Cesarean Delivery in Family Medicine (Position Paper)

Overview and Purpose

Overview and Justification

Obstetric care is an integral part of many family physicians’ scope of practice and an important component of family medicine residency training.^1-4 A substantial percentage of perinatal care in the United States is provided by family physicians, especially in rural and underserved communities, in which family physicians provide a disproportionate amount of maternity care.^5,6 The percentage of family physicians living and working in rural communities (15.7%) exceeds that of any other physician specialty,⁷ and studies have shown that family physicians play a vital role in maintaining access to obstetric care in rural communities. For example, researchers found that the majority of physicians performing both vaginal and abdominal deliveries in rural hospitals in 15 states were family physicians.⁶ In the smallest and most remote of these hospitals, including critical access hospitals, family physicians were more likely to be the only health care professionals performing maternity care services and cesarean deliveries. According to a 2021 study, 57.3% of family physicians who perform cesarean deliveries do so in rural counties and 38.6% do so in counties that have no obstetrician/gynecologists.⁸

An American Academy of Family Physicians (AAFP)/American College of Obstetricians and Gynecologists (ACOG) joint statement asserts that access to high-quality maternity care is an important public health concern in the United States.⁹ The maternal mortality rate in the United States is one of the highest in the developed world,¹⁰ with higher rates of mortality occurring among Black individuals, individuals with low income, and individuals living in rural areas.^11,12 The AAFP’s position paper on striving for birth equity states, “The factors driving these disparities are complex and intersect with clinical care, patient health, and public health on many levels. The [AAFP] believes family physicians can play a significant part in addressing the disparities in maternal morbidity and mortality because they are trained to provide comprehensive care across the life course, including prenatal, perinatal, and postpartum care, for people in the communities where they live.”¹³ A cooperative relationship among family physicians, obstetrics subspecialists, and nurse midwives is essential in order to provide pregnant individuals with consistent, comprehensive care. The most important objective must be the highest standard of obstetric care, regardless of specialty.

Cesarean delivery is one of the most common surgical procedures in the United States.¹⁴ According to the National Center for Health Statistics (NCHS), approximately 1.2 million cesarean deliveries are performed in the United States annually.¹⁵ In 2018, 31.9% of U.S. births were cesarean deliveries.¹⁵ Previous cesarean delivery, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia are some of the most common indications for cesarean delivery.^16,17 Despite the use of risk-assessment systems and protocols, the need for cesarean delivery can arise suddenly and unpredictably during the course of labor, so health care systems must plan for obstetric emergencies. An essential component of modern perinatal care is the prompt availability of surgical intervention that does not require transporting the patient, particularly in rural communities in which travel can be complicated by geography or weather or there may not be adequate time or resources to transfer patients to a distant health care facility.^18,19 Patients in rural areas benefit when their local hospital can handle obstetric emergencies by offering safe cesarean delivery.¹⁹

Provision of cesarean delivery by well-trained family physicians augments maternity care services available to patients or, in some cases, provides a service that would not otherwise be available^.6,8,20 Quality patient care requires that all physicians—regardless of specialty—practice within their ability, as determined by documented training and experience, demonstrated abilities, and current competence.^9,13 Given that there are family physicians who currently perform cesarean delivery and family medicine residents who are being trained to provide this service, it is important to have shared common standards of perinatal care, as well as a common understanding of the place of cesarean delivery within a family physician’s scope of practice and within the health care delivery system.

This document should serve as a resource for family physicians who are training to perform cesarean delivery and planning to include this service in their practices. It also will help hospital and health plan credentialing committee members and administrators, obstetrics subspecialists, nurse midwives, and clinical staff understand the role of family physicians in providing cesarean delivery.

