Maternal deaths from placenta accreta

In a 2009 article about the risks of repeat cesareans, Dr. Marlin Mills, medical director of perinatal services with Banner Desert Medical Center in Arizona, noted that the rate of placenta accreta has risen sharply since the 1950s:

"In the 1950s, the incidence was something like 1 in 30,000 women," Mills said, adding that newer studies, conducted within the last decade, suggest that the rate has climbed to as high as 1 in 2,500 or even 1 in 500. "So there is definitely an increase in occurrence," he said. "And in women with C-sections, that's where we've really seen an explosion."

Just today, I read at Birthing Beautiful Ideas that New Jersey has witnessed several maternal deaths from placenta accreta in the past year. I watched the NBC video about the risks of multiple cesareans, in which an accreta survivor shared her story. Her physician was Dr. Abdulla Al-Khan, Director and Section Chief of the Division of Maternal-Fetal Medicine/Surgery at Hackensack University Medical Center. The NBC report quotes Dr. Al-Khan:

"We have lost a lot of mothers in the State of New Jersey from accreta." The doctor says about 40 women died last year in New Jersey as a result of accreta....Dr. Al-Khan says he's seen more and more cases of this potentially deadly condition, and he blames the continued rise in the number of c-sections. "If we don't do anything about decreasing cesarean section rates in this country, we are going to have a lot of mothers who will lose their lives." [Note: the NBC report misquoted Dr. Al-Khan; the total number of maternal deaths in NJ last year was around 42, of which several were from accreta. Read more in my interview with Dr. Al-Khan.]

Now, I agree with Kristen at Birthing Beautiful Ideas that this shouldn't turn into yet another scare-fest for pregnant women. She commented:

To be clear, I do not want to cast such a dark pallor over placenta accreta (or any other placental abnormalities whose risks are increased with multiple cesarean surgeries) that I end up adding just as much hype to the risks of repeat cesarean section as many others do to the risk of uterine rupture during a VBAC.  These are serious risks, and they are risks that are both associated with prior c-section.  But they should be communicated in a way that offers women the opportunity to make an empowered and informed decision about their births–not a hyped-up exaggeration that makes them terrified about their births.

Still, the reality of placenta accreta should make both pregnant women and maternity care providers think carefully before entering into a cesarean section, whether a primary or repeat. Neither VBAC nor ERCS is without risk, but in our obstetrical climate, VBAC is often discussed largely in terms of risks and repeat cesarean largely in terms of benefits.

Although I haven't personally had to weigh these risks & benefits, a good friend of mine is in the middle of this struggle. Her first baby was vertex, born fairly uneventfully, and attended by an OB. (Incidentally, she gave birth kneeling, which her OB had never seen before. This blows my mind a bit...how can someone with probably thousands of births under their belt never have attended a single kneeling/hands & knees birth?) When she became pregnant the second time, she planned a home birth until her baby was discovered to be breech. She found the one OB in the entire area who would attended a vaginal breech birth, only to go into labor when he was out of town. So with no other options, she very reluctantly agreed to a cesarean.

Now she's 37 weeks pregnant with another persistently breech baby. The only legal home birth midwives cannot attend primary VBACs at home, nor do most of them have much experience attending breech births. After searching high and low, she finally found a CNM/OB practice that she liked. If all is normal, the CNM will attend the birth, and the OB comes in only if there's a more complicated situation. Once she found out this third baby was again breech, she began grilling her OB about vaginal breech birth. It turns out he's done some vaginal breeches. While he's not thrilled at the prospect, he's at least willing. I recently sent her OB more information about Dr. Frank Louwen and upright breech births, including a DVD of his presentation at the 2nd International Breech Conference.

Anyway, back to my point: my friend has told me multiple times: "I really, really don't want a c-section with this baby. I hated having a cesarean last time; I was totally devastated by it. I worry about all of the things that could happen during a second surgery. I worry about the long-term health consequences 10, 20, 30 years down the road. I know it will be so much harder to have a VBAC if I have two previous c-sections. I might want to have more children and the risks of yet another c-section really concern me. Plus I don't know how I would cope with three small children and abdominal surgery to recover from; I have no family who can help out after the baby's born."

Giving birth after cesarean is about so much more than the risk of uterine rupture.

Just this morning, my friend called me with good news. She had just had a successful external cephalic version! For now, her breech dilemma is solved, and VBAC looks a lot more likely (and a lot less stressful!). I'm hoping that her baby stays head-down. And if not, that her OB is willing to try an upright vaginal breech birth. In any case, I hope that she can give birth the way she wants: vaginally, autonomously, and with  respectful, compassionate caregivers.