There are so many factors that enter into this topic. I'm not sure where I would really start. I was trained as a Resident 1973-1977 and once I settled down into the full time practice of OB/Gyne, it was 1978, late in the year. I came to a large cllinic practice in Central WI. which had a Level 3 or Level 4 NICU and received a lot of referals from the northern half of the state. We hired the first Parinatologist shortly after I arrived and at one time had 3 in our practice. Our C-section rate was at the most in the low teen's. One of the issues that changed starting in the late 60's or so was the issue of Malpractice and litigation that complicated the decision making process. I have special feelings in that area. The training received in those years was changing because of the advent of Fetal-Maternal monitoring and that coupled with the rapidily improving Ultrasound equipment and the ability to use it was moving rapidly. In the large residency programs the use of alternative methods of delivery assistance was taught, Forceps, Vacuum assistance and methods of determining fetal well being. I remember that I was at the bedside of many patients that needed support. The use of Epidurals and othat forms of pain relief were starting to be used. I, personally, persued the use of these methods when I was a Senior Med student. I was fortunate enough to have made contact with the Head of Anesthesia at Lying-In Hospital at the University of Chicago and get exposed to many methods of dealing with the issue of pain during labor. It was about that time that the Lamase method of tolerating labor came into vogue and that method of "Self-Hypnosis" was a good tool to add to the many learned. This can look more like a second article on the topic so we should move to today. We have NOT solved all the problems in Medicine and particularly child birth. There are several factors that play a role, in my opinion. A serious problem is the establishment of rapport with any patient. What follows is the confidence that what is going to happen in a situation that is filled with fear and mystery has been lost and the mechanistic approach has taken hold. Enter the Hospitalist and the disconnection of the patient from their trusted Physician. This problem needs to be reversed and the suggestions of the author would be a good start. Corporate Medicine (Socialized Medicine) is NOT the answer.
You raise an important point. Obstetrics has shifted from a continuity-based, relationship-driven model to a more fragmented, system-based one, and that affects trust and decision-making.
The goal of next-day cesarean review is not to replace clinical judgment, but to restore reflection and accountability in a setting with more handoffs and less continuity.
In my own case reviews, I found that a substantial number of cesareans had no clearly identifiable indication documented, which underscores the need for structure. Maybe implement a requirement where every attending completes a brief justification form for each cesarean, with routine review to ensure clarity, consistency, and accountability in decision-making?
In socialized medicine, the government finances and operates healthcare delivery, and care is funded through taxation and provided based on medical need rather than ability to pay. In corporate medicine, healthcare delivery is financed and operated by large private entities, including hospital systems, private equity firms, and insurance corporations.
Your parentheses imply that you are *very confused about these two models. And your all-caps points to a doubling down on your ignorance.
I so sorry that you are so dilussional. You have not experenced any of the Socialized systems, e.g. the UK or Canada. The UK is different because it is a two teared system with both Private Medicine and the National Health Service. In Canada it is the socialized system or NOTHING. The crux of the matter is that the "Money Pot" has a finite amount of funds and the Administration of those funds requires increased compensation to those administrators because the cost of living goes up. This results in a decrease in service to the people receiving services. The same thing occurs in Corporate Medicine but the cut comes, first to more exotic services, say Infertility then moves to less exotic areas and finally to an extended time for the simpler or less exotic procedures. I would like you point me to a Socialized Medicine system that has worked and the Society that has implimented it maintained their freedom.
The consistent presence of universal healthcare across the world’s happiest countries is not incidental. It reflects a baseline societal commitment to reducing financial and health-related insecurity, which are major drivers of stress and perceived well-being. When access to care is guaranteed, individuals are less burdened by fear of illness-related costs, and population-level trust in institutions tends to be higher. Universal healthcare does not create happiness on its own, but it is a foundational condition that removes a major source of unhappiness.