Section I – Scope of Practice for Family Physicians

Family medicine is a specialty based on comprehensive care that encompasses a wide range of medical services. Family physicians practice among diverse populations and in geographically varied settings, including rural communities. They choose a personal scope of practice based on factors that include their training experiences, their practice interests, and the needs of their patient populations and communities. Broadly speaking, the following indicate the extent to which cesarean delivery is within the current scope of family medicine:

• The joint AAFP/ACOG statement on cooperative practice and hospital privileges affirms that surgical delivery is within the scope of family medicine.⁹
• The AAFP’s recommended maternity care curriculum guidelines for family medicine residents describe training in advanced obstetric skills, which include performance of cesarean delivery.¹ The guidelines note that some advanced skills may be considered “core” skills in certain family medicine residency programs (e.g., programs that offer advanced obstetrics fellowships).
• In the United States, there are approximately 48 family medicine fellowships in obstetrics, many of which seek to train family physicians to perform cesarean delivery independently.^2-4,21 Many graduates of these programs practice in rural and/or underserved areas and have cesarean delivery privileges.
• The Society of Teachers of Family Medicine (STFM) Group on Hospital Medicine and Procedural Training published a consensus document that lists cesarean delivery among the advanced procedures that are within the scope of family medicine.²²

Studies have shown that the maternal and infant outcomes of cesarean deliveries performed by family physicians in active practice or in training can meet or exceed national standards.^23,24 A 2013 study showed that patients who had a cesarean delivery performed by a family physician did not face increased overall risk.²⁵ In addition, there is some evidence that individuals who receive perinatal care from family physicians have lower cesarean delivery rates than patients cared for by obstetrics subspecialists.^24,26 This is important for social and financial reasons and because surgical delivery carries a significantly increased risk of maternal morbidity and mortality compared with vaginal delivery.

Section II – Training Methodology

Cesarean delivery is a major abdominal surgical procedure that typically is learned during residency, extended residency, or fellowship training. Another possible route to the acquisition of cesarean delivery skills is preceptorship by a family physician, an obstetrics subspecialist, or a general surgeon who already has these privileges. Because cesarean delivery is a major surgical procedure, it would be unusual to acquire cesarean delivery skills in brief (e.g., weekend or weeklong) courses.

The AAFP’s recommended curriculum guidelines indicate that family medicine residents who seek cesarean delivery training because of their planned practice sites should be able to acquire this advanced skill during the course of a three-year residency.¹ Data indicate that many family physicians have achieved proficiency in operative delivery during residency, preparing them to perform cesarean delivery in various practice settings.^23,24,27 In 2009, an STFM task force published a consensus document affirming that cesarean delivery proficiency can be achieved in traditional family medicine residencies.²²

In approximately 48 U.S. family medicine fellowships in obstetrics,²¹ cesarean delivery is identified as a key skill and training is provided. These fellowships increase the likelihood of family physicians performing cesarean deliveries. A survey of 165 graduates of family medicine fellowships in obstetrics throughout the United States found that 66% of graduates had obtained cesarean delivery privileges.³ In addition, approximately half of the graduates of traditional family medicine fellowships in obstetrics work in rural areas for at least part of their career, which increases access to maternity care.^3,4

Another training model involves a four-year family medicine residency curriculum that includes an enhanced obstetrics track. A review of the first six years of one residency program’s enhanced obstetrics track found that residents who completed it had cesarean and high-risk delivery numbers comparable to those of residents completing an obstetrics/gynecology residency.²⁷ More recently, studies have focused on graduates of the 14 programs participating in the Preparing the Personal Physician for Practice (P4) project, a 5-year national demonstration project for innovations in family medicine residency training. One study found that graduates of P4 programs who were exposed to innovations that lengthened training were more likely to report including cesarean delivery in their practice compared with graduates of P4 programs with a standard length of training.²⁸ Another study found that graduates of a P4 program with a flexible longitudinal track in maternal/child health were much more likely to perform cesarean deliveries as the primary surgeon compared with all other P4 graduates.²⁹

