Too Bad We Can't Just "Ban" Accreta-The Downstream Consequences of VBAC Bans

By Jen Kamel

April is Cesarean Awareness Month (CAM), and throughout the month, Science & Sensibility will be covering issues that are directly related to the number of cesareans (1,284,339 in 2013) performed every year in the United States.  To start our CAM series off, Jen Kamel, founder of, shares important information about placenta accreta.  Tomorrow, April 3rd, is the Hope for Accreta Awareness National Blood Drive, as part of the 30 Day Hope for Accreta Challenge sponsored by the Hope for Accreta nonprofit that provides consumer information and offers support to families affected by placenta accreta. – Sharon Muza, Community Manager, Science & Sensibility

cam lamaze 2015Even though the American College of Obstetricians and Gynecologists (ACOG) and the National Institutes of Health (NIH) have described vaginal birth after cesarean (VBAC) as a safe, reasonable, and appropriate option for most women, VBAC bans (hospital or practice wide mandates that requires repeat cesareans for all women with a prior cesarean) remain in force in almost half of American hospitals. It’s true that scheduled repeat cesareans almost always successfully circumvent the most publicized risk of VBAC (uterine rupture) by virtually eliminating its incidence and for this reason, many people celebrate and credit the repeat cesarean section for resulting in a good outcome for mother and baby. But what most people do not consider is that VBAC bans translate into mandatory repeat cesareans, and those surgeries expose women and babies to a condition far more life-threatening and difficult to treat than uterine rupture: placenta accreta.

Photo Credit:

Photo Credit:

Placenta accreta occurs when a placenta abnormally attaches to (accreta), in (increta), or through (percreta) the uterine wall. No one knows exactly why some women develop accreta other than there is some abnormality in the area where the fertilized egg implants (Heller, 2013). Anyone who has had a prior surgery on her uterus is at a substantially increased risk of accreta and, as it happens, cesarean section is the most common surgery in the United States (Guise, 2010). In fact, the rate of accreta has grown along with the rate of cesarean surgery: from 1 in 4,027 pregnancies in the 1970s, to 1 in 2,510 pregnancies in the 1980s, to 1 in 533 from 1982-2002 (American College of Obstetricians and Gynecologists [ACOG], 2012). That rate escalates to 1 in 323 among women with a prior uterine surgery and the risk rises at a statistically significant rate with each additional cesarean section (Silver, Landon, Rouse, & Leveno, 2006).

Up to seven percent of women with accreta will die from it (ACOG, 2012). After the baby is born, the placenta does not detach normally, causing bleeding, which can’t be stopped before the doctors are able to either surgically remove the placenta or perform an emergency cesarean hysterectomy. Babies die from accreta due to the very high rate of preterm delivery associated with accreta. In fact, 43% of accreta babies weigh less than 5.5 lbs (2,500 gm.) upon delivery (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013). Accreta is not a routine complication. Accreta is serious.

As Silver (2006) points out, the risk of accreta after two cesareans (0.57%) is greater than the risk of uterine rupture after one prior low transverse cesarean during a non-induced/augmented planned VBAC (0.4%) (Landon, Hauth, & Leveno, 2004). In other words, women are literally exchanging the risk of uterine rupture in a current pregnancy for the more serious risk of accreta in future pregnancies. This poses a striking public health issue when you combine what the CDC (2012) has reported for numbers of unintended pregnancies–49%–and the lack of access to vaginal birth after cesarean: over half a million repeat cesareans every year, resulting in higher rates of accreta.

Yet due to the nonmedical factors that inhibit access to VBAC and influence how the risks and benefits of post-cesarean birth options are communicated to the public, women are rarely informed of these risks in a transparent and straightforward way. Additionally, it can be very difficult for the woman to obtain social support when confusion and fear about giving birth after cesarean remains the norm.

Given all this, providers are ethically obligated to inform patients of the future implications of their current mode of delivery. However, it can be especially difficult for providers working within the political climate of a hospital where VBAC is banned to frankly inform their patients of this reality. How can providers clearly explain to women the risks and benefits of their options, with VBAC as a viable option, when they do not offer that option at the facility? Such a situation could even result in professional ramifications for the provider, like revocation of hospital privileges. Additionally, some providers do not offer VBAC, “not because of an explicit hospital policy against it, but because [they] were unwilling to stay in the hospital with a woman attempting [a planned VBAC]” (Barger, Dunn, Bearman, DeLain, & Gates, 2013).