With respect, I'm not sure you have, checks notes, any knowledge about my experiences in the UK or Canada, sir. And it's delusional, not, dilussional. I think this conversation is done, as Dr. Grunebaum has more patience with you than I.
THIS IS A VERY WELL-DONE RESPONSE TO THE MAIN ARTICLE..... I, TOO, TRAINED IN OBGYN FROMM 1973-1977.... I, TOO, WENT INTO PRIVATE PRACTICE IN 1977.... I TOTALLY AGREE WITH Dr WINEMAN WITH HIS ANALYSIS... I MUST ADD, HOWEVER, THAT MY C-SECTION RATE THROUGH MY CAREER WAS ABOUT 32%, EVEN WITH PEER REVIEW.... MY PHILOSOPHY WAS THAT NOBODY WAS GOING TO SECOND GUESS ME AS TO WHETHER OR NOT I DELAYED DOING A C-SECTION OR NOT.... NOBODY WAS GOING TO HAVE TO PAY FOR A DAMAGED BABY BUT ME AND THE PARENTS WHO HAVE TO DEAL WITH HAVING A BABY BORN AS A RESULT OF A DELAYED C-SECTION.... DOING A C-SECTION IS A JUDGEMENT CALL ON THE PART OF THE OBSTETRICIAN.... I NEVER HAD A DEAD OR BRAIN DAMAGED BABY BORN UNDER MY CARE DURING THE 27 YEARS THAT I PRACTICED OB.... IN ADDITION, EXPECTING TO HAVE WEEKLY MEETINGS WITH OB ATTENDINGS IS IMPOSSIBLE AND IMPRACTICAL..... HIGH C-SECTION RATES ARE HERE TO STAY..... SORRY (not really!!)....
Dr. Titton, M.D. I understand and agree with you. Medicine, has been, and is still, an Art! And we are all tasked with making decisions, and sometimes, in seconds or minutes. I understand from whence you come!
When I complete my operative report, I review the indications for the procedure. In it, I detail all methods used for induction or augmentation of labor, any resuscitative measures, and why the decision was made to move to cesarean delivery. This is also helpful because it helps me advise patients for their next delivery- are they a good TOLAC candidate?
Almost impossible to implement. Most hospitals our now staffed with hospitalists in a move that has been driven by ACOG to reduce work hours. Many of them don’t live nearby. Can’t get them to come in even once a month, let alone weekly or twice weekly as you propose. Could try virtual, but they’ll want to be paid. I did find in the past that reporting data to all of the providers with transparency helped with accountability.
You raise a legitimate operational challenge, and I appreciate the honesty. The hospitalist model has fragmented accountability in ways that ACOG has never fully reckoned with. You are right that you cannot mandate what you cannot enforce.
But I want to separate two things: the logistics of who reviews, and the principle that every cesarean warrants a conversation. The principle does not change because implementation is hard. A cesarean is a major abdominal surgery. It carries risks for this delivery and for every delivery that follows. That conversation belongs in the standard of care regardless of staffing models.
Being a hospitalist cannot absolve you of responsibility.
Your point about transparent data reporting is exactly right — and in my view it is the most scalable tool we have. When every provider sees their own cesarean rate alongside their colleagues', behavior changes. Not always. Not fast. But it changes. Data with names attached is the most uncomfortable mirror in medicine, and discomfort is where improvement begins.
Virtual peer review is a workable middle path. Yes, people want to be paid. So do the patients recovering from unnecessary surgery.
Require that every cesarean be documented with a brief structured indication — one or two sentences entered at the time of delivery — and feed that data into a monthly transparent report distributed to every provider on staff, hospitalists included. When the data is visible, named, and discussed at a mandatory quarterly virtual review that takes 30 minutes and counts toward CME, participation stops being optional and starts being professional expectation.