As with many other procedures, the number of cesarean deliveries a physician must perform during training to gain competence has not been extensively studied. Because individual learners develop competence at different rates and therefore may require different numbers of procedures to attain proficiency, the literature documents high variability in the training numbers necessary for mastery of procedural skills.^22,30,31 One study of the cesarean delivery training curriculum in a three-year family medicine residency program found an average of 60 cesarean deliveries performed per resident.²⁴ In a survey of family medicine maternity care fellowships, the estimated mean num­ber of cesarean deliveries per­formed annually by fellows was 108.6 (SD=48.2), with a range of 60 to 190 performed.² The STFM Group on Hospital Medicine and Procedural Training has proposed a three-tier system for maternity care training, delineating advanced maternity care with cesarean delivery as the top tier which would require the completion of 50 primary cesareans as the primary operator verified by a faculty member.³⁰ Experts who convened at the Family Medicine Maternity Care Summit suggested that family physicians should perform at least 70 cesarean deliveries before they are assessed for competence.³²

The variability of training numbers for cesarean delivery emphasizes the need for routine supervision and review of trainees, and the need for proctoring in training and assessment of competence that is not heavily based on training numbers; this approach is common in other surgical specialties. Acquisition of the psychomotor skills needed for cesarean delivery should be coupled with the development of cognitive skills required to know when to perform the procedure and how to manage medical and surgical complications, such as those listed in Table A1. Family physicians should be able to recognize and manage complications of cesarean delivery and obtain subspecialist consultation when necessary. Another important topic that should be part of cesarean delivery training is identification and understanding of preoperative risk factors that should prompt consultation, referral, or transfer of patients before surgery (Table A2). .

Section III – Testing, Demonstrated Proficiency, and Documentation

Testing and demonstration of proficiency in major surgical procedures such as cesarean delivery are usually done by direct observation during training or during a period of proctorship under another physician who is more experienced. The literature describes several processes for supervising physicians to determine whether physicians completing training are proficient in cesarean delivery.^24,27,30,32

The volume of cesarean deliveries needed to maintain proficiency has not been extensively studied. In a 15-year retrospective study that showed maternal and infant outcomes of cesarean deliveries performed by family physicians met or exceeded national standards, the number of cesarean deliveries performed by study participants ranged from five to 22 procedures per year.²³ A 2008 survey of graduates of U.S. family medicine fellowships in obstetrics found an overall average of 28.9 cesarean deliveries per year, with 22.5% of respondents averaging more than 30 procedures per year.³

The AAFP believes that documentation of training and experience is of utmost importance, not only for residents preparing for their first application for hospital privileges, but also for practicing physicians.³³ The AAFP recommends that family physicians document all significant training and experience so that it is recorded and can be reported in an organized fashion. Family physicians seeking to document their experience may do so in a variety of ways. These include keeping a file of operative reports and discharge summaries for patients on whom they have operated, or assembling a case database that includes details such as those suggested in Table A3.

In 2009, the American Board of Physician Specialties (ABPS) began offering certification in family medicine obstetrics.³⁴ For eligible applicants, the process of certification for family medicine obstetrics with surgical qualification involves satisfactory completion of a written examination and an oral examination, and confirmation of surgical competence by peer observers. Board certification in family medicine obstetrics from the ABPS is recognized by the U.S. Department of Labor, the Council for Affordable Quality Healthcare (CAQH), and the Centers for Medicare & Medicaid Services (CMS).^35-37

In the opinion of the AAFP, this certification should not be a requirement for privileges in routine obstetric care and should not be mandatory for certification in advanced maternity care skills, such as high-risk obstetrics and cesarean delivery.³⁸ It is one of several possible mechanisms for verification of training and competence in obstetrics. However, since some existing hospital bylaws may require physicians to be board certified or board eligible in obstetrics, some family physicians have found obtaining ABPS board certification instrumental in obtaining hospital privileges in both rural and urban settings.

Section IV – Credentialing and Privileges

For hospitals and medical staff, the policies of respected national organizations are the best source of guidance on the credentialing of appropriately trained, competent family physicians who seek hospital privileges. In their joint statement on cooperative practice and hospital privileges, the AAFP and ACOG state the following⁹:

“The assignment of hospital privileges is a local responsibility, and privileges should be granted on the basis of training, experience, and demonstrated current competence. All physicians should be held to the same standards for granting of privileges, regardless of specialty, in order to [ensure] the provision of high-quality patient care. Prearranged, collaborative relationships should be established to ensure ongoing consultations, as well as consultations needed for emergencies.

