During a recent trip to the Navajo Nation, Window Rock, Arizona, to attend a birth as a certified nurse midwife, I experienced a contentious, Catch 22 situation faced by many indigenous health workers trying to provide services to marginalized communities.
The sovereign territory of the Navajo Nation overlaps New Mexico, Arizona and Utah. I knew full well that catching this baby in the wrong state--but still working within the primary boundaries of Navajo Nation--could potentially land me in jail. That’s why I went straight to my lawyer to discuss the terms of my CNM licensing on the Navajo Nation and how my insurance liability covered me or this situation, or left me legally vulnerable.
Like many reservations, the Navajo Nation has its own governing body and laws, while also adhering to U.S. government regulations. It’s this complex relationship that makes it nearly impossible to build new structures, support new businesses, or even provide basic necessities like electricity to its residents.
I hold 5 different licenses to practice Nurse-Midwifery in New Mexico. I’m regulated by the New Mexico Department of Health and the New Mexico Board of Nursing, and am certified by the American Midwifery Certification Board. I’m also CPR and NRP certified, and I have to adhere to New Mexico Board of Pharmacy standards. But even with that level of expertise, I still had to worry about going to jail while attending this birth on the Navajo Nation territory, outside the boundaries of federally-established Indian Health Services. I often wonder how many of the white colleagues I interact with at professional conventions throughout the year have ever had to face this kind of profoundly unsettling career dilemma.
Many consider the Indian Health Services to be the backbone of health care for tribally-enrolled members, but it has been falling short of that since its inception. This public health irony—or cruel joke depending upon your perspective—underscores the absurdity of organizations like the American College of Nurse Midwives, American College of Obstetrics and legislative bodies attempting to define what “safety” or “midwifery” is in Native American and Indigenous communities.
They simply do not have the knowledge, tools or insight to produce empathic, effective strategies and protocol--but that is exactly what is happening all over the United States and Hawaii where SB 1033 was signed into law on April 30, 2019, SB 1033 first asserts the mandate that regulation of midwifery as a “profession” is necessary in Hawaii, and that the term “midwife” connotates an expectation of care by consumer and the community. It defines who engages in the practice of midwifery, by standards of settler colonizers who are not beholden to the cultural infrastructure that has kept communities well for centuries.
Though the bill contains language intended to temporarily exempt birth attendants and traditional Hawaiian healers from this requirement, attempting to craft a legal definition of midwifery assumes that we all navigate in our communities the same way when we don’t. Those in the position to define terms and legislation for Indigenous midwives generally need lots of education about our communities. Many of us who travel to other locations spend the majority of our time explaining the historical context of our plight to those in positions of authority.
Over the past 100 years, and in the name of “safety,” state and government legislative bills like SB 1033 have forced Indigenous midwives to assimilate into the western medical system. This has created barriers not only for Indigenous midwives who have been practicing for years but also for the communities they serve. If you were to read reports on provider shortage areas, you would find many of our communities zoned as these. But guess who serves those communities? Traditional indigenous midwives.
Indigenous communities across the nation share many common truths when it comes surviving the impacts of colonization by settlers on their conquest to riches and ownership. Many of us-Indigenous midwives are forced to mitigate complex spaces of white privilege in pursuit of our education and our current day medical systems. Those of us who have chosen this route had the intention of bringing those skills back to our communities. What we faced after coming home was an overlay of restrictive laws, and closed or outdated healthcare systems that don’t allow us an inch of flexibility to help people the way they want to be helped, and in ways that we know will be successful. We’ve faced a high cost to work in our communities; some have even had to fashion underground workforces of traditional midwives who may or may not be working in their fullest capacities. Those of us who were called to midwifery and had community support for apprenticeships with traditional midwives are being forced to give up our sovereign rights to practice as we always have because of laws like SB 1033.
These legislative bills don’t just impact the practicing traditional Indigenous midwives in Hawaii. Though often enacted with a lot of fanfare, too often they set a negative precedent for the entire country. Indigenous midwifery is being defined and fought for by Indigenous women who are coming into their power as birth keepers. Native American midwives make up 1% of Nurse-Midwifery and 0.5% of Certified Professional midwives practicing in the United States. State to state regulations where many of our traditional territories and sovereign land overlap leave us navigating the limitations of state-mandated regulations that strip away our rights to provide midwifery care in our own territories.
When laws are put in place by those who do not understand the territories we live in and our social structures that give us the ability and trust to work as midwives in our communities, it actually creates more systematic barriers to health care in our communities.
While we look for ways to address the Native American maternal health crisis, Hawaii’s Senate Bill 1033 reminds us how the potential land mines of over-regulation, state-to-state licensing boundaries and regulations devoid of cultural context can mortally wound Native American midwives’ ability to serve their own communities.
All in the name of “safety,” defined by those who have no idea what that means for the people they’re trying to protect.