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Connect with District VIII on Facebook

District VIII on FacebookIn an effort to provide you with current information regarding women’s health, District VIII has joined Facebook. We are updating our page regularly with news specifically relevant to District VIII members. You can find us at

ACOG national is also on Facebook at If you’re a Facebook member, log in and click on the “Like” button on the ACOG national and District VIII pages. Then, you’ll be able to comment on and share any updates posted. You’ll also get ACOG national and District VIII news sent directly to your Facebook news feed.

Anyone can view Facebook pages, but only Facebook members can interact with ACOG national and District VIII. To become a Facebook member, sign up at

ACOG national is also on Twitter at To follow its feed, go to and sign up as a member. You’ll be the first to hear ACOG news!


From the chair

Dr. Susan M. LemagieSusan M. Lemagie, MD

Congratulations to ACOG Fellow Robert M. Wah, MD, who was elected president-elect of the American Medical Association (AMA) in June. Dr. Wah is a nationally recognized expert in health information technology. He currently serves as chief medical officer for Computer Sciences Corporation, where he works with public and private agencies using technology to improve health care. He also teaches and sees patients at Walter Reed National Military Center in Bethesda, MD, and at the National Institutes of Health.

Dr. Wah will serve as president-elect for one year and be sworn in as AMA president in June 2014. Born and raised in Oregon, Dr. Wah graduated from the University of Oregon and received his medical degree from the Oregon Health Sciences University. Dr. Wah is a strong advocate for women’s health and an honorary member of District VIII! 

The AMA works closely with ACOG on women’s health issues, such as supporting federal funding for research on perinatal and postpartum depression, enhancing maternal mortality review at the state level, and lobbying against shackling incarcerated pregnant women in labor. ACOG currently has one of the largest groups in the AMA House of Delegates. By joining the AMA and selecting ACOG as your medical specialty society, you can help us continue to have a strong and united voice for our patients.

HPV vaccination controversies
Human papillomavirus (HPV) vaccination has been in the news a lot recently, with studies showing HPV infection decreasing by half in girls ages 14 to 19 since the HPV vaccine has been available. This is great news, and we in medicine celebrate it. However, parents’ fears seem to be increasing, and fewer girls are being vaccinated. According to a study published in Pediatrics in April, almost 44% of parents say they do not intend to have their children receive the vaccine.

Why are parents refusing what we regard as a no-brainer? We know the HPV vaccine is safe and effective at preventing cancer. However, there is a lot of misinformation out there claiming that the vaccine has never been shown to prevent cervical cancer, that it causes significant health problems, and that it’s safer to just get Pap smears. Outlets relaying this information also tend to caution that the media and doctors are just trying to sell vaccines for big corporations and that the National Institutes of Health receives royalties from the sale of the vaccine. 

The Japanese Ministry of Health stopped recommending the vaccine in mid-June due to large numbers of vaccinated girls complaining of long-lasting pain and numbness. Complex regional pain syndrome has rarely been linked to immunizations in the US. Other countries have sited conversion disorder, when signs and symptoms appear with no underlying physical cause, or mass hysteria as possible explanations for large numbers of girls experiencing vaccination side effects.

The Centers for Disease Control and Prevention (CDC) addressed Japan’s action during its telebriefing on HPV prevalence in June, when a medical epidemiologist from the CDC immunization safety office stated the CDC has not established that the vaccine has caused any serious adverse events.

We need to be aware of this type of information, so we can answer our patients’ and their parents’ questions. Has anyone found a good response to those who refuse the vaccine? The authors of the Pediatrics study encourage doctors to stress the immunization’s efficacy and safety. The National Cancer Institute has a tutorial on the HPV vaccine that may be helpful.

Grand Wailea2013 ADM
I am looking forward to a successful Annual District Meeting at the Grand Wailea in Maui, HI, September 26–28. I hope you will join us!

If you’d like to participate in the “Dancing with the Docs” competition, please let me know. District VIII Junior Fellows won the mirror ball trophy last year, but I hear we will have some competition from Districts V, VI, and IX.

Awards and honors
‘Tis the season to start thinking about applying for ACOG awards. The Council of District Chairs (CDC) Service Recognition Award is given to districts and sections in recognition of outstanding activities contributed to the field of ob-gyn. The Alberta Section won in 2010 for its safer birth practices initiative, and the Oregon Section won in 2009 for its medical student recruitment efforts. If your section has a project you’d like to submit for the award, contact Stephanie Williams at 202-863-2588 or for more information. The deadline for submissions this year is November 30.

Deadlines for other awards, including the Pete and Weesie Hollis Community Service Award, the ACOG Award for International Service, and the Arthur P. Gold Foundation Humanism in Medicine Award (a new award for practicing physicians who demonstrate compassion and respectful care for a patient’s physical and emotional wellbeing) are on the ACOG website. These awards are presented at the Annual Clinical Meeting.

The State Legislative Advocacy Awards (one for accomplishment and one for improvement) and the new ACOG Junior Fellow Rising Star in Advocacy Award are presented at the Congressional Leadership Conference, The President’s Conference.

Remember, we can’t win unless we have nominees, and self-nominations are accepted! Recognition is a powerful motivator.


From the editor

Dr. Stella M. DantasStella M. Dantas, MD, District VIII secretary

We have such wonderfully talented Fellows in District VIII. This issue of the Gazette highlights many of the outstanding programs and people in our district.

District VIII was extremely proud this year to have our beloved James T. Breeden, MD, immediate past ACOG president and past District VIII chair, preside over the Annual Clinical Meeting. His presidential program was inspiring and eye-opening with lectures by Malcolm Potts, MD, titled “Sex, Ideology, and Religion: How Family Planning Frees Women and Changes the World,” and Gary Chapman, PhD, titled “The Five Languages of Apology.” The program seemed to stimulate conversations for days.