It is for this reason that some argue that VBAC bans create a conflict of interest among providers (ACOG, 2011; Charles, 2012). On one hand, they are bound by ethical obligations to the patient’s well-being, respect for patient autonomy, and support of an informed decision-making process. But these obligations are threatened by financial and professional ties to the hospital.

ACOG stresses throughout their guidelines and committee opinions that informed consent and patient autonomy are paramount (ACOG, 2011). They share how obstetrics should be moving from a paternalistic system to a more collaborative model (ACOG, 2013). They acknowledge that women should be allowed to accept increased levels of risk (ACOG, 2010). They assert how there is no “right” or “wrong” answer, only what is right or wrong for a specific woman (ACOG, 2010). And they are clear that restrictive VBAC policies cannot be used to force women to have a repeat cesarean or to deny a woman care during active labor (ACOG, 2010).

Yet, with 48% of women interested in the option of VBAC, 46% of them cannot find a provider or facility to attend their VBAC (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). Only 10% of U.S. women have a vaginal birth after cesarean, as opposed to another cesarean (National Center for Health Statistics, 2013). Barriers to VBAC remain firm.

Those barriers often include one-sided counseling to women of the risk of uterine rupture in a VBAC. Rarely are they told of the complication rates of accreta, which are higher across several measures. This is true when we look at maternal mortality (7% vs. 0%) (ACOG, 2012; Guise, et al., 2010), blood transfusion (54% vs. 12%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), cesarean hysterectomy (20-70% vs. 6%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), and maternal ventilation (14% vs. 3%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012). Further, 5.8% of accreta babies will die within the first week of life (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013) in comparison to 2.8 – 6.2% of uterine rupture babies (Guise, et al., 2010).

Accreta results in higher rates of mortality and morbidity because it requires a complex response which most hospitals are not equipped to provide. A 2012 study advises, “Treatment of placenta accreta is best accomplished in centers that have the expertise to handle the management, which involves multiple disciplines, including blood bank, interventional radiology, anesthesia, and surgical expertise, gynecologic oncology, urology, or obstetric subspecialty expertise” (Heller, 2013).

It ís worth noting that uterine rupture does not require this level of response in order to generate a good outcome. As Aaron Caughey, OB-GYN and Chairman of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland explains, “From an obstetrician standpoint, there are no particular special skills to managing a VBAC. Even in an emergency situation, we all have the surgical skills to deal with it” (Reddy, 2014).

Because some hospitals are not equipped to manage an accreta, some women who are diagnosed prenatally find themselves traveling hundreds of miles away from their family in order to deliver with accreta specialists.

At 19 weeks pregnant, Dawn was diagnosed with percreta, the most severe form of accreta where the placenta goes through the uterine wall and attaches to other structures in the abdominal cavity. She had nine prior pregnancies. Dawn was among the 93% of women who were never informed of the risks of accreta when she was pregnant after her first, second, or third cesarean (Kamel, 2014). All she heard were the dangers of VBAC. Thus, she had three cesareans.

Mother after cesarean hysterectomy in ICU.
© Dawn Johnson-Baranski

Mother after cesarean hysterectomy in ICU.
© Dawn Johnson-Baranski

When she got pregnant again, she heard the word accreta for the first time upon her diagnosis as is the case in 59% of women diagnosed with accreta (Kamel, 2014). Dawn ultimately traveled from her home in rural Virginia to Houston, Texas, at 27 weeks pregnant, to the Fox-Texas Children’s Pavilion for Women, an accreta specialty center. Due to complications related to her percreta, her son was delivered by cesarean hysterectomy at 33 weeks. Her son spent 19 days in the NICU before they could return back home to Virginia (personal communication, March 30, 2014).

It’s because accreta is so dangerous, complex to treat, and unknown to the general public, that professionals and researchers are sounding the alarm about the risk exchange that happens when repeat cesarean is chosen (or forced) over VBAC. As Dr. Elliot Main, Medical Director of the California Maternal Quality Care Collaborative, cautions, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean” (Main, 2013). (The state of California has a 9% VBAC rate, just a point below the national rate) (State of California Office of Statewide Health Planning and Development, 2013). A 2009 study from the Netherlands advises, “Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture” (Zwart, et al., 2009). And a 2012 study warns, “Because cesarean delivery now accounts for about one-third of all deliveries in the United States, rates of abnormal placentation and subsequent hysterectomy will likely continue to rise” (Bateman, Mhyre, Callaghan, & Kuklina, 2012). By reducing the primary cesarean rate and increasing access to VBAC, we could also reduce the incidence of accreta, cesarean hysterectomy, and hemorrhage.

