Legal issues aside, women are best served when midwifery is legal and flexible, and when hospitals maintain good relationships with the midwives in the community. Birth is safest when women have the freedom to choose the birth that fits them best, and when the barriers to transport are minimal.
My experience casts this in sharp relief. My last pregnancy, I was technically high risk, but could not stomach the thought of planning a hospital birth. My home is about 4 minutes from the hospital, and the hospital has a program for homebirth transport, specifically intended to facilitate transports so that women are not emotionally or physically traumatized by them, and so that midwives do not hesitate to transport if there is a problem.
So I hired a licensed CPM, totally legal in my state, and we consulted with a perinatologist who thought I was nuts for wanting a homebirth but respected my right to be a nutbar, and did exactly what we asked, no more. So I spent my pregnancy on lovenox, got my amnio (I have a child with a chromosome disorder, and could not deal with going through it again), and my laid-back midwife let me pretty much call the shots as far as what we did as far as prenatal care went. So when the doc muttered about big baby, we just looked at each other and smiled and paid him no mind (and rightfully so, babe was 60th percentile at birth for his gestational age!) He was able to fret all he wanted to about me being fat and old, and we just carried on with what we knew.
I grew a healthy baby, a stubborn baby, who liked his head just so.... which happened to be high and asynclitic, so high that despite having loads of contractions with his sisters for months, I barely had prodromal labor with him at all, even castor oil, eventually, produced very little response.
The pregnancy was brutally painfully difficult phsyically, and by 40 weeks 5 days my body was not tolerating it well, I was losing the ability to sleep, which was causing my blood pressure to go up, and when a fibro flare started after we'd tried to get labor going again, I decided at 41 weeks to transport for pitocin. I'm almost 40, my stamina for labor was fading rapidly, and I was hitting a point with pain from the fibro that was going to limit my ability to have the active birth I wanted at home.
I cried, spent a while writing a birth plan, emailed it to my midwife, she emailed it to the stork doc on call... and the doc said, "It looks good to me."
We went in.
The staff were respectful. They let me call the shots in every way that counted. We worked together as a team. They did not do a single vaginal exam that I did not request. When I told them, after 7 hours with no progress, to turn off the pit and let me talk to my family, they did it without question. When baby's heart rate was rock steady throughout, they switched to intermittent monitoring because it was so hard to keep him on the monitor, as he was active. When we decided to turn the pit back on and use Spinning Babies and traditional Mexican rebozo techniques to turn the badly asynclitic head (ear presenting!) they watched with interest and helped as requested.
After 15 hours, with slow, slow progress, when I realized that I couldn't stop fighting the contractions, I had to insist on an epidural, they did not want to give it to me. And when it became apparent that yes, in fact, the baby was going to be born vaginally, the doctor stepped back, my midwife supported my perineum, and my husband caught the baby. They didn't mess with the cord, they didn't even mind when I said, "He's crying, and pink, please let him be for now" when they said it was the time they usually did vitals. I stood to deliver my placenta, much to their shock, and we left less than 8 hours after the birth. It was hard, and brutally difficult, and really scary at one point... but it did not damage me the way the planned hospital birth of my first child did.
This birth could NOT have happened in an illegal state, or with an adversarial hospital team. I would have been planning a UC, probably in secret from the perinatologist. It pretty much had to happen exactly as it did, given the cards we were dealt.
When I told the perinatologist who my midwife was, he said, "Oh, she's great, I like her."
When we went in, the nurses treated her as an equal, she took heart tones more than once with their blessing and mine, did far more than a doula could (and I've been a doula, so I know).
I've had a homebirth, and two hospital births, and that first hospital birth nearly broke me, then turned me into a birth warrior. The homebirth was surprisingly difficult. And this birth? This birth showed me that it's possible to walk the path of the frosted mini wheat, as my husband puts it. Pitocin and epidural? They were awful. Horrible. Would never recommend them if someone didn't have a medical need to birth now. But the things that were most important? My husband caught our son. No one messed with his cord. No one messed with him. They never even put the band on his ankle, he was just never out of our sight. We didn't have to fight for ANYTHING except leaving early, and that was merely a discussion, not a battle. We didn't even leave AMA, they signed us out officially. They sent me home with APNO for heaven's sake. The multiple lactation consultants on staff are actual IBCLCs. Decent, respectful hospital care CAN happen, and legal midwifery only helps that.
Had I followed the perinatologist's advice, they would have induced me at 39 weeks. The midwife bought me 2 full weeks for my cervix to ripen. She saved me from a c-section. She helped smooth our postpartum magnificently. We'd have rather had the birth at home, but when castor oil doesn't even give you the runs, and hours of cervical manipulation (at my request) fail to trigger more than a couple contractions, and it is clear that there's something holding things up, well, I'm just glad the transport went as smoothly as it did.
My son still likes to cock his head to the right (and we've done plenty of CST about it). He's very persistent about it. We probably corrected his head 20 times in the last month of pregnancy, it just never stayed long enough to drop until I had contractions happening, and they weren't happening until his head was lower... a catch 22 we couldn't fix without pitocin (we tried so many things).
My second child, born at home, would have been much worse off in a hospital, due to her chromosome issues. At home we had the flexibility to kangaroo 24/7, get her slowly up to speed on weight gain, sort out breastfeeding with the help of a pediatrician. In the hospital, she would have been a mandatory NICU admission. I followed my instincts and she's done as well as anyone could possibly expect a child with her syndrome to do. And she was also helped by a legal midwife.
I just wish states and hospitals would quit their "Homebirth is unsafe" crusade and work on making birth as safe as possible no matter how women choose to deliver.