Sarah Bauer remembers several things clearly about the hot summer Sunday when her son was born at home during the COVID-19 pandemic.

How freeing it was to walk through the pain of labor in her house and yard as the sun went down. How when contractions pressed on past midnight, her husband, midwife and doula were there to assist.

It was much different than the experience she believes she would have had at a hospital, where few visitors were allowed and walking the halls would be out of the question.

Bauer and her husband had weighed both options for the birth — hospital or house — but ultimately the pandemic crystallized their thinking.

“When people ask me about it, I definitely can say it’s not for everyone. I try not to romanticize it when I talk to people,” she said. “But being in the comfort of my own home helped me have the birth I wanted to have, as hard as it was.”

Very few births occur at home in the islands — they typically account for fewer than 2% of all Hawaii births every year. But as the COVID-19 pandemic upends parents’ plans, some say they are swapping a hospital experience and its medical resources for a birth at home because of anxieties about visitor restrictions and possible exposure.

Local midwives say they are fielding a record number of inquiries.

Meanwhile, doctors are moving most of their appointments from in-person to online, but worry mothers may be missing out on prenatal care or face serious consequences if they attempt a birth at home without proper assistance.

Weighing Birth Options During A Pandemic

Holly Hoffman, who welcomed a baby boy at her Waimea home in December, shared Bauer’s apprehension about giving birth in a hospital during the pandemic.

“At the end of the day, you’re going to interact with a lot of different people and nurses,” she said. “Once we decided to have the home birth, it took a lot of that stress off.”

Hoffman’s first two daughters were born at a hospital, and initially she had planned the same for her son. But she had envisioned her family would be there, and this time around they’d be barred from the hospital room.

“I really wanted them to see their mom giving birth, and that it’s something happy their body can do, and not this intimidating painful thing,” she said. “Having it in the comfort of our own home meant they could be there.”

The increase in interest has been a boon for midwives like Nina Millar, a registered nurse and certified professional midwife who has attended births for nearly four decades on Hawaii island. The number of births she attends doubled during the pandemic, she said. She attends as many as seven births per month now.

“What I’m finding is people are choosing home birth because they’re feeling conflicted about going into the hospital settings where they could be exposed to people with COVID,” she said.

A survey conducted by the Hawaii Commission on the Status of Women in September documented several grievances from women who had hospital births last year, during the pandemic.

A handful said they faced labor alone until they met criteria for official hospital admittance. Most were permitted only one person in the delivery room, and could not switch that support person.

Some said they felt suffocated wearing a mask during delivery, and others believed they were rushed out of the hospital and discharged without sufficient time for recovery.

Tanya Smith-Johnson, who co-authored the report, works as a certified professional midwife and serves as policy director at the Healthy Mothers Healthy Babies Coalition of Hawaii, a local advocacy organization.

“They’re hearing the stories of people getting induced early or rushed out of the hospital and they just don’t want that for themselves, especially people of color, because they’re already dealing with so much in this kind of birthing space,” she said, referring to the racial and ethnic disparities documented in mothers’ illness, mortality and infant health.

As a result, midwives like Millar and Smith-Johnson say they have become so busy they sometimes turn clients away.

“People are in their third trimester and changing their minds about not wanting to give birth in the hospital,” said Smith-Johnson. “Midwives are stretching themselves because they’re trying to accommodate.”

A Baby Bust?

It’s still too early to tell how the pandemic has affected the number of babies born in the islands, but nationally, economists predict there will be a record decline in births. If there have been any significant changes to birth numbers in Hawaii, state data has not yet captured them, local experts say. Babies conceived after the lockdowns began are just now being born.

“I believe it is too early to tell,” said David Fouse, a research and analysis supervisor at the Hawaii Department of Health’s Office of Health Status Monitoring. He said more data has yet to trickle in as doctors complete paperwork from last year. “The data for 2020 should still be considered preliminary,” Fouse said.

Every year for the past four years, about 200 to 300 babies were born at home, according to records from the Department of Health’s Office of Vital Statistics. The majority of the rest are born in hospitals. Some births happen at home, but they’re not planned. In other cases, place of birth is not listed.

