Hi Kanna,
You do seem like you're genuinely looking for answers, and I appreciate that you haven't resorted to the playground antics you mention.
I did still feel a bit odd about your post and after thinking about it, realized it was because saying you want to make homebirth safer carries with it the implication that there are flaws that need to be improved. Now, if I'm wrong, and your standpoint is more about how to continue to improve what I think is a good system, then I misunderstood and apologize. If there was a specific hole in the system, I would definitely want to fix it immediately. To me, the data hasn't shown that there is a safety issue with out-of-hospital birth.
I am curious to see the MANA data released, but as I've worked extensively with the researchers in how to ensure we are fully compliant and that our clients are 100% represented in their data set, I don't have any conspiracy theories about why it isn't out yet. Up until 6/2011, entering births in that database has been voluntary for midwives. In 6/2011, it became mandatory for all clients of licensed Oregon midwives to be entered into the database at the start of care. So, I think it will be a while before we get a full picture of what's going on.
Now, about the data already being discussed: I've heard criticism regarding using the CDC wonder data for out of hospital births, for reasons already mentioned on this thread and the one before it. Even if the numbers were 100% accurate, I don't think it gives a complete picture of midwifery care, and from the outside it's hard to understand. How can we know what the story of those infant losses were? Did the clients know ahead of time, and still choose to welcome their baby at home? Most hospitals, when confirming a fetal demise during pregnancy, will encourage the parents to go home and tale their time, and come back when they're ready to birth the baby. They may choose to continue with a homebirth plan in that case. Or, a baby with anomalies incompatible with life, known in advance by ultrasound. Or, a baby with unknown anomalies when the parents declined ultrasound in pregnancy. I just can't help but think that those are in the numbers too.
As for evidence of negligent/incompetent midwives, I don't think the anecdotal evidence of these birth stories being posted is enough. I'm not AT ALL blaming or pointing fingers at the grieving parents. I feel devastated by their losses, and the possibility of losing a baby affects EVERY DECISION I make as a midwife. But. We don't have both sides of the story. We don't have these women's charts (not that we should, I just bring that up as a way to see the other side of the story). With only the grieving, understandably heartbroken, parents' side of the story, it's difficult for me to judge whether there was negligence involved. Not to say I'm not judgmental!
But I try, when thinking of my fellow care-providers, to believe they thought they were acting in the best interest of the family, or supporting the family's wishes. (Not just midwives. I also believe that about OBs, pediatricians, etc). So, I don't believe there is enough evidence to support the idea that midwives are poorly-trained and acting negligently, and that we need to do something about it.
As a licensed midwife in my state of Oregon, we are required to peer review any birth that meets our non-absolute or absolute risk criteria. Also, absolutely anyone (even from within our board) can file an anonymous complaint about a midwife, where our board then reviews the chart involved, contacts the parents, etc. We are creating a much more extensive review process as well, where we can request a peer review of a challenging case, with detailed chart review etc. Some of us even get to attend the hospital review when a loss happens (and is transported to the hospital). So, from my perspective, there is a system of checks and balances going on.
In terms of licensed or unlicenced: I do think, especially in this climate that it makes sense to require licensure. In my opinion, many midwives who are unlicensed cannot afford the fees involved. To compare, the CNM yearly license fee is under $200 (maybe even under $100? Feel free to correct me on this) and the midwifery licensure fee is now $1800 a year. For most midwives, that is prohibitively expensive. Why? A busy midwife working in a birth center (not a great example, bc part of working in a birth center is that these fees are covered for you) makes around $4000 a month before taxes. That yearly license fee represents almost a month of take-home pay. There isn't any other license that can be compared cost-wise. So, if we did come to a place of thinking safety would be better maintained if midwives were licensed, we'd need to get somewhere on that fee.
Speaking of CNMs, you had mentioned "upgrading" the CPM to a CNM. Unfortunately, the CNM degree has it's flaws, which is why I chose not to get it. I wasn't interested in a bachelor's in nursing, and didn't find it relevant for my midwifery studies. I was much more drawn to the program I attended, a Bachelor's in midwifery, with (at least) three years of school dedicated to midwifery alone. I don't agree that you have to be a nurse first to be a midwife, and wanted to spend as much time as possible on midwifery studies.
The other thing being brought up a lot is malpractice insurance. Again, prohibitively expensive. I definitely hear what people are saying about having babies with life-long care needs. But again, I don't see this as a safety issue: our clients know completely from the first visit when they sign the hiring agreement exactly what our education is, level of experience, and that we don't carry malpractice insurance. Because I know people don't always read what they sign, I go over it verbally too. So, if the client is made aware that we don't carry it, and still makes a choice to hire that midwife, what's the problem there? Again, not seeing anything that needs changing because these are things we already do. From what I've read by the people vocally hurt and angry about their midwifery care, a lot of it seems related to lawsuits: upset that they felt they had no recourse against their midwife. Again, because we don't know both sides of the story, we don't know whether the clients knew any of that going in. I do know both sides for one of the stories circulating here, and like all stories, the two sides are very different. Knowing that information makes me have a (healthy, I think) dose of skepticism about the other stories. I know it's an unpopular position to question grieving families, so let me be absolutely clear: I'm devastated for your loss. I can't even begin to know what you've been through. I just can't judge the midwife from your stories without knowing both sides, seeing the chart, etc, things that aren't going to happen.
What I said about malpractice also brings up something else I've seen lately: a lack of belief/understanding about informed choice. There seems to be a belief that if women were given true information, they wouldn't choose what they've been choosing. That seems so insulting to those women! Not everyone is going to make the same choices, and women have a right to choose their care provider. We go to great lengths to make sure a woman has all the information at hand, and I can safely say we give a lot more time to this than hospital-based providers do. On every test/screen that comes up, we give clients a pamphlet about it with pros and cons, risks and benefits, possible outcomes. We also discuss the test and make sure they know what the hospital protocol and standard of care is. We have time for this in our hour-long appointments. If something has an especially increased risk (but is still legal!) we have the client write out themselves what we've discussed, and what the risks are. That way, we know they really get it and they're not just signing their names to a piece of paper.
Sorry for the lengthy post! In summation, I think we have to agree there's a lack of safety before trying to make it more safe. Mainly because if we don't know what is unsafe, how can we correct it?