We appreciate Professor_'s comments regarding our paper 1

on family-centered birth for patients with placenta accreta spectrum (PAS):

• Who should be the companion during a family-centered PAS surgery?

• How to offer continuous support to the patient and her family after the surgery?

• How should risky information be delivered to the patient?

• What type of anesthesia is indicated in each case and how interdisciplinary management affects or is affected by the presence of a companion in the operating room?

Professor _____ points out several questions that go far

beyond the usual questions when facing PAS and we agree with him that experience is required to answer these questions, but above all, having overcome the basic problems that most reference hospitals are concerned with in regard to PAS (reduce bleeding and serious complications, prevent mortality and provide hospitals with the basic resources for optimal care).

Having overcome those "priority" problems, it is easier to think about offering the highest quality during the management of PAS, including key dimensions but generally overshadowed by the risk of dying, such as the psychological impact on the patient and her family, 2 the decrease in care costs, fertility preservation, the opinion of the patients about losing her uterus 3 and humanization of birth.

Training in the management of PAS is difficult; multiple factors are required, including personal and group will, a hospital with a high flow of patients that supports the improvement, and the inclusion of quality policies such as self-assessment, research, and inter-institutional collaboration. Additionally, the support of other hospitals in the region is required, that choosing to transfer patients to the reference center instead of admitting with them and trying to solve the problem themselves.

Addressing the concept of "center of excellence" for PAS is almost impossible for hospitals in settings with limited resources. Requirements such as more than 5 years of experience, 100 patients (2-3 per month) treated and availability of many human and technological resources, 4,5 seem unattainable for most hospitals, 6 at least in Latin America. 7 In this context, joining efforts between hospitals in the same region is perhaps the only feasible strategy to improve the results of PAS management.

Most interdisciplinary groups choose to go through their " training curve" alone, without sharing their successes and failures with other groups, and even more serious, without being advised (and less supervised) by other groups with more experience. This is shown by the multiplicity of management options published, 8,9 each one defended by the group that applies it, and the small number of multicenter prospective studies evaluating the same management strategy in different hospitals (which would require that at least one hospital gives in, and applies the surgical technique used in another hospital) or by comparing two different management strategies head-to-head (which implies that several hospitals apply at least two different surgical techniques, which requires training in the technique preferred by another group).

Our group has experienced the difficulties of the traditional individualistic approach. In our city (with 2.2 million inhabitants), there were 10 hospitals that considered themselves reference centers for PAS, operating around 3 cases per year, without sharing any type of information with the other hospitals. Additionally, there was no clear pathway of care for PAS in our country, nor education or research initiatives at the regional level. Considering the economic and cultural limitations of our region, we have invested time in evaluating the usefulness of sharing knowledge, 10 with an emphasis on mistakes made, improvement opportunities 11 and collaborative research. To our surprise, very inexpensive strategies such as informal telemedicine, 12 virtual education and communication facilitated by free or low-cost platforms 13 have had a positive impact on the diagnostic and therapeutic performance of various PAS teams.

Of course, our appreciations must be confirmed with additional studies, but we cannot stop emphasizing the importance of collaborative work to travel faster on the path to excellence and address elements such as patient preferences (choosing who accompanies her in elective surgery, deciding whether to preserve her uterus or her fertility in selected cases, etc.) and the family psychological impact of this serious diagnosis; without neglecting strategies to make the management of PAS increasingly safer.