The standard of training should allow any physician who receives training in a cognitive or surgical skill to meet the criteria for privileges in that area of practice. Provisional privileges in primary care, obstetric care, and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented. All physicians should be subject to a proctorship period to allow demonstration of ability and current competence. These principles should apply to all health care systems.”

According to these guidelines, it would be improper to base the granting of privileges on the specialty of a physician’s residency training. This perspective is in line with the policies of other organizations with influence on credentialing and privileging, including the American Medical Association (AMA) and The Joint Commission.

The AMA’s policy on patient protection and clinical privileges states, in part, “Concerning the granting of staff and clinical privileges in hospitals and other health care facilities, the AMA believes: (1) the best interests of patients should be the predominant consideration; (2) the accordance and delineation of privileges should be determined on an individual basis, commensurate with an applicant's education, training, experience, and demonstrated current competence. In implementing these criteria, each facility should formulate and apply reasonable, nondiscriminatory standards for the evaluation of an applicant's credentials, free of anti-competitive intent or purpose.”³⁹

The Joint Commission's standards also require that the decision to grant or deny privileges, and/or to renew existing privileges, must be an objective, evidence-based process in which there are no barriers to granting privileges for a given activity to more than one clinical specialty. The Joint Commission Comprehensive Accreditation Manual states, “Credentialing involves the collection, verification, and assessment of information regarding three critical parameters: current licensure; education and relevant training; and experience, ability, and current competence to perform the requested privilege” [MS.06.01.03].⁴⁰ All of the criteria regarding current licensure, training, experience, competence, and ability to perform the requested privilege should be “consistently evaluated for all practitioners holding that privilege” [MS.06.01.05].⁴⁰

Current hospital and health care organization policies and procedures for credentialing family physicians in cesarean delivery vary markedly from site to site. In hospitals that have a department of family medicine, the department may credential its own members. In hospitals that have no experience with family physicians performing cesarean delivery, there may be no mechanism for credentialing in this procedure. If a hospital has coexisting departments of family medicine and obstetrics, the departments may or may not have a cooperative credentialing arrangement.

Family physicians moving to a new practice site would benefit from extensively researching the policies and procedures of their chosen site regarding privileges for cesarean delivery and other procedures, and obtaining these privileges before actually moving to the new practice site, if possible. This approach is particularly advisable if a family physician is the first to request cesarean delivery privileges in an environment in which obstetrics subspecialists alone hold such privileges.

The number of procedures performed in training is often used as a criterion for credentialing; however, numbers alone do not demonstrate quality of outcomes. Family physicians seeking cesarean delivery privileges should have extensive documentation of their experience, including the following³³:

• Number of procedures performed during training and in practice
  
• Outcomes data (see suggested items in Table A3)
• Letters from instructors, preceptors, and proctors that document training, experience, demonstrated abilities, and current competence

Using community need as a reason to grant or deny privileges to family physicians is not consistent with The Joint Commission, AMA, or joint AAFP/ACOG credentialing guidelines and should not be done. Services provided by family physicians, obstetrics subspecialists, and nurse midwives are different and offer patients options for care. Obstetric services are provided by family physicians in the context of whole-person family care and usually with subsequent neonatal care. Furthermore, “turf battle” situations could lead to legal action on the basis of discrimination and restraint of trade (i.e., antitrust).