There is no evidence that ACOG is promoting OB hospitalists to reduce work hours (https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/02/the-obstetric-and-gynecologic-hospitalist?utm_source=chatgpt.com). Instead, ACOG describes the model as a potential strategy to improve patient safety, the availability of skilled clinicians, and the quality of care. Many hospitals require attendance at department meetings to maintain privileges, so if your hospitalists aren't attending those meetings where accountability for cesarean section rates could be discussed, then petition your medical staff office to change their bylaws. This speaks more to medical staff than it does to the "can't get them to come in once a month."
Across medicine, limits apply: surgeons cannot operate without indication, cardiologists do not place stents without demonstrable benefit, and antibiotics are not prescribed without appropriate justification.
Obstetrics is no different. A cesarean delivery is a major surgical procedure that requires a clear clinical indication or a well-documented, informed patient request grounded in ethical justification.
Physician autonomy does not extend to performing interventions based solely on preference; it is bounded by professional responsibility, evidence, and accountability for maternal and neonatal outcomes.
Every operation, including cesarean delivery, should include a thorough explanation of the indication and clinical justification for the procedure. In the setting of a cesarean section, a few sentences should document the maternal and fetal clinical findings that support the decision for cesarean delivery, the course of labor (if indicated), and, especially, if the cesarean met criteria, for active stage arrest (https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management). Agree with Dr. Ferenchick, these descriptions are also helpful in the patient's *next labor for aiding both patient and physician in clinical decision making and recommdations.
I've been retired from full-time practice > 20 years, and locums work for >5. When I first started practicing in a rural Wyoming hospital, we had to get the other OB's consent that a cesarean was indicated (we were partners, also!) "Before-review," essentially (that was eliminated soon enough, unfortunately.) Working closely with trusted and experienced L&D nurses, there was general consensus particularly when prolonged labor was encountered, and interventions proved unsuccessful. My later practice in a metro hospital (MSP, MN) was notable for the fact that our practice had 8 FTE CNMs who had their own clientele. Our 5-6 MDs had a cesarean rate about 25%; our CNMs, 9%. And theirs was not a cherry-picked practice: women who were overweight, on the margins, and of mixed ethnicities often chose the CNM practice over our predominantly male MD providers. What factors went into that low rate? Of course, complications were managed by the MDs and thus shifted from "theirs" to "ours." But that certainly did not account for all the difference. And I served my time on the QA committee, a mostly thankless job. Most providers were too busy to bother attending our meetings. I will say this, though: the CNMs' time was structured so that a woman in labor was "attended"; not very often was I "in the room" with the laboring patient for hours upon hours. A different level of care? Perhaps. And this from a prompt to Google Gemini: https://share.google/aimode/edAfMyUlDZSwVZcIs. CNM team care in Great Britain's rate: about 10%. Finally, the devastating impact of rural hospital OB unit closures; how do we handle that, saving moms a 60 minute drive to the delivery unit? CNM team care, and "flying squads" (like, in helicopters??)
Frankly I think this article is 20 years too late. We have and I’m sure you all do, have QA committees that review cases and cite outliers. Our L&D nurses, without hesitation, will not hesitate to question indications. OB Hospitalists do most of our deliveries now and algorithms are closely followed. I finished residency in 1984. In those days, your “feeling” if she’s going to make it was good enough. We had attendings where nurses told you to make your decision now, because Dr. X is about to finish office hours and will “section anyone who isn’t to deliver.” Those days are over.
And why do African American women have higher Cesarean rates?
1- Social determinants of health?
2-Lifelong Nutrition?
3-Genetic factors as regards shape of the pelvis and musculature of the pelvic floor ?
