I had DD at home at an NHS-attended HB in 2006 and i'm now at 40+1 with #2, whom we plan to have at home with an independent midwife. Things are a little different in the UK because there is a standardised training requirement and a regulatory body which ALL midwives must have and answer to, whether they are independent or NHS.
Some of the differences i noticed just between NHS and IM models (in the NHS model a team of 4-7 community midwives did my appointments under the back-up of a named obstetrician, in the hopes that one or more of those midwives would be able to attend my birth, so i wouldn't be with a total stranger, which was something i wanted to avoid, with the IM model i have one midwife who cares for me and attends me in labour, and she has a back-up who i have met who will attend me in labour too, the back-up MW is included in the fee):
1. at my booking appointment with DD, in a busy hospital, after being seen by a nurse a radiographer and a midwife and being in 4 different waiting rooms for a total of 3 hours, when measured with a machine which brings back vivid memories of all the times, when i was a teen, when i watched my mother having heart attacks, die and be resuscitated, my BP was 153/85 - i have whitecoat hypertension even when checked with a sphig, and the machine only makes it worse, and told them this. The midwife informed me that whitecoat hypertension "doesn't exist" and sphigs "are banned due to the mercury in them".
At my booking with my IM after an hour in my own home drinking tea and getting to know my midwife (who had already offered invaluable and FREE advice over email while i went through 2 miscarriages) a little better, my MW informed me that she only uses the sphig and doesn't like the machines much. Her sphig doesn't contain mercury. My BP was 122/70.
2. During my pg with DD i developed hypothyroidism. I had a large goiter, my already "high" BP went up, i had swelling in my face and hands, i had painful joints. I saw 9 midwives, 2 Obs and 3 registrars. None of them diagnosed me. I was checked for PE 6 times (i never spilled protein, my bloods were always normal), but never for anything else.
About a month ago at an appointment with my IM (which have all been in my own home and never less than 50mins - usually they are 2 hours or more, but that time she had a woman in labour to get to) she noticed i seemed twitchy and that my BP and the babe's heartrate were a little higher than normal. Within 2 days she'd helped me figure out my thyroxine was too high and i'd had my dose reduced which maintained my health, rather than curing something after the event.
3. From 39+6 with DD my BP was so high at appointments (every time they took it, with the machine, they gave me a sage warning that i'd have to go to hospital, i'd need a csection, and my baby might die IF i didn't "make it go down") that i had to go to hospital for monitoring 3x a week. I am very scared of hospital - that's why i birth at home. The obstetrician's response to this was to say "but labour wards aren't for ill people" - unfortunately that one blase statement doesn't wipe away my vivid memories of seeing my mother in various stages of illness and recovery (she had 2 terminal illnesses, a heart complaint and then cancer, and died, thankfully in a hospice, when i was 24) or the physical response i have to them when i see, hear and smell a hospital. Would i go there to save my life or my baby's? Yes. Would i go there and expect to dilate and birth normally? Um, not in a million years! It is fine if you are the sort of person who can birth without oxytocin, whose emotional state is completely detatched from their physical (though i think you'd bleed to death at the dentist if that was really true) but for most women emotions DO play an important part in how birth goes. During that time (i had DD at 41+4) i had 5 VE's, 4 membrane sweeps, one of which was very painful, a GTT i didn't consent to (in fact i declined it right before they did it anyway!) and lots and lots of blood tests for PE. Not to mention having my BP taken, with the dreaded machine, at least 4 times in every visit, sometimes as much as 7 times. I was rigid with fear each time. It was awful enough that i considered stopping at one child so i wouldn't have to go through it again.
At this stage with my IM i've had no VE's, my BP is a little higher than at booking, but still well within normal, she has carefully monitored my mood and general demeanour, which with hypothyroidism is actually a very good indicator of wellbeing. She wrote in my notes we will discuss a sweep if i make it to 41 weeks but has openly said she doesn't do them usually (though will if asked and it seems safe).
4. During DD's birth the midwife arrived to find me moaning and groaning through contractions and feeling like i needed to push. A VE found me not in what they call active labour (i was 50% effaced and 2-3cm dilated) and the midwife said i should "think about pain relief options" because "what we can do at home is very limited". She left. DD rotated and descended in one contraction. I spent 2 hours gritting my teeth and trying not to push. After 2 hours she returned with her back-up, gave me the gas and air and told me to "try to calm down". I continued for an hour to fight desperately not to push, then DD's head crowned. The midwife was thoroughly shocked, we'd never met before, she assumed i was a noisy wimp, rather than a woman in transition whose cervix hadn't read the textbook.
Obviously i haven't had this baby yet, i don't know what my birth will hold for us all. But i do know with complete confidence that if i am noisy my midwife will know it's because i'm feeling something - she KNOWS i'm not a complainer, she knows HOW to respond to me, because she knows ME. Under my skin? Well, she's not a burrowing parasite! I don't see how she could do her job properly without knowing me well. If i wanted an impersonal medical back-up i'd UC and call an ambulance when i was pushing. That is not nearly as safe, even for low-risk women, as homebirth with an experienced midwife with whom they have a pre-existing relationship, but if i wanted it that's how i'd get it.
I think expecting a midwife to be able to show up and "catch" the baby without any personal prior knowledge is very unrealistic. Sorry, but there it is. If you die, it's on her shoulders, if your baby dies, likewise. In the UK no-one will insure IM's so if we decided to sue her it would be her actual family that was destroyed. Every time an IM takes on a client she takes on substantial personal risk, both in terms of her own self (pretty sure no-one wants to be responsible for a death) and financially. There are IM's here who have been sued for injuring babies at a dystocia birth where the baby could have actually died even in hospital - because there was no Ob there to say "well we did all we could" she was under substantial suspicion. If the same baby had had the same outcome in hospital there would have been a lot of back-slapping and "well done for saving the baby" for the Ob and a "sorry, these things happen" for the family. For every midwife that takes on a woman the risk of that pregnancy and birth is being shared. And she deserves to be remunerated for that doesn't she? You get the baby for taking your risk - what does she get? Do we pay the police only if the other guy ACTUALLY has a gun? Or the paramedic only if the old guy really WAS having a heart attack after all? No, we pay them for the risks they take and the responsibilities they carry for protecting and caring for the rest of us.
To be honest if i wanted someone who could show up, catch my baby in such a way that was a) what i wanted and b) perfectly safe, i wouldn't be looking for a midwife, i'd need a psychic.