At some institutions, ability to manage complications of cesarean delivery may be a requirement for obtaining privileges. For example, the ability to perform a cesarean hysterectomy for persistent hemorrhage may be required, in spite of the fact that cesarean hysterectomy is a rare procedure that a family physician would not typically need to perform.⁴¹ All physicians, regardless of specialty, would be expected to seek consultation for a rare condition, and numerous effective temporizing techniques are available to manage severe blood loss during cesarean delivery while consultation is being arranged.^42-44 In addition, a significant percentage of patients who are at high risk of severe hemorrhage and subsequent cesarean hysterectomy—most notably those who have a history of previous cesarean delivery or placenta previa—can be identified before surgery.⁴⁵ Although no risk-assessment system can predict the outcomes of all cesarean deliveries, preoperative risk factors (Table A2) for complications of cesarean delivery that are outside of the family physician’s scope of practice can be identified to prompt consultation, referral, or transfer of patients before surgery, as necessary.

A family physician who performs cesarean delivery should have an established system for consulting with partners, other family physicians, general surgeons, and obstetrics subspecialists, as appropriate. In addition, resources (e.g., laminated protocol cards, an electronic database) should be available in the delivery suite for immediate reference if assistance is needed. Telemedicine consultation might be especially useful for family physicians who practice in rural communities.¹⁹

Section V – Miscellaneous Issues

A.  Quality programs
Family physicians who perform cesarean delivery should establish ongoing case-review programs to monitor their delivery and surgical outcomes. Table A3 provides a suggested model for collection of data on maternal and infant outcomes that can be compared with standard outcomes.

B.  Public health and community implications
High-quality surgical care is important for good perinatal outcomes. Because family physicians are the most widely available physicians, particularly in rural and underserved areas, expanding and improving cesarean delivery skills could improve access to modern perinatal care for many patient populations.^18,19 There is extensive literature that documents better birth outcomes when local maternity care services are available.^46-49 The survival of small rural hospitals often depends on their ability to continue providing perinatal care. Therefore, rural hospitals need physicians who can perform normal deliveries and operative deliveries.^4,8,19

C.  Research agenda
The research agenda related to cesarean delivery by family physicians should focus on four major areas:

1. Documenting the ongoing outcomes of cesarean delivery by family physicians
2. Investigating differences between family physicians and obstetrics subspecialists in the management of labor and cesarean delivery rates
3. Evaluating training methods (including cognitive and procedural aspects of training); identifying the points at which proficiency in cesarean delivery and other procedures is reached; and determining what learner qualities predict earlier master. 
   • This area of research should include investigating whether tools such as videos, multimedia programs, and simulators can be developed to prepare physicians to manage rare complications
4. Identifying conditions under which a trial of labor after cesarean (TOLAC) is acceptable and evaluating the effect of policies regarding vaginal birth after cesarean (VBAC) on access to care for individuals in rural communities
   • See the AAFP’s clinical practice guideline Vaginal Birth After Cesarean for additional information.⁵⁰

D.  Relationships with other organizations
The AAFP and ACOG should maintain a dialogue on the issue of cesarean delivery by family physicians. The AAFP/ACOG Joint Statement on Cooperative Practice and Hospital Privileges and the AAFP’s recommended maternity care curriculum guidelines for family medicine residents should be periodically reaffirmed and revised.^1,9 Cooperation between family physicians and obstetrics subspecialists for the common goal of improving access to quality maternity care and availability of such care should be encouraged.The AAFP and ACOG should maintain a dialogue on the issue of cesarean delivery by family physicians. The AAFP/ACOG Joint Statement on Cooperative Practice and Hospital Privileges and the AAFP’s recommended maternity care curriculum guidelines for family medicine residents should be periodically reaffirmed and revised.^1,9 Cooperation between family physicians and obstetrics subspecialists for the common goal of improving access to quality maternity care and availability of such care should be encouraged.

Section VI – References

1. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents. Maternity care. AAFP; 2018. AAFP Reprint No. 261. Accessed March 15, 2021.
http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint261_Maternity.pdf

2. Peterson LE, Blackburn B, Phillips RL Jr, et al. Structure and characteristics of family medicine maternity care fellowships. Fam Med. 2014;46(5):354-359.

3. Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332.

4. Rodney WM, Martinez C, Collins M, et al. OB fellowship outcomes 1992-2010: where do they go, who stops delivering, and why? Fam Med. 2010;42(10):712-716. 

