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Two weeks overdue with her first child, Jessica Stahle was given medication to start her labor, received an epidural and had the amniotic sac surrounding her son broken open. Because his umbilical cord was compressed and his heart rate dropped, she had a Caesarean section.
The North Salt Lake mother blames the surgery for her postpartum depression and a hazy month of recovery on pain killers. So she didn't want to risk having another one for her second birth.
She hired a midwife, and Liam, now 16 months, was born in a birth tub in her dining room. "It really came down to wanting to be in charge of my body," she said.
In doing so, the 24-year-old entered a turf battle between midwives and obstetricians over what types of births should be allowed at home.
Sen. Margaret Dayton, R-Orem, is sponsoring a bill at the behest of the Utah Medical Association to restrict "direct-entry midwives," who are licensed by the state and attend home births. While a compromise has been reached on most of the proposed changes, three sticking points remain: breech babies, twins and vaginal births after a previous Caesarean, called VBACs, all of which midwives can currently deliver.
Weighing risks: The UMA says the three types of births belong in hospitals, where an emergency C-section is available within minutes for rare complications, such as a lack of oxygen to the baby or a ruptured uterus.
"If it's normal and uncomplicated and truly low-risk, I honestly believe it's the person's choice," said Catherine Wheeler, a former UMA president who has been working on the bill. "Breech is called malpresentation because it's not normal presentation. Having an incision in your uterus [from a Caesarean] is not normal and having twins is not normal either."
But pointing out that repeat C-sections can cause infections or hemorrhages and complicate future pregnancies, midwives say women - not the state - should decide what level of risk they are willing to take.
"Parents should have the right to choose with true and informed consent," says Holly Richardson, a licensed midwife. "It's not black and white."
According to state reports mandated in 2006, licensed midwives have delivered six breech babies, three sets of twins and 17 VBACs since then. One mother with a breech baby went to a hospital for a C-section. The rest delivered at home with "excellent outcomes," Richardson wrote in the reports.
The risk of a uterine rupture during a VBAC is less than 1 percent for women who have a certain type of scar from a previous surgery, according to the Mayo Clinic. That statistic, midwives and moms say, means delivering at home is safe.
But doctors and nurses disagree. "Do we need to have a bad outcome to change the law?" asks Ann Deneris, a nurse midwife who works at hospitals.
A question of access: Part of what is fueling home births for women who had a prior Caesarean, midwives say, is a lack of providers willing to let them have a vaginal delivery, due to liability concerns or for convenience.
Utah's C-section rate is growing - jumping by 38 percent from 1997 to 2006, when they made up 22 percent of the 53,075 births in Utah. Meanwhile, VBACs have dropped slightly, with 6,639 performed in 2006.
In Salt Lake Valley hospitals, where there are anesthesiologists and doctors on call 24-7 for emergency surgery, VBACs are more common. Nearly all Utah hospitals reported successful VBACs in 2006, though the numbers are low in rural areas.
Utah's VBAC rate is high compared to the national average - almost 19 percent versus 10 percent. But it should be closer to 60 percent, says Julie Gainer, a Utah County obstetrician who specializes in high-risk pregnancies. She urges her patients - especially ones who want several children - to try to deliver vaginally because the risks of surgery grow with each C-section. For other doctors, "It's quite easier to say, 'Let's do a repeat C-section,' " Gainer says.
Obstetrician Michael Varner, who believes VBACs should be done at hospitals, says doctors need to do a better job of avoiding C-sections in the first place.
"I hope [this] dialogue can motivate the health care system to do better in terms of listening to what women say they want and to reduce unnecessary interventions," he said.
As for Stahle, she is training to become a midwife and hopes to have another child at home. "With home births, our aim is healthy moms and healthy babies, just as at a hospital. But it's also happy moms and happy babies. I don't think you have to sacrifice the [birth] experience for the health of mom and baby."
The safety record of Utah midwives
The state started regulating midwives in 2006 - there are now 16 - to make home births safer. Those regulations limited them to attending "normal" births. But normal was never defined, which prompted the latest legislation.
To get a license, so-called "direct-entry midwives" must be certified in adult and infant CPR, newborn resuscitation and through an accredited midwifery program.
These midwives have cared for 334 women since 2006. Among the complications listed in state-mandated reports: One baby died of unlisted causes, another suffered oxygen deprivation and four mothers were taken to the hospital because of hemorrhages.
The statistics don't include home births attended by unlicensed midwives.