Following multiple uterine rupture lawsuits in the 1990s, some hospitals crafted their restrictive VBAC policies around litigation fears. However, the concern over lawsuits resulting from “VBAC gone wrong” may soon be overshadowed by the worry of being sued when women or babies die from accreta, after failing to adequately respond to this dangerous condition and/or denying access to VBAC (Associated Press, 2013; Children to sue hospital over death of mother, n.d.). This will certainly become the case as the public becomes more aware of the connection between VBAC bans, cesareans, and accreta.

It could also become a public relations nightmare as Americans begin to realize that litigation fears–not patient safety, drive hospital policy. This becomes more likely as more women are diagnosed with accreta.

As mothers are the ones who carry the risk of either uterine rupture or accreta, shouldn’t they be the ones deciding which set of risks are tolerable to them? As ACOG (2010) says, “the ultimate decision to undergo [planned VBAC] or a repeat cesarean delivery should be made by the patient in consultation with her health care provider” –  not by hospital administrators, malpractice insurance companies, or providers who simply don’t want to deal with VBAC.

As Dr. Howard Minkoff (2010) shared at the 2010 NIH VBAC Conference, “We should be starting with a sense of what’s the best interest of the mother. Unfortunately, the decision here is not always who are better equipped, it’s more like who are willing. There are a lot of hospitals that are quite capable of providing VBACs but exercise an option not to do it particularly if there’s someone nearby that will take that on for them.”

Hospitals around the country, and particularly those that are located in areas where VBAC bans mean that all women have repeat cesareans, are seeing and will continue to see increasing numbers of accreta. They have no choice but to manage it – which can be especially problematic for smaller facilities in rural areas that don’t offer the sophisticated response accreta requires.

But motivation remains the driving factor in hospital VBAC policy even in rural hospitals. Take the five small community hospitals in New Mexico that serve the Navajo Nation. As Dr. Jean Howe (2010), their Chief Clinical Consultant for Obstetrics, shared at the 2010 NIH Conference, these rural facilities collectively deliver 3,000 babies each year and maintain a 15% cesarean rate and a 38% VBAC rate. Numbers like that just don’t happen. They are the result of motivated administrators, providers, and patients who want VBAC to be an option at their facility.

The bottom line is, VBAC bans simply delay risk. The sooner hospital administrators and the American public realize this, the sooner we can mobilize–reducing future risks of accreta by making VBAC a viable option in more hospitals. It is one thing for a woman to knowingly plan a repeat cesarean understanding this risk. That is her choice as both VBAC and repeat cesarean come with risk. However, it is unconscionable when a woman is not presented with her options and she develops accreta in a subsequent pregnancy.

As the American public becomes more aware of the serious risks associated with repeat cesarean, will more providers and facilities be sued as a result of accreta-related complications and death? Will it have to come to fear of litigation, again, in order for hospitals to throw aside their current VBAC bans, listen to what the NIH, ACOG, and the medical research has to say; to create an environment that is supportive of VBAC, respect a mother’s right to make her own medical decisions, and prepare accreta-response protocols?

Women are entitled to understand what that first cesarean means in terms of their future birth options and their long term health. Consumers and providers should work with hospital administration to reverse VBAC bans, review current VBAC policies to insure they are aligned with national guidelines and evidence, and improve response times for obstetrical emergencies through team training and drills (Cornthwaite, Edwards, & Siassakos, 2013). Providers should have frank conversations with patients about the immediate and long-term risks and benefits of their options within the context of intended family size, acknowledging that sometimes the stork delivers when you’re not expecting it. This is about administrators, providers, professionals, and consumers working together for better processes and healthier outcomes. Let’s get to work.