5. American College of Obstetricians and Gynecologists. Health disparities in rural women. ACOG Committee Opinion No. 586. Obstet Gynecol. 2014;123:384-388.

6. Young RA. Maternity care services provided by family physicians in rural hospitals. J Am Board Fam Med. 2017;30(1):71-77.

7. American Academy of Family Physicians. Family medicine facts. Table 2: Demographic characteristics of AAFP members (as of December 31, 2018). Accessed March 15, 2021. https://www.aafp.org/about/the-aafp/family-medicine-specialty/facts/table-2.html

8. Tong ST, Eden AR, Morgan ZJ, et al. The essential role of family physicians in providing cesarean sections in rural communities. J Am Board Fam Med. 2021;34(1):10-11.

9. American Academy of Family Physicians, American College of Obstetricians and Gynecologists. AAFP-ACOG joint statement on cooperative practice and hospital privileges. Accessed March 15, 2021. http://www.aafp.org/about/policies/all/aafp-acog.html

10. MacDorman MF, Declercq E, Cabral H, et al. Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol. 2016;128(3):447-455.

11. American Academy of Family Physicians. Striving for birth equity: family medicine's role in overcoming disparities in maternal morbidity and mortality. Accessed March 15, 2021. https://www.aafp.org/about/policies/all/birth-equity-pos-paper.html

12. Kozhimannil KB, Interrante JD, Henning-Smith C, et al. Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15. Health Aff (Millwood). 2019;38(12):2077-2085.

13. American Academy of Family Physicians. Maternal/child care (obstetrics/perinatal care). Accessed March 15, 2021. https://www.aafp.org/about/policies/all/maternal-child.html

14. McDermott KW, Freeman WJ, Elixhauser A. Overview of operating room procedures during inpatient stays in U.S. hospitals, 2014. HCUP statistical brief #233. December 2017. Accessed March 15, 2021. www.hcup-us.ahrq.gov/reports/statbriefs/sb233-Operating-Room-Procedures-United-States-2014.pdf

15. Martin JA, Hamilton BE, Osterman MJK, et al. Births: final data for 2018. Natl Vital Stat Rep. 2019;68(13):1-47.

16. American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014;123(3):693–711.

17. Quinlan JD, Murphy NJ. Cesarean delivery: counseling issues and complication management. Am Fam Physician. 2015;91(3):178-184.

18. Dresang L, Koch P. The need for rural family physicians who can perform cesareans. Am J Clin Med. 2009;6(2):39-41.

19. Cullen J. Family physicians ability to perform cesarean sections can reduce maternal and infant mortality. J Am Board Fam Med. 2021;34(1):6-9.

20. Kozhimannil KB, Casey MM, Hung P, et al. The rural obstetric workforce in US hospitals: challenges and opportunities. J Rural Health. 2015;31(4):365-372.

21. American Academy of Family Physicians. Family medicine fellowship directory. Accessed March 15, 2021. https://www.aafp.org/medical-education/directory/fellowship/search

22. Kelly BF, Sicilia JM, Forman S, et al. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):398-404.

23. Deutchman M, Connor P, Gobbo R, et al. Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study. J Am Board Fam Pract. 1995;8(2):81-90.

24. Heider A, Neely B, Bell L. Cesarean delivery results in a family medicine residency using a specific training model. Fam Med. 2006;38(2):103-109.

25. Homan FF, Olson AL, Johnson DJ. A comparison of cesarean delivery outcomes for rural family physicians and obstetricians. J Am Board Fam Med. 2013;26(4):366-372.

26. Hueston WJ, Applegate JA, Mansfield CJ, et al. Practice variations between family physicians and obstetricians in the management of low-risk pregnancies. J Fam Pract. 1995;40(4):345-351.

27. Eidson-Ton WS, Nuovo J, Solis B, et al. An enhanced obstetrics track for a family practice residency program: results from the first 6 years. J Am Board Fam Pract. 2005;18(3):223-228.

28. Eiff MP, Hollander-Rodriguez J, Skariah J, et al. Scope of practice among recent family medicine residency graduates. Fam Med. 2017;49(8):607-617.

