Skyrocketing caesarian section rate means placenta accreta is no longer just the fine print

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Finally, the mainstream media has come out with the beginnings of a critical investigation into birthing in Australia. The Herald today published “Fatal flaws in steady rise of caesareans”. Apparently some Sydney obstetricians have opened a bleary eye and started doing some extrapolating on C section rates, something feminists and birthing advocates have been raising the alarm on for decades. But the people who are causing the problem, the people with the power to change it, have been sitting on their butts about it until the crisis is well and truly in our faces. (Sound familiar? Medical and nursing workforce crisis, anyone? Climate change?)

New South Wales “maternity specialists” have been putting their heads together about the rising rate of placenta accreta. The Herald makes it seem that they’re worried more about the resources implications than about damage to women, but I guess that’s the way to get people’s attention.

At that meeting, convened by NSW Health, officials presented a nightmare scenario: based on current trends a rise in the number of caesarean sections from 30 to 39 per cent of births would mean more than 1000 extra operations a year, diverting resources from other services.

Compare that with the 1970s, when the rate of caesarean sections was about 5 per cent.

By the 1980s caesareans made up about 10 to 15 per cent of all births.

But then came a dangerous combination: medical advances made anaesthesia safer as society moved towards the quick, clean and convenient over the potentially long, drawn out and messy. The result: a significant shift towards elective caesarean sections. The rate reached 19 per cent in 1994, 27 per cent in 2002 and 28.5 per cent in 2003. Now it makes up nearly one-third of all births.

Placenta accreta is a highly dangerous condition in which the placenta adheres to the inner wall of the uterus. Placenta accreta raises the risk of premature birth and bleeding in pregnancy. After birth (whether vaginal or surgical), the adherent placenta doesn’t separate properly. This leads to retained placenta, catastrophic bleeding, hysterectomy (often), or death (sometimes). Sometimes the placenta doesn’t just adhere, but grows right into or through the uterine wall – placenta increta or placenta percreta.

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Placenta accreta used to be rare. However, with the rising incidence of primary and repeat Caesarean sections, the rate is rising. People in the UK were warning the world about this expected rise 25 years ago. With every C section a woman has, her risk of undergoing a hysterectomy or other major complications rises and rises. A major Utah study published two years ago delineated this starkly: “Maternal morbidity associated with multiple repeat 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.

In a Western Australian study published four years ago, it was found that 78% of placenta accreta cases occurred in women who had had a previous C section. 91% of these women required a hysterectomy, and the median blood loss was three litres (a woman’s body only contains about five and a half litres). Placenta accreta is the leading cause of postpartum hysterectomy, an operation with a case fatality rate of 4%.

This is no minor, readily-manageable complication. But many cases are preventable: by not performing unnecessary caesarean section surgery in the first place. The rate of medically-appropriate C sections is likely to lie around 15%. The NSW rate is around 30%; Western Australia is above 34%; and some private hospitals are running at rates well above 50%. And contrary to celeb media beatups, the driver for this isn’t from women who can’t be bothered having a labour and birth; it is coming from the obstetric profession, whose obsession with paternalistic control over women’s bodies is killing women and babies. This needs to stop.



Categories: gender & feminism, medicine, violence

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6 replies

  1. Did you read the other recent study on c-sections that showed women having a first baby were more than seven times more likely to have an emergency hysterectomy if they had a c-section, and that the risk increases with every subsequent c-section? Abstract here:
    http://www.greenjournal.org/cgi/content/abstract/111/1/97
    ~Women undergoing their first vaginal delivery were found to have a 1 in 30,000 chance of having a peripartum hysterectomy
    ~Women undergoing their first cesarean delivery were found to have a 1,700 chance of having a peripartum hysterectomy.
    ~Women undergoing their second cesarean delivery were found to have a 1 in 1,300 chance of having a peripartum hysterectomy
    ~Women undergoing their third or more cesarean delivery were found to have a 1 in 220 chance of peripartum hysterectomy.
    ACOG’s journal said:
    “This study has confirmed the significant risk of peripartum hysterectomy associated with prior cesarean delivery. These data provide evidence that cesarean delivery leads to a greater than seven times increase in the odds of having a peripartum hysterectomy to control hemorrhage. A similar risks was noted in a recent U.S. study using the Nationwide Inpatient Sample. We have also been able to identify that the risk also then extends beyond the initial cesarean delivery into subsequent deliveries; women who have more than one previous cesarean delivery have more than double the risk of peripartum hysterectomy in the next pregnancy, and women who have had two or more previous cesarean deliveries have more than eighteen times the risk. This full quantification of these risks provides the evidence needed to comprehensively counsel women about the risks of primary cesarean delivery and to counsel against cesarean delivery without a specific medical ndication.”
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  2. I thought you’d post on this, Lauredhel – I noticed it yesterday but was busy celebrating my mum’s birthday. About time the myths of c-sections being always the simple and easy choice got a bit of balance with the real risks.
    Tangent: the idea that Caesarean sections are named after Julius Caesar, who was allegedly born in this way, cannot be true. In ancient times women did not survive such surgery, which was usually performed as they lay dying in labour or immediately after their death, yet Caesar Dictator’s mother is attested as surviving until her son’s middle age, when he gave her a funeral so lavish that it scandalised the Senate. The name must derive from some other Caesar.

  3. Silly me, I thought most caeasars were the result of private hospitals and obstetricians telling women it was their best option. But I was wrong. I must be the only woman who has had two caesars – one unplanned because of failed induced labour, and the other ‘elective’ because I got tired of being told that I was going to have a dead baby if I selfishly insisted on pushing her out myself. No, it’s all because women are demanding them.
    link
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  4. Yes, the named-after-Caesar thing is a myth – the word caesarean comes from the Roman law, lex Caesaria, that required one to be performed on a woman who died during childbirth or late in pregnancy, to try to deliver a live child.
    Rebekka’s last blog post..Photos

  5. Ah, some Googling led me to Justinian’s Digesta.

    ”It is the rule of kings that forbids the burial of pregnant women before the young is excised from their bodies…” This Lex Regia, or Law of Kings, is attributed to Numa Pompilius, a legendary king of Rome during the eighth century BC. The Lex Regia became the Lex Caesaria under the emperors.”

    One of my babies was born via emergency caesarean, and I’m glad that she was. However, I would much rather have had a vaginal birth, which if it had gone the way of my son’s birth would have meant a much more rapid recovery for a start.
    I don’t remember ever hearing about the risk of placenta accreta during my pregnancies, when the various birth options were discussed.

  6. Neither do I. The only thing I heard after my first was that I might be only able to have four children, and that they would all likely be caesars. I only heard about VBAC by accident. Then I got into the politics of vaginal vs caesar, midwife vs obs. That’s why that article makes me so mad, it’s not women wanting caesars, it’s the doctors. I fought long and hard before I gave into the ‘dead baby’ argument. No one ever mentioned placenta accreta, or hysterectomies, only the possibility of placenta praevia, which is an automatic caesar anyway. I consider myself lucky that an obs in Alice did a procedure to check my fertility and while he was there removed a great deal of scar tissue from my first caesar and probably helped me to fall pregnant. Certainly made life a lot more comfortable. All this mysterious pain I had been suffering disappeared. No one ever mentioned that either.
    Mindy’s last blog post..Which circle are you???

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