American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics & Gynecology, 116(2), 450-463. Retrieved from

American College of Obstetricians and Gynecologists. (2011). Code of Professional Ethics. Retrieved May 16, 2013, from ACOG:

American College of Obstetricians and Gynecologists. (2012, July). ACOG Committee Opinion No. 529: Placenta accreta. Obstetrics & Gynecology, 201-11. Retrieved from

American College of Obstetricians and Gynecologists. (2013). Elective surgery and patient choice. Committee Opinion No. 578. Obstetrics & Gynecology, 122, 1134-8. Retrieved from

Associated Press. (2013, Nov 25). $15 million awarded in Illinois childbirth death lawsuit. Retrieved from Insurance Journal:

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy and Childbirth. Retrieved from

Barger, M. K., Nannini, A., Weiss, J., Declercq, E. R., Stubblefield, P., Werler, M., & Ringer, S. (2012, November).
Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor. Journal of Perinatology, 32, 837-843. Retrieved from

Bateman, M. T., Mhyre, J. M., Callaghan, W. M., & Kuklina, E. V. (2012). Peripartum hysterectomy in the United States: nationwide 14 year experience. American Journal of Obstetrics & Gynecology, 206(63), e1-8. Retrieved from

Charles, S. (2012, Jul-Aug). The Ethics of Vaginal Birth After Cesarean. The Hastings Center Report, 42(4), 24-27. Retrieved from Medscape:

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership:
an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics and Gynaecology, 27, 571-581. Retrieved from

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from

Eshkoli, T., Weintraub, A., Sergienko, R., & Sheiner, E. (2013). Placenta accreta: risk factors, perinatal outcomes, and
consequences for subsequent births. American Journal of Obstetrics & Gynecology, 208, 219.e1-7. Retrieved from

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010).
Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from

Hale, B. (n.d.). Children to sue hospital over death of mother. Retrieved from Daily Mail:

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197. Retrieved from

Howe, J. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 14:45-17:08. Retrieved from Vimeo:

Kamel, J. (2014, Dec 14). Online poll of 227 women with prior cesareans.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a
Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589. Retrieved from

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

Minkoff, H. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 11:16. Retrieved from Vimeo:

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4).
Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention:

National Center for Health Statistics. (2013). User Guide to the 2012 Natality Public Use File. Hyattsville, Maryland:
National Center for Health Statistics. Retrieved from

Reddy, S. (2014, Dec 8). A type of childbirth some women will fight for. Retrieved from Wall Street Journal:

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated With Multiple Repeat
Cesarean Deliveries. Obstetrics & Gynecology, 107(6), pp. 1226-1232. Retrieved from

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for
Selected Medical Procedures in California Hospitals, 2012. Retrieved from

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the
Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8),
pp. 1069-1080. Retrieved January 15, 2012, from

About Jen Kamel

Jen kamel head shot 2015

Jen Kamel is a consumer advocate and a leading national speaker on the medical facts and political, historical climate surrounding vaginal birth after cesarean. She is the founder of and has brought her workshop “The Truth about VBAC: Politics, History and Stats” to over 900 people around the country, giving accurate, current information about post-cesarean birth options directly to families, practitioners, and professionals. This program is also available online. Jen also offers a complimentary email course on VBACs.



April 2, 2015 07:00 AM by Important new article from Lamaze International about the dangers of repeat c-sections. | Mother Ear [?]

Jen, thank you for the informa

April 3, 2015 07:00 AM by Michele L. Ondeck, MEd,RN, LCCE, FACCE
Jen, thank you for the informative information about Placenta Accreta. Hoping all childbirth educators incorporate the message into their classes.

BRAVA, Jen! Strong words, and

April 3, 2015 07:00 AM by The Well-Rounded Mama
BRAVA, Jen! Strong words, and deservedly so. I've written about Accreta several times on my blog, and just did a post about the Hope for Accreta Awareness Blood Drive. I've also had several friends who have been through accreta and lost uteri, a baby, and nearly their lives. VBAC bans do indeed simply delay the risks. I understand and empathize with the fear of litigation, but I cannot understand how hospitals can ethically justify having a VBAC ban.