29. Young RA, Casey D, Singer D, et al. Early career outcomes of family medicine residency graduates exposed to innovative flexible longitudinal tracks. Fam Med. 2017;49(5):353-360.

30. Coonrod RA, Kelly BF, Ellert W, et al. Tiered maternity care training in family medicine. Fam Med. 2011;43(9):631-637.

31. Dijksterhuis MG, Voorhuis M, Teunissen PW, et al. Assessment of competence and progressive independence in postgraduate clinical training. Med Educ. 2009;43(12):1156-1165.

32. Magee SR, Eidson-Ton WS, Leeman L, et al. Family medicine maternity care call to action: moving toward national standards for training and competency assessment. Fam Med. 2017;49(3):211-217.

33. American Academy of Family Physicians. Privileging policy statements. Accessed March 15, 2021. http://www.aafp.org/about/policies/all/privileges.html

34. American Board of Physician Specialties. Board certification in family medicine obstetrics. Accessed March 15, 2021. http://www.abpsus.org/family-medicine-obstetrics

35. U.S. Bureau of Labor Statistics. How to become a physician or surgeon. Accessed March 15, 2021. https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm#tab-4

36. American Board of Physician Specialties. About the ABPS. Accessed March 15, 2021. https://www.abpsus.org/a-recognized-choice-for-physician-board-certification/

37. Primary care services furnished by physicians with specified specialty and subspecialty. 42 CFR §447.400 (2012). Accessed March 15, 2021. https://www.govinfo.gov/content/pkg/FR-2012-11-06/pdf/2012-26507.pdf

38. American Academy of Family Physicians. Hospital medical staff, board certification for membership. Accessed March 15, 2021. https://www.aafp.org/about/policies/all/hospital-medical-staff.html

39. American Medical Association. Patient protection and clinical privileges H-230.989. Access March 15, 2021. https://policysearch.ama-assn.org/policyfinder/detail/privileges?uri=%2FAMADoc%2FHOD.xml-0-1620.xml

40. The Joint Commission. Joint Commission Comprehensive Accreditation Manual: Hospital Edition. The Joint Commission; 2021.

41. Shellhaas CS, Gilbert S, Landon MB, et al. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol. 2009;114(2 pt 1):224-229.

42. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007;62(8):540-547.

43. Fawcus S, Moodley J. Postpartum haemorrhage associated with caesarean section and caesarean hysterectomy. Best Pract Res Clin Obstet Gynaecol. 2013;27(2):233-249.

44. Main EK, Goffman D, Scavone BM, et al. National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage [published correction appears in Obstet Gynecol. 2015 Nov;126(5):1111] [published correction appears in Obstet Gynecol. 2019 Jun;133(6):1288]. Obstet Gynecol. 2015;126(1):155-162.

45. Machado LS. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. N Am J Med Sci. 2011;3(8):358-361.

46. Nesbitt TS, Connell FA, Hart LG, et al. Access to obstetric care in rural areas: effect on birth outcomes. Am J Public Health. 1990;80(7):814-818.

47. Nesbitt TS, Larson EH, Rosenblatt RA, et al. Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use. Am J Public Health. 1997;87(1):85-90.

48. Larimore WL, Davis A. Relation of infant mortality to the availability of maternity care in rural Florida. J Am Board Fam Pract. 1995;8(5):392-399.

49. Kozhimannil KB, Hung P, Henning-Smith C, et al. Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the United States. JAMA. 2018;319(12):1239-1247.

50. American Academy of Family Physicians. Clinical practice guideline: vaginal birth after cesarean (reaffirmed 2019). Accessed March 15, 2021. http://www.aafp.org/pvbac

(B1997) (2016 COD) (January 2022 COD)

Appendix

Table A1: Complications of Cesarean Delivery

Table A2: Preoperative Risk Factors for Complications of Cesarean Delivery

Table A3: Suggested Data List for Documentation of Cesarean Delivery Experience

(1997) (July 2021 BOD)