Overall, Fouse and doctors like Dr. Men-Jean Lee say one thing seems certain: fewer babies are being born in the islands each year. Perhaps it is a reflection of the Hawaii exodus as more families move away, or maybe the pandemic is discouraging people from having babies. It’s hard to tell for sure, said Lee, an OB-GYN and maternal and fetal medicine specialist at Kapiolani Medical Center who oversees the maternal and fetal medicine division.

To Lee, the pandemic’s effects are most palpable in how prenatal and postnatal care has shifted. Some mothers are eager to come in for prenatal check-ups in person, while others avoid the hospital entirely.

If there has been an increase in home births, they may not be reflected in the data. Home births have historically been difficult to track, according to Lee, since some parents may not file a notification of birth to report it, as required by law. In rarer circumstances, families may not even file a birth certificate and children may not have complete paperwork until they enter school.

“Those numbers from DOH may not be 100% captured,” she said. “This has been a social dilemma in the state.”

Then there may be cases of unregulated birth attendants who do not file paperwork or report births that had issues or complications, Lee said.

Hawaii midwives are trying to reach patients fearful of the hospital by meeting them where they live, via the Midwifery Integration Home Visitation Program, or MI-Home.

Lee recalled one patient who lived on a neighbor island who wanted to deliver her baby on her own due to pandemic fears. Ultimately, the baby had to be flown to the hospital’s intensive care unit and experienced severe brain damage. Lee recalled another patient who planned to have just a doula attend the birth, although doulas are not medically certified to deliver babies.

“It’s really sad that some people are feeling pressured to do something like that,” she said.

National studies show babies born at home face higher chances of not getting enough oxygen, having seizures or experiencing brain damage. On the other hand, planned home births in the U.S. result in fewer C-sections. A 2014 study found only 11% of 17,000 mothers who labored at home were transferred to the hospital, according to the Midwives Alliance of North America. The greatest appeal of a home birth for many mothers is the ability to go through labor at one’s own pace without medical intervention in a comfortable setting.

Barriers To Home Birth

Demand and interest in home births may be growing, but there are several roadblocks.

There are few midwives in Hawaii to begin with because of few local training options. It wasn’t until 2019 that certified professional midwives became licensed by the state.

Just 14 certified professional midwives have applied for and received their licenses so far, according to Le‘a Minton, the board president of Midwives Alliance Hawaii who is a licensed certified nurse midwife and works for the University of Hawaii’s Midwifery Integration Home Visitation Program. Others may still be practicing without a license. The new licensure law includes a grace period that lasts through 2023.

Then there are monetary roadblocks. According to Minton, most families pay out of pocket.

Currently only two certified nurse midwives on Kauai and one on the Big Island are able to accept Med-QUEST, the insurance program for low income families, after completing the credentialing it requires.

To get a midwifery license, malpractice or professional liability insurance is not required, so many midwives choose to go without it for various reasons including cost savings, according to Minton. Otherwise, medical professionals in general must carry that sort of insurance in order to work in a hospital or medical facility.

Hawaii home birth services are more affordable than in other states, running between $2,500 to $4,000, compared to $8,000 to $12,000 elsewhere.

It’s still costly, particularly during times of economic struggle.

Making the decision to pay out of pocket is “huge,” Smith-Johnson said, especially “in this moment when people are struggling to pay for food and rent.”

Smith-Johnson senses a turning point for the industry. The recent professional recognition and regulation that come with the new state licensing system could encourage more mothers to consider it. The pandemic may encourage more people to enter the profession.

She says traveling midwives can play a role in caring for rural or minority communities, including the Black, Latino, Native Hawaiian and Pacific Islander communities. Nationally, Black mothers have among the worst birth outcomes and face the highest pregnancy-related maternal mortality rates in the nation, data show.

“Hawaii is just a little microcosm of what happens from a larger perspective,” Smith-Johnson said. “When you really dig deep and look at things, we have birth disparities here, we have racism, colorism and anti-blackness here too, and that has an effect.”

Hawaii could take several steps to add more options for parents, she said.

Hawaii needs a local midwifery school. And midwives could collaborate to start a birthing center. Such centers are popular in other states because they provide hospital perks in a more comfortable environment.

“In my opinion, that would be beautiful for Hawaii,” she said. A school could “really pull people from the community to serve their community.”