District VIII sections sponsored 17 medical students to attend the ACM this year. The students were able to take part in:

  • Medical student workshops on preparing a curriculum vitae and personal statement and choosing a residency
  • Hands-on skills sessions
  • Lectures and panels on residency training and dimensions of practice
  • A residency fair

In this issue, Leslie K. Palacios-Helgeson, a second-year medical student at the University of Colorado in Denver, shares her experience at the ACM. Students find the medical student programs at the ACM and the ADM invaluable. Thank you to the district and sections for continuing to prioritize medical student activities and involvement in ACOG. If you know of any students who deserve a scholarship to attend an ACOG meeting, please send me his or her information at

District VIII is also very fortunate to have two District VIII members involved in the ACOG Committee on Patient Safety and Quality Improvement: Sandra Koch, MD, vice chair of the committee, and W. Lawrence Warner, MD, Utah Section vice chair. Please read their articles on the Choosing Wisely campaign and arriving at the appropriate cesarean delivery rate. Both articles are powerful examples of why quality improvement is so important not only to our specialty but to the sustainability and advancement of health care.

At the Congressional Leadership Conference, The President’s Conference, this year, ACOG recognized District VIII with two honorable mentions for the State Legislative Advocacy Awards. The Hawaii Section received recognition in the category of “Most Improved.” Lori E. Kamemoto, MD, MPH, Hawaii Section chair, shares 10 lessons learned from the section’s first experiences with proposing bills. The section jumped right into the legislative arena, and it paid off!

Last but not least, our celebrity District VIII member Ralph W. Hale, MD, past ACOG executive vice president, has been appointed chair of the executive committee of the National Practitioner Data Bank. In this issue, he details ACOG’s involvement in the NPDB and its structure.

Please do not miss out on a tropical educational opportunity this year—the Annual District Meeting in Maui, HI. Tod C. Aeby, MD, District VIII program chair, has a wonderful meeting planned!

As always feel free to contact me at if you have feedback, article suggestions, or questions on how to become more involved in the district or your section. Your opinions and experience are invaluable resources to our fellowship.

I hope to see you all at the ADM!


Twenty-first century learning in Maui

Dr. Tod C. AebyTod C. Aeby, MD, District VIII program chair

“Pedagogy” is the science and art of education. While decades of education research have led to a greater understanding of how adults learn, medical education has been delivering instruction in basically the same manner for the past 100 years. The Planning Committee for the District V, VI, VIII, and IX Annual Meeting believes it’s time to start applying modern pedagogy to ob-gyn instruction. The committee has put together an outstanding program for the ADM that will deliver 15 CME hours of cutting-edge educational talks, topic reviews, and in-depth discussions on controversial subjects in women’s health.

Maui, HI

The ADM will be held September 26–28 at the Grand Wailea in Maui, HI. The keynote speaker, Charles Miller, PhD, assistant professor at the University of Minnesota, will bring us up to speed on mobile learning technologies. To help increase engagement in our attendees, he will be sharing the University of Minnesota’s innovative learning platform, Flipgrid. Additionally, the meeting will have its own unique learning community hosted by Ning. Using these technologies, your education will begin before you even get to Maui and will continue long after you’ve watched that last glorious sunset. When you register for the meeting, be sure to include your email address so that we can get you on board.   

In addition to the formal program, several other learning opportunities will be available. Junior Fellows and young physicians are sponsoring a leadership development course, led by Ralph W. Hale, MD, past ACOG executive vice president, and will offer individual oral case list review sessions for anyone who feels they might like some practice. There will also be several clinical symposia and a presentation by the University of Hawaii Institute for Astronomy (with remote viewing through the telescopes at the top of Haleakala!).

If you haven’t registered, it’s not too late. But, at $199 per night for this world-class meeting facility, the room block is going fast


Junior Fellow news

Dr. Stacy TsaiStacy Tsai, MD, District VIII Junior Fellow chair

I had the pleasure of representing District VIII at the Junior Fellow Congress Advisory Council Meeting at the Annual Clinical Meeting in New Orleans. Junior Fellows are spearheading some new and exciting national initiatives I would like to share.

First, the JFCAC developed a DVD on Social Media Professionalism in the Medical Community. The 4-minute video seeks to foster awareness of the consequences of posting inappropriate information or unprofessional pictures while using social media and technology applications.

The JFCAC also drafted a guide to medical education in advocacy to assist ob-gyn residency program directors in meeting new Council on Resident Education in Obstetrics and Gynecology (CREOG) learning objectives on health advocacy. The guide was presented at the 2013 CREOG and Association of Professors of Gynecology and Obstetrics Meeting and was well received. 

Junior Fellow legislative chair positions have been created for districts and sections throughout ACOG. The JFCAC hopes the addition of these positions will encourage more Junior Fellow involvement in the legislative process. District VIII will be adding this position to its advisory council soon. The newly appointed officer will work closely with the District VIII Fellow legislative chair on important district-wide issues.

Meghan A. McSorley, MD, PhD, MPH, immediate past Washington Section Junior Fellow chair, put together an informative toolkit to assist in planning statewide legislative days. She submitted this project to the 2012 Junior Fellow Initiative Toolkit Contest. If you have a project you would like to share with others, please consider submitting it. The deadline for submissions is November 30.

Lastly, please join us at the Annual District Meeting in Maui, HI, September 26–28. Some of the Junior Fellow events include:

  • Leadership Development Luncheon and Course, Thursday, September 26, 1 to 4:30 pm: Whether it