Conversation with Dr. Abdulla Al-Khan about maternal mortality

I emailed Dr. Abdulla M. Al-Khan, the maternal-fetal medicine specialist at Hackensack University Medical Center who was quoted in the NBC report on the risks of repeat cesareans. I asked him for more information on placenta accreta-related deaths: Were the numbers the journalist mentioned accurate and indicative of extensive underreporting of maternal deaths? Or had the journalist misquoted or misinterpreted the figures?

This afternoon*, I received a telephone call from Dr. Al-Khan. He was happy to speak with me more about these issues. First off, we talked numbers. Had 40 women in New Jersey died last year due to placenta accreta? He clarified that in 2009, there were about 42 maternal deaths in New Jersey; the journalist had inaccurately interpreted the numbers. Twelve of those 42 deaths he identified as "preventable losses," all related to hemorrhage: placenta accreta, uterine atony, etc. These numbers are very disturbing, he told me, because we're talking mostly healthy, young women. He couldn't give a precise number of how many of those twelve deaths were related to accreta--the figures haven't been released yet--but he said that a good proportion of the twelve were from accreta.

His hospital has seen a lot of placenta accretas. And almost every day, he hears personally from colleagues and other hospitals of another case of placenta accreta. He was very concerned about the high incidence of accreta and emphasized that public awareness of this issue is essential.

We then discussed underreporting of maternal mortality. New Jersey is the only state in the U.S. with a Maternal Mortality Review, which collects and investigates pregnancy-associated and pregnancy-related deaths. The latest Maternal Mortality Review covers 2002-2005 (PDF). Subsequent years will be reviewed in the next report. In those years, maternal mortality figures from New Jersey are as follows:

2002: 39 cases
2003: 49 cases
2004: 51 cases
2005: 34 cases

Of these deaths, slightly less than half were pregnancy-related. The overall maternal mortality rate in New Jersey during those years was 37.4/100,000. The pregnancy-related mortality rate in NJ, a subset of maternal mortality, was 12.6/100,000.

I asked Dr. Al-Khan about the reliability of maternal mortality figures. New Jersey is the only state with reliable figures due to its unique mortality review committee. Underreporting of maternal mortality is a widespread problem in the US. Without a comprehensive state- or nationwide- review process, the figures we have (13.3/100,000 live births as of 2006) still do not accurately reflect the true maternal death rate. (For more information on maternal mortality in the U.S., read Amnesty International's detailed report.) In the United States, litigation is one major factor in this underreporting, because it holds up many details and figures surrounding maternal deaths for several years while litigation is underway.

We concluded our conversation with a brief chat about cesarean rates. He is deeply troubled by New Jersey's 40% cesarean rate, and also by the fact that the national cesarean rate is not far behind.


My academic & blogging activities do not take place in a vacuum. When he called, I was stirring a batch of granola in the oven. Zari was in the kitchen helping. Dio had just woken up from a nap and was a bit cranky. I kept feeding the kids spoonfuls of hot granola to keep them happy and quiet during the phone call. C'est la vie chez les Freezes!

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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.

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Cesarean section and VBAC, yet again

I seem to be on a cesarean section and VBAC kick lately, but there are just so many things to discuss and so many new articles and studies coming out. And with close to 1 in 3 births occurring via c-section in the U.S., these topics are certainly relevant to anyone who is of childbearing age!

First, continuing our discussion of the ethics of refusing to perform elective c-sections, I came across this comment from an Australian physician who argues that that doing an ECS to stave "save the vagina" or "prevent urinary incontinence" is not a valid reason. She argues that an ECS is like a healthy weight woman requesting gastric bypass surgery to prevent future obesity. From the article Caesarean beliefs "misguided" from the Sydney Morning Herald:

WOMEN who choose to have an elective caesarean in the belief that it will prevent incontinence and genital prolapse are "misguided" and may be putting their health, and that of their baby, at unnecessary risk.

That is the view of Jenny King, a urogynaecologist at Westmead Hospital, who questions the right of women to choose surgical births to avoid pelvic floor problems.

Evidence is mounting that repeat caesareans cause harm and there are doubts that they provide the protection they were thought to provide, she said.

Dr King will present the findings of a review of about 9000 births at Westmead Hospital in 2004 at the annual scientific meeting of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Auckland on Sunday.

She projected that surgical birth could prevent 35 per cent of urinary incontinence in women under 50, but the method of delivery made minimal difference to pelvic dysfunction later in life.

"Incontinence is an emotional issue, but I looked at the data and you have got more chance of losing a baby from the complications of a caesarean section than getting incontinence problems," she said.

"If a young woman of healthy weight asked a gastric surgeon for lap-band surgery to prevent the possibility of becoming obese later in life, surely no one would agree to that.

"So why does a pregnant woman have the right to surgery she doesn't need?"

Women who have a caesarean are at much greater risk of a ruptured uterus, hysterectomy or infection. And their babies are more likely to be born premature, have serious breathing problems or need intensive care.

Next, an article in the Arizona Republic discussing how C-sections are linked to future birth risks. The article focuses on one worrisome trend due to the rapid rise of c-sections: placenta accreta. Once something that was an obstetrical rarity (1 in 30,000 in the 1950s when the c-section rate was in the low single digits), accreta now is as high as 1 in 2,500 to 1 in 500. The article also stresses the relative safety of VBAC, emphasizing that as many as 90% of women with a previous c-section are candidates for a VBAC.

Studies and textbooks suggest that the risk of developing an accreta is as high as 4 percent in women who have had two previous Cesareans; that jumps to 60 percent with three C-sections, their physicians said.

And while Valley hospitals can't say exactly how many women they are seeing with the complication, those that traditionally deliver the most babies say it's a trend they're watching.

Earlier this year, St. Joseph's saw three women with the condition in one week, Chambliss said.

"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."

I've posted about this before, but I wanted to remind readers of this recent study about Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Not surprisingly, it found that cesareans become progressively more dangerous for the mother. I bolded the parts relating to placenta accreta. It seems the 60% statistic from the previous article comes from women with two previous c-sections who also have placenta previa. Here's the abstract:

OBJECTIVE: Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002).

RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Thanks to Unnecessarean and Birth Faith for the links!

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