"We should be having these discussions of whether or not to have a child after a cesarean and it's important to be discussed," she said. "But it's not part of every physician's current counseling to discuss the long-term ramifications."
Karkowsky said women should have conversations with their spouses and doctors about family planning, especially when they have had previous cesareans. Sometimes a C-section is a "reasonable choice," she said. "A safe cesarean can be truly life-saving for mother and baby."
But where a woman with multiple previous cesareans chooses to deliver is also important.
In her Atlantic Monthly piece, she describes the complex multi-team effort to deliver a baby when a woman has developed placenta accreta and will require a hysterectomy immediately after delivering the baby.
Staffing for the surgery required gynecologic oncology, interventional radiology, urology, neonatal intensive care, a blood bank, anesthesiology, nursing and critical care.
"I work in a well-staffed, wonderful medical center, which always has the capacity to handle anything," she said. "In a smaller setting, it is hard. Women need to look at the available resources to them. Some don't have a choice."
Barbara George was lucky to deliver at the high-risk pregnancy center at Hackensack University Medical Center, where a team of doctors performed seven hours of complex surgery, first delivering the baby in a sternum to pubic bone vertical incision, then cauterizing veins to detach the placenta from the bladder and finally a hysterectomy.
She had the most dangerous form of placenta accreta, called percreta, and the placenta dangerously penetrated the entire uterine wall and had attached itself to her bladder.
Had she known she was at risk for placenta accreta, George said she would have considered other options.
"In my heart, I wanted a larger family," she said. "I would have gone ahead and maybe had a surrogate or adopted, but I would not have put my life at risk. I was putting my children at risk of growing up without a mother. If someone wants a larger family, there are other ways."