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The Honolulu Advertiser
Posted on: Sunday, August 10, 2003

Moloka'i midwives are almost like your 'ohana

By Joan Kenly Stebbins
Special to The Advertiser

It is difficult to go far on Moloka'i without encountering someone who knows of the island's two midwives. The two women have become important to many families because they staff the only childbirth clinic on the island.

It happened to this writer as soon as I got off the plane at the Moloka'i Airport.

Several young people were jostling and laughing, about to board a plane, as a man made grand hand motions through the window inside the airport.

The man was Pastor William Umi from the Moloka'i Calvary Door of Faith Church. I told him I was writing an article about the midwives of Moloka'i, and he said, "Wait, wait, you have to meet my wife!"

Ester Torres-Umi appeared from across the small lobby, carrying one child in her arms, another in tow. Pregnant with her 12th child, she was one of the midwives' star patients. All but the first of her children had been delivered on Moloka'i by the midwives.

A gentle woman, Ester Torres-Umi has lived on Moloka'i all her life. She comes from a large family. (The pastor was an only child.) They had come to the airport to see off their oldest son, who was visiting O'ahu and Kaua'i with his church group.

How does Torres-Umi care for so many keiki? She smiled and said, "They all help with each other."

Torres-Umi likes giving birth under the care of midwives because "they know me, and I know my own body." She is most comfortable giving birth on her knees.

Though the midwives can administer drugs, they rarely do. Most Moloka'i mothers say they would rather handle the pain than endanger the baby. With a midwife by their side, helping them work with the contractions, pain can be controlled, they say. It's their own birth culture.

It's a birth culture that developed out of necessity because Moloka'i has no obstetricians or gynecologists in residence.

In 1985, family-practice doctors on Moloka'i stopped providing prenatal care and delivering babies after their malpractice insurance premiums increased from $8,000 to $80,000 a year.

Enter the midwives of Moloka'i.

Soon after the doctors ceased obstetric care, the Moloka'i General Hospital Board of Trustees hired a certified nurse midwife to serve expectant mothers. Though the idea of giving a registered nurse (even one with an advanced degree and two years of special training) responsibility for the care of pregnant women was generally accepted on the Mainland, it was a new concept to Hawai'i.

Midwives are able to administer drugs and perform an episiotomy. They are not involved with any high-risk surgery, except as assistants to doctors. Malpractice insurance does not cost what it would for a doctor's practice, because midwives do not handle high-risk deliveries.

With a population of slightly more than 7,000, Moloka'i now has two certified nurse midwives. The two women, both low-key and modest, run the Women's Health Center on Moloka'i.

After nearly 18 years, the midwife program on Moloka'i has delivered nearly 1,000 babies, with a 100 percent success rate, with no deaths in any of the cases, for both mother and child. Janice Kalanihuia, director of Moloka'i General Hospital, attributes the success rate to careful attention to safe practices and parent education.

Although on Moloka'i their insurance is paid by the hospital, the midwives believe that the more personal relationships they form with expectant mothers (and families) make lawsuits less likely.

JoAnn Johansen, a certified nurse midwife, earned a master's degree in nursing from Yale and a master's in public health from Columbia University.

Brigid Mulloy, also a certified nurse midwife, knew growing up that she wanted to do that work. She enrolled in the nursing program at the University of Wyoming specifically to attend the Frontier School of Midwifery and Family Nursing.

Both women have passed their national exams and have hospital privileges.

Just outside of Kaunakakai, the Women's Health Center clinic is on the grounds of Moloka'i General Hospital. It is affiliated with The Queen's Medical Center on O'ahu, though since Moloka'i's facilities are small and modest, the two properties bear little resemblance.

New babies are delivered in birthing rooms within the hospital. But the clinic, in a tiny building, is the place where expectant mothers, teenagers taking birth control or any woman seeking health advice can go for help. (There is a back entrance to help assure privacy.)

The midwifery program is designed to meet the needs of an economically disadvantaged, isolated community. Both the Joint Commission on the Accreditation of Health Organizations and the state Department of Health accredit Moloka'i General Hospital, including its midwife program.

Women's Health Center financing comes from Quest (a state insurance program), a Maui County Community Partnership Grant, and state and federal sources.

Part of the protocol the midwives are required to follow is to make a list of cases that must be checked by an obstetrician/gynecologist.

Dr. Eesha Bhattacharyya is that ob-gyn. Educated at Loma Linda University in California, he lives on O'ahu, practices at Castle Professional Center, and flies to Moloka'i twice a month. He is the program's primary backup and gives medical guidance on cases that are, or may become, high risk.

Sometimes Bhattacharyya recommends that a high-risk patient spend the last several weeks of her pregnancy on O'ahu (an expensive proposition for most families). For those rare cases when complications develop unexpectedly, an air ambulance is available to take patients on a 30-minute ride to Honolulu.

Bhattacharyya notes that midwives assist with most births throughout the world. A midwife works with the doctor on O'ahu, and several of O'ahu's hospitals have midwives on staff.

The midwives of Moloka'i work on salary, as opposed to most nurses, who receive hourly wages. Between the two, a midwife is available 24 hours a day, seven days a week.

Expectant mothers come to the health center every three weeks during the first trimester, every two weeks during the second trimester and once a week the last month of pregnancy.

Johansen is on call 24 hours a day for two weeks, and then Mulloy takes the next two weeks. A woman is seen by the same midwife throughout her pregnancy.

Hawaiians and other Pacific islanders make up 68 percent of the population on Moloka'i. 'Ohana plays a strong part in their lifestyle.

By delivery time, the midwife and the expectant mother know each other well, and know that they can depend on one another to accomplish the task. Once labor starts, the midwife is with the mother until the baby arrives.

At Moloka'i General Hospital, labor and delivery take place in one room, in a single bed covered with a Hawaiian quilt; lighting is soft.

During labor, it is not uncommon to see the entire extended family lined up in the hallway outside the delivery room — rice cooker and all. The expectant woman's husband, mother, sisters and children are allowed to surround her during her labor.

"The program is moving into the second generation," said Mulloy. "We are starting to see women that as infants we helped into the world (now) at our doorstep as expectant mothers. The Moloka'i birthing culture has come full circle. That is very gratifying."