her right to informed consent as it unnecessarily places heavy bias against home birth and will, by choice of obstetrician, criminalize a woman's decision to birth out of hospital.
1. ("Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician." - Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician by Patricia A. Janssen, PhD et al. CMAJ. 2009 September; 181(6-7): 377–383. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/ )
Giving control of home birth to obstetricians is akin to giving Monsanto control and regulation of the organic food industry. It entirely defeats the purpose of home birth which is to have the choice of being independent of obstetrics except in case of emergency.
In another letter regarding S.B. 2569, it was said that the bill will "Violate women’s medical privacy by requiring home birth providers to report a woman’s 'intent to give birth at home' to the State Department of Health, potentially endangering women by exposing their private medical information to partners or family members who don’t agree with their birth choices."
Many mothers choose home birth for religious reasons. It is unconstitutional to deny women their right to choose a religious midwife for home birth for religious reasons as it goes against the first amendment which states "Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof..."
The California College of Midwives states: " Women have a constitutional right to have an experienced, non-medical helper of their choice present in their home during the normal spontaneous events of physiological childbearing...Home-birth parents and home-based practitioners must persistently and consistently challenge this unconstitutional monopoly of normal maternity care. The history of a 100 Years war against midwifery is most recently evidenced in exclusive supervisory language that continues to criminalize both traditional and nurse-midwifery practice without obstetrician supervision while legally permitting physicians to withhold this statutorily-mandated participation with immunity. Domiciliary maternity care depends upon establishing the constitutional right of us as childbearing families to utilize an experienced (non-medical) helper of our choice. It may be necessary to legally establish that prosecution of non-medical midwives is an unconstitutional restraint of trade and an unfair business practice.
" Since our incorporation as a United States territory up to this present time, childbirth has been and remains to this day statutorily neutral — NO LAWS constrain the manner, the place or the persons able to provide non-medical assistance to childbearing women. The Medical Practices Act does NOT identify normal childbirth as a medical, pathological, abnormal or risky condition, no statute mandates that childbirth be attended by medically-trained persons OR that attendance at childbirth by non-medical persons is a criminal offense. [No] valid statute forbids parents from choosing an experienced helper of their choice NOR does any statute restrict non-medical birth assistance to state certified medical care providers."
It is insulting to imply that home birth mothers are ignorant and/or do not care for the welfare of their child and that no mother is capable of making healthcare decisions either for herself or her baby. In a society where hospital birth is the norm and fear of death in childbirth is universally taught, it is irrational to expect that mothers who choose to birth at home with the care provider of their choice do so out of laziness or lack of education. On the contrary, hospital birth is the norm and home birth the choice of mothers who have invested time and thought and made a decision based on a far superior level of research than a mother who simply chooses a hospital birth by default.
The decision should be left in the hands of mothers who have heavily weighed their options and act in the interest of themselves and their child as opposed to obstetricians who act in the best interest of their business
SB 2569 has been gutted and replaced with language calling for the organization of a task force designed to allow midwives in Hawaii to self-regulate their practice. Midwife care in Hawaii will be allowed to continue without regulation from the medical board and midwives will be permitted to set their own regulations.
Thank you to every single one of you that stood up for midwifery in Hawaii!
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