There are so many factors that enter into this topic. I'm not sure where I would really start. I was trained as a Resident 1973-1977 and once I settled down into the full time practice of OB/Gyne, it was 1978, late in the year. I came to a large cllinic practice in Central WI. which had a Level 3 or Level 4 NICU and received a lot of referals from the northern half of the state. We hired the first Parinatologist shortly after I arrived and at one time had 3 in our practice. Our C-section rate was at the most in the low teen's. One of the issues that changed starting in the late 60's or so was the issue of Malpractice and litigation that complicated the decision making process. I have special feelings in that area. The training received in those years was changing because of the advent of Fetal-Maternal monitoring and that coupled with the rapidily improving Ultrasound equipment and the ability to use it was moving rapidly. In the large residency programs the use of alternative methods of delivery assistance was taught, Forceps, Vacuum assistance and methods of determining fetal well being. I remember that I was at the bedside of many patients that needed support. The use of Epidurals and othat forms of pain relief were starting to be used. I, personally, persued the use of these methods when I was a Senior Med student. I was fortunate enough to have made contact with the Head of Anesthesia at Lying-In Hospital at the University of Chicago and get exposed to many methods of dealing with the issue of pain during labor. It was about that time that the Lamase method of tolerating labor came into vogue and that method of "Self-Hypnosis" was a good tool to add to the many learned. This can look more like a second article on the topic so we should move to today. We have NOT solved all the problems in Medicine and particularly child birth. There are several factors that play a role, in my opinion. A serious problem is the establishment of rapport with any patient. What follows is the confidence that what is going to happen in a situation that is filled with fear and mystery has been lost and the mechanistic approach has taken hold. Enter the Hospitalist and the disconnection of the patient from their trusted Physician. This problem needs to be reversed and the suggestions of the author would be a good start. Corporate Medicine (Socialized Medicine) is NOT the answer.
You raise an important point. Obstetrics has shifted from a continuity-based, relationship-driven model to a more fragmented, system-based one, and that affects trust and decision-making.
The goal of next-day cesarean review is not to replace clinical judgment, but to restore reflection and accountability in a setting with more handoffs and less continuity.
In my own case reviews, I found that a substantial number of cesareans had no clearly identifiable indication documented, which underscores the need for structure. Maybe implement a requirement where every attending completes a brief justification form for each cesarean, with routine review to ensure clarity, consistency, and accountability in decision-making?
In socialized medicine, the government finances and operates healthcare delivery, and care is funded through taxation and provided based on medical need rather than ability to pay. In corporate medicine, healthcare delivery is financed and operated by large private entities, including hospital systems, private equity firms, and insurance corporations.
Your parentheses imply that you are *very confused about these two models. And your all-caps points to a doubling down on your ignorance.
And lastly, OBGYN hospitalists have been shown to lower cesarean section rates, https://www.sciencedirect.com/science/article/pii/S000293781300656X, https://pubmed.ncbi.nlm.nih.gov/25446697/#' https://pubmed.ncbi.nlm.nih.gov/26348175/
I so sorry that you are so dilussional. You have not experenced any of the Socialized systems, e.g. the UK or Canada. The UK is different because it is a two teared system with both Private Medicine and the National Health Service. In Canada it is the socialized system or NOTHING. The crux of the matter is that the "Money Pot" has a finite amount of funds and the Administration of those funds requires increased compensation to those administrators because the cost of living goes up. This results in a decrease in service to the people receiving services. The same thing occurs in Corporate Medicine but the cut comes, first to more exotic services, say Infertility then moves to less exotic areas and finally to an extended time for the simpler or less exotic procedures. I would like you point me to a Socialized Medicine system that has worked and the Society that has implimented it maintained their freedom.
The consistent presence of universal healthcare across the world’s happiest countries is not incidental. It reflects a baseline societal commitment to reducing financial and health-related insecurity, which are major drivers of stress and perceived well-being. When access to care is guaranteed, individuals are less burdened by fear of illness-related costs, and population-level trust in institutions tends to be higher. Universal healthcare does not create happiness on its own, but it is a foundational condition that removes a major source of unhappiness.
The US is #24
With respect, I'm not sure you have, checks notes, any knowledge about my experiences in the UK or Canada, sir. And it's delusional, not, dilussional. I think this conversation is done, as Dr. Grunebaum has more patience with you than I.