Jen, thank you so much for onc

April 5, 2015 07:00 AM by Elizabeth Quinn
Jen, thank you so much for once again providing such an informative and helpful article. You have a wonderful gift of being able to wade through the murky world of statistical research and present it in a palatable way to the average reader, such as myself. I had a question regarding one statistic you quoted, "Further, 5.8% of accreta babies will die within the first week of life (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013) in comparison to 2.8 ?? 6.2% of uterine rupture babies (Guise, et al., 2010)." It's been quite a while since I wrote a research paper so I was wondering if you could explain the 2.8-6.2 variation. That's a big jump in the number of babies that die from accreta and I didn't understand why a range was given in that study. Thanks again for all your hard work! It's because of the efforts of women like you and websites like Science and Sensibility that I was able to acquire the information I needed to make an informed decision to attempt a vba2c and succeed! I also used your list of questions to ask a care provider when I interviewed new ob's upon my decision to pursue a vba2c, printed the whole list out and took it with me. The OB I chose loved it and said 'yes please fire away! I love VBAC moms, they know their stuff and want to know more!'

Thank you for breaking this do

April 5, 2015 07:00 AM by Deena H. Blumenfeld, ERYT, RPYT, LCCE, FACCE
Thank you for breaking this down so clearly, Jen. I find that care providers don't often share the risks for future pregnancies when discussing c-section. When mothers have all the information, they can make an appropriate, informed choice about this and all future pregnancies. I will be sharing this with all of my students, first time moms, VBAC moms and all mothers.

@Elizabeth Quinn Hi Elizabeth!

April 7, 2015 07:00 AM by Jennifer Kamel
@Elizabeth Quinn Hi Elizabeth! That is a great question. Guise, et al was the 400+ page evidence report which was the basis of the 2010 NIH VBAC Conference. Guise collected the evidence to date on VBAC and repeat cesarean and then excluded studies that di

So helpful, thanks for replyin

April 7, 2015 07:00 AM by Elizabeth Quinn
So helpful, thanks for replying!

Dear Jen - also as a vba2c can

April 11, 2015 07:00 AM by Deborah Anne Reichard
Dear Jen - also as a vba2c candidate it has been so important for me to read about accreta risks as none have been flagged to me. In fact I have had to ask my own contacts to dig up studies for me- many of which are very hard to make sense as a non-medical person. It is such a Gray area and even risks of induction after Ceasers are not really discussed. I think there is a lot to cover for a VBAC mother to be and to be able to cut down as many possible risks as she can is s helpful path. I will certainly be reading more of your VBAC facts. With great thanks

Hi @Debbie! Oh yes, inducing V

April 23, 2015 07:00 AM by Jennifer Kamel
Hi @Debbie! Oh yes, inducing VBACs is another area where misinformation and confusion reigns! I hear people say all the time that inducing a VBAC is just dangerous. Period. End of sentence. No discussion. And induction without medical indication, yes, that is not worth the increased risks association with induction. But what if we have a mom with a partial placental abruption (which is a medical indication for induction per ACOG), vaginal birth is still an option, but mom is not in labor? Should she just have a repeat cesarean because inducing a VBAC is just too risky? Hospital based health care providers who do not induce VBACs sentence their patients to mandated repeat cesareans when a situation arises where baby needs to be born sooner rather than later, but not necessarily in the next 5 minutes. (Induction should not take place in the out-of-hospital environment due to the increased monitoring required and the increased risks associated with induction.) As we discuss in the article above, there are serious implications for that repeat cesarean so the immediate and long term risks and benefits of induction vs. repeat cesarean must be considered. Due to these various factors, ACOG leaves the option of inducing VBACs open. I think it's a good thing for women with a medical indication to have the option of induction rather than going straight to cesarean. I know that if I was in that situation, I would appreciate the acknowledgment that this choice was mine to make in consultation with my health care provider as we review the risks and benefits of my individual situation. Read more here: Best, Jen

This is the first I've heard a

May 5, 2015 07:00 AM by Joyce LeBlanc
This is the first I've heard a name put to my experience! My son was born premature and I had a horrific experience! I didn't have an epdural, but they did an episiotomy, since my son was in distress. I recall hearing " we're losing her " after they tried unsuccessfully to remove placenta, then they took me into surgery - I never knew until now what it was. I knew from my husband that I lost a lot of blood. They released me from Brigham & Women's Boston with a hematocrit of 14 when now I know it should be roughly 37% to 49% ! It was Columbus Day weekend so I never saw the same person twice. I'm so glad attention is being brought to this so other women don't have to experience the same.

to this article, ?Women ar

May 26, 2015 07:00 AM by VBAC birth success rates, risks & how to prepare
to this article, ?Women are literally exchanging the risk of uterine rupture in a current pregnancy [?]

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