Liz, first I want to say that your midwife was completely incompetent and there is no excuse for the substandard care you received! I am terribly sorry for your loss.
The situation in the US is very complex. Because only 1% or so of mothers will choose home birth, we are at a significant disadvantage to impact the overall mindset that the average citizen, much less the medical community has about home birth and midwifery care. I don't believe more regulation is needed. I do believe regulation comes with a price, which will lead to fewer options in the future, and a good probability of the eventual death of home birth if we keep ramping up outside regulation.
I believe the best way to improve midwifery care and home birth safety is in creating very educated home birth consumers. When consumers know what to look for in a quality midwife, and know enough to take equal responsibility for their birth with confidence, safety can only improve. Now, I am not blaming parents who have experienced poor outcomes for not being "educated enough." Hardly! I believe that home birth and midwifery care are not about trusting a midwife to manage the birth for you under her expertise, but about a shared responsibility with the parents, using the midwife's educated opinion as a guide, but also heeding parents' intuition and knowledge. Referring back to Liz's birth, I believe her midwife ignored her feelings about transfer, until the tragedy was too late to be averted. She (Liz) knew, but didn't have the power in the moment to act on that knowledge.
I have had two of my home births with what I, and the local community, consider under-educated midwives, though we came through both relatively unscathed. I know for sure one has retired, and I believe (and hope!) the other is no longer practicing, though she does still have a web page up. I learned a lot of things from these women. One places primary importance on home birth, rather than on the health of mother and baby. She fears hospitals and medical care. Strangely, this devolves into her practicing as a "med-wife" herself, using medical equipment to treat factors that should have been transferred for proper medical care, which places her clients at even more risk. As far as I know, she hasn't had a death, but I do know she has had preemies transferred days later than they should have been in real distress. She calls herself a hands-off midwife, but if you get into a lengthy discussion with her, you will pick up on her anti-hospital, anti-standard-of-care perspective, and I think these should be real red flags. She also did not complete her apprenticeship, but would probably lie if you asked her outright. I didn't find out until I was in early labor, when we'd developed a rapport and we're chatting between contractions. She also has a terrible-to-nonexistant relationship with other midwives in the state.
The other midwife is a lot more subtle. She was a byproduct of the sixties/seventies re-emergence of home birth. She learned to be a midwife while midwifing friends, a la Ina May. Her mantra is that every woman is a midwife. I consider that another red flag, because it is denying the value of education, relying more on intuition and learning by doing. As a movement, we've come beyond this, and it is no longer necessary to wait until you've seen a complication to learn what it takes to manage it. This midwife, like Liz's, denied me transfer for hours when I knew that my baby was not descending at all while pushing. I begged three separate times, over 5-6 hours of pushing at home, to transfer before I finally put my foot down and demanded my husband take me in. Thankfully, there was nothing life-threatening, just my cervix was caught between my pubic bone and little boy's ginormous head. But, I experienced the stigma of the transfer. In other's opinions, I transferred for "pain meds", which is not completely accurate to the situation.
Significant factors both these midwives have in common is that they both would attend a majority of births alone, or only with a student. There was a rather underground or rebellious feeling to their practices, even thought it wasn't necessary in this particular community. There was no collaboration with anyone in the mainstream medical community, and they did not participate in the state midwifery community, or were only peripherally involved.
As part of educating perspective home birth consumers, I believe recognizing and communicating the above red flags would be a key factor in deciding to hire a particular midwife. Other things to look for may be a midwife who requires more from her clients, such as diet logs, required reading, worksheets, or other methods of educating her clients so that they can fully participate with the decision making in their own care. It's not enough for a midwife to give a brief, oral "informed consent" and expect parents to be able to make a considered decision on the spot.
Since using these two midwives, I have found a practice that I think exemplifies a quality, safe midwifery/home birth practice. When we originally met, the midwife would always bring an assistant, preferably another midwife. She had open channels of collaboration with other care providers in her home community, and in most of the various communities she served. She actively sought out relationships with mainstream providers so that her clients could get respectful care, no matter what their needs ended up being. She truly put the health and wellness of her clients above her own comfort in making these strides. I was involved in a number of births with her in which we transferred clients during labor. These varied from simple pain med transfers, to true medical need, though long before they became emergencies. Medical transfers were not hemmed and hawed over, but once the condition was recognized, the decision was made and we packed and left. Transfers were most often made to providers we had a relationship with, but even those we didn't were met with respect, as we entered professionally and provided accurate, professional records of care. Some transfers even resulted in a new care provider relationship to benefit future clients. Clients were never stigmatized for a transfer! Now, she has a full partner midwife. They collaborate care and share births, participate in regular internal chart reviews, and are active in the state midwifery organization and peer-review system. None of this required regulation. This midwife began her practice before regulation in our state, and was one of the first to be licensed by the state when regulation came about. But there was no significant change in the way her practice was run, other than altering a few forms to match the state requirements. Wisdom can't be imposed on someone externally. It is a quality they already possess and use, or they don't.
I am currently expecting twins, so I have been experiencing first hand the collaborative arrangement with one of the area OBs. All notes have been shared (or will be) between care givers. I maintained my prenatals with the midwives, and consented to U/S scans to document the growth and positions of the babies. We originally thought we would have to do a hospital birth, but as things have progressed in such an ideal manner, we are prepared to give birth at home. One stipulation for this home birth has been that I create a document covering my research and decisions regarding the care of this pregnancy and birth. After turning in my first two-page draft, I was asked to add a number of other factors. I recognize and appreciate that I'm being held to a high-degree of responsibility as a parent, and that the midwives know that they are not the only responsible parties. I'm asking a lot of them, to rather venture out of their comfort zone (I'll be the first out-of-hospital twin birth for this practice, though not the first twin pregnancy/birth the one midwife has managed).
I think this paints a very realistic picture of what a healthy, safe midwifery practice should look like. As consumers, we have the ability to hold our care-givers to this standard, by choosing not to use midwives which fall short. We need to be vocal within any group we are involved where we might meet other home birth mothers that there are qualities which show truly superior care, and that we shouldn't settle for less. Not that there won't be some women who prefer other, but they should make that decision after informing themselves not just because they don't know the options.