WOW!!!.... SO MUCH HATRED!!!.... JUST THINK, CANADA CAME IN SECOND IN OLYMPIC HOCKEY THIS YEAR.... YOU SHOUD BE HAPPY.... SPREAD THE LOVE....
Thank you for the spelling lesson.
THIS IS A VERY WELL-DONE RESPONSE TO THE MAIN ARTICLE..... I, TOO, TRAINED IN OBGYN FROMM 1973-1977.... I, TOO, WENT INTO PRIVATE PRACTICE IN 1977.... I TOTALLY AGREE WITH Dr WINEMAN WITH HIS ANALYSIS... I MUST ADD, HOWEVER, THAT MY C-SECTION RATE THROUGH MY CAREER WAS ABOUT 32%, EVEN WITH PEER REVIEW.... MY PHILOSOPHY WAS THAT NOBODY WAS GOING TO SECOND GUESS ME AS TO WHETHER OR NOT I DELAYED DOING A C-SECTION OR NOT.... NOBODY WAS GOING TO HAVE TO PAY FOR A DAMAGED BABY BUT ME AND THE PARENTS WHO HAVE TO DEAL WITH HAVING A BABY BORN AS A RESULT OF A DELAYED C-SECTION.... DOING A C-SECTION IS A JUDGEMENT CALL ON THE PART OF THE OBSTETRICIAN.... I NEVER HAD A DEAD OR BRAIN DAMAGED BABY BORN UNDER MY CARE DURING THE 27 YEARS THAT I PRACTICED OB.... IN ADDITION, EXPECTING TO HAVE WEEKLY MEETINGS WITH OB ATTENDINGS IS IMPOSSIBLE AND IMPRACTICAL..... HIGH C-SECTION RATES ARE HERE TO STAY..... SORRY (not really!!)....
Dr. Titton, M.D. I understand and agree with you. Medicine, has been, and is still, an Art! And we are all tasked with making decisions, and sometimes, in seconds or minutes. I understand from whence you come!
The men here definitely in their feelings. Verging on hysterical one might say.
When I complete my operative report, I review the indications for the procedure. In it, I detail all methods used for induction or augmentation of labor, any resuscitative measures, and why the decision was made to move to cesarean delivery. This is also helpful because it helps me advise patients for their next delivery- are they a good TOLAC candidate?
Almost impossible to implement. Most hospitals our now staffed with hospitalists in a move that has been driven by ACOG to reduce work hours. Many of them don’t live nearby. Can’t get them to come in even once a month, let alone weekly or twice weekly as you propose. Could try virtual, but they’ll want to be paid. I did find in the past that reporting data to all of the providers with transparency helped with accountability.
You raise a legitimate operational challenge, and I appreciate the honesty. The hospitalist model has fragmented accountability in ways that ACOG has never fully reckoned with. You are right that you cannot mandate what you cannot enforce.
But I want to separate two things: the logistics of who reviews, and the principle that every cesarean warrants a conversation. The principle does not change because implementation is hard. A cesarean is a major abdominal surgery. It carries risks for this delivery and for every delivery that follows. That conversation belongs in the standard of care regardless of staffing models.
Being a hospitalist cannot absolve you of responsibility.
Your point about transparent data reporting is exactly right — and in my view it is the most scalable tool we have. When every provider sees their own cesarean rate alongside their colleagues', behavior changes. Not always. Not fast. But it changes. Data with names attached is the most uncomfortable mirror in medicine, and discomfort is where improvement begins.
Virtual peer review is a workable middle path. Yes, people want to be paid. So do the patients recovering from unnecessary surgery.
Require that every cesarean be documented with a brief structured indication — one or two sentences entered at the time of delivery — and feed that data into a monthly transparent report distributed to every provider on staff, hospitalists included. When the data is visible, named, and discussed at a mandatory quarterly virtual review that takes 30 minutes and counts toward CME, participation stops being optional and starts being professional expectation.
