After her husband was sent off to Iraq, leaving her with a 2-year-old daughter and an infant, Camia donn Pfingsten would pull out tapes of her son's childbirth to remind herself that she could overcome the separation.

"If I could get through the birthing process, I knew I had the power to do anything," she said.

This wasn't just any birthing process. Two years before, her daughter had been born via Caesarean section. Pfingsten was insistent that the next one would be without any intervention, including anesthesia.

Pfingsten falls directly in the path of one trend, the growing number of C-sections. But she bucks another. She's among women who are, at a slowing rate, choosing a vaginal birth after Caesarean, or VBAC.

Nearly three years ago, while living in Germany, Pfingsten was hoping to deliver underwater using natural childbirth methods. But before Emelie donn made her entrance into the world, she turned "stargazer," as Pfingsten's obstetrician put it, her head turning upward. Between that twist and the epidural's slowing effect on labor, Pfingsten's planned natural childbirth segued into major surgery.

"Overall, the C-section was a good experience ... but for me, it wasn't what I wanted," Pfingsten said.

Ebbing away some of the joy of childbirth were the facts that she wasn't able to hold her baby right away. Her recovery was also long and arduous.

Though she'd read everything she could find on childbirth, Pfingsten wasn't prepared, either: "The only thing my husband and I didn't read in the books about was C-sections."

Two years later, the birth of son Michael the old-fashioned way, via birth canal, at Tripler was a complete contrast: no medication of any kind, using a midwife, though of course there were doctors on standby.

Afterward, "I felt like I was the queen of the world," Pfingsten said.

Yes, it's up to the mother to request a VBAC, but as Katie Barbieto, the nurse who heads the labor and delivery unit at The Queen's Medical Center knows, there's more to it than that.

"I think that VBACs are physician-driven," said Barbieto. "It is the mom who makes that decision to have (a trial of labor after C-section) but ultimately the physician either supports or discourages it."

Here, nurses support — and childbirth educators encourage — VBACs, Barbieto and others said, but the numbers of would-be mothers taking childbirth classes is down.

That may have something to do with the rise in medicated births, adds Pat Goding, a nurse and now a doula and childbirth educator.

"Overall, people's concern is a healthy mom and healthy baby," said Dr. Eesha Bhattacharyya, a local obstetrician.

Bhattacharyya said he gives information and tries to follow his patient's wishes — including using midwives, not requiring constant baby monitoring ... and attempting VBACs, when possible.

"Early on, (the common belief was) once a C-section, always a C-section, because all were done vertical incision on the uterus," he said. Now, however, more obstetricians are using a horizontal incision in a different spot, meaning less likelihood of a uterine rupture, he said. Ruptures can be catastrophic.

"I heard in the Mainland that insurance companies actually were requiring you to do a trial of labor (after C-sections), because it's cheaper," said Bhattacharyya, noting after that, "the complication rate started to rise."

It's not as if all C-section mothers should attempt VBACs, the doctor said, but added: "For my practice, if somebody wants a VBAC, meets the criteria and doesn't have high-risk factors, that's the appropriate choice."

Still, Bhattacharyya isn't surprised by the lower VBAC rates.

"When you look at all the factors and history of what's happened, it'd be what you expect," he said.

Many issues contribute to a high C-section rate, Bhattacharyya said, including medical guidelines and legal pressures. Doctors see the risks and ask themselves, "Why am I continuing to push for vaginal?"

"I can understand that idea," he said. "I don't think doctors in our community do it for convenience, (but) people have different tolerance levels."

They may have had to cope with a complication leading to what he calls "a bad outcome," which is code for losing a mom or a baby.

The rate of morbidity of VBAC complications — like a rupture of the uterus at the previous C-section scar — is around 1 percent, but even that is too high to risk either mom or baby, he said.

Ruptures cause emergency C-sections, with just minutes to get the baby out: "You see a few of those, you're less likely to be enthusiastic."

So even though early on the medical community embraced VBACs, Bhattacharyya believes "we're in an appropriate place," though ... "in Hawai'i, people are not as enthusiastic as they were."

Queen's nurse Barbieto agreed: "We see very few (trials of labor after Caesarean) anymore. It's way too bad. A couple of incidents have swayed the community to not want to try."

But Goding, who heads up the Hawai'i Childbirth Educators Association, said there are excellent reasons to attempt a VBAC, if a mom has the opportunity.

Recovery from a VBAC is easier than a second C-section. Plus, there are emotional reasons.

After a C-section, a mom might think, "I failed." A VBAC is success for doing what women have been doing since the beginning of time.

"It's that element of trusting your body," Goding said.

Pfingsten felt that. She wasn't delivering the first time, she said: "I was delivered upon."

Even a family friend, a doctor, tried to talk her out of a VBAC. "(He) heard I was having VBAC and asked, 'What are you doing? You are jeopardizing the life of your child,'" recalled Pfingsten. "I didn't want to jeopardize my child. I prayed about it, talked about it, and prayed some more. ... I knew I had a really good support team. The doctors were right outside the room, if need be."

So Michael was born, all 9 pounds of him, naturally. She was able to hold him immediately and feed him right away.

"It was a great experience," said Pfingsten, who recently opened a home business, Arbonne International. "After my daughter, I felt that, but wasn't happy with having to be cut open to have her join us. With my son, I felt like the most powerful woman in the world."