There is no evidence that ACOG is promoting OB hospitalists to reduce work hours (https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/02/the-obstetric-and-gynecologic-hospitalist?utm_source=chatgpt.com). Instead, ACOG describes the model as a potential strategy to improve patient safety, the availability of skilled clinicians, and the quality of care. Many hospitals require attendance at department meetings to maintain privileges, so if your hospitalists aren't attending those meetings where accountability for cesarean section rates could be discussed, then petition your medical staff office to change their bylaws. This speaks more to medical staff than it does to the "can't get them to come in once a month."
Across medicine, limits apply: surgeons cannot operate without indication, cardiologists do not place stents without demonstrable benefit, and antibiotics are not prescribed without appropriate justification.
Obstetrics is no different. A cesarean delivery is a major surgical procedure that requires a clear clinical indication or a well-documented, informed patient request grounded in ethical justification.
Physician autonomy does not extend to performing interventions based solely on preference; it is bounded by professional responsibility, evidence, and accountability for maternal and neonatal outcomes.
https://cesarean-indication.netlify.app/
Every operation, including cesarean delivery, should include a thorough explanation of the indication and clinical justification for the procedure. In the setting of a cesarean section, a few sentences should document the maternal and fetal clinical findings that support the decision for cesarean delivery, the course of labor (if indicated), and, especially, if the cesarean met criteria, for active stage arrest (https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management). Agree with Dr. Ferenchick, these descriptions are also helpful in the patient's *next labor for aiding both patient and physician in clinical decision making and recommdations.
I've been retired from full-time practice > 20 years, and locums work for >5. When I first started practicing in a rural Wyoming hospital, we had to get the other OB's consent that a cesarean was indicated (we were partners, also!) "Before-review," essentially (that was eliminated soon enough, unfortunately.) Working closely with trusted and experienced L&D nurses, there was general consensus particularly when prolonged labor was encountered, and interventions proved unsuccessful. My later practice in a metro hospital (MSP, MN) was notable for the fact that our practice had 8 FTE CNMs who had their own clientele. Our 5-6 MDs had a cesarean rate about 25%; our CNMs, 9%. And theirs was not a cherry-picked practice: women who were overweight, on the margins, and of mixed ethnicities often chose the CNM practice over our predominantly male MD providers. What factors went into that low rate? Of course, complications were managed by the MDs and thus shifted from "theirs" to "ours." But that certainly did not account for all the difference. And I served my time on the QA committee, a mostly thankless job. Most providers were too busy to bother attending our meetings. I will say this, though: the CNMs' time was structured so that a woman in labor was "attended"; not very often was I "in the room" with the laboring patient for hours upon hours. A different level of care? Perhaps. And this from a prompt to Google Gemini: https://share.google/aimode/edAfMyUlDZSwVZcIs. CNM team care in Great Britain's rate: about 10%. Finally, the devastating impact of rural hospital OB unit closures; how do we handle that, saving moms a 60 minute drive to the delivery unit? CNM team care, and "flying squads" (like, in helicopters??)
Frankly I think this article is 20 years too late. We have and I’m sure you all do, have QA committees that review cases and cite outliers. Our L&D nurses, without hesitation, will not hesitate to question indications. OB Hospitalists do most of our deliveries now and algorithms are closely followed. I finished residency in 1984. In those days, your “feeling” if she’s going to make it was good enough. We had attendings where nurses told you to make your decision now, because Dr. X is about to finish office hours and will “section anyone who isn’t to deliver.” Those days are over.
And why do African American women have higher Cesarean rates?
1- Social determinants of health?
2-Lifelong Nutrition?
3-Genetic factors as regards shape of the pelvis and musculature of the pelvic floor ?
Don’t even try to suggest racism
We need adequate time to dedicate for this purpose. This is part of the challenge, and since now the rate is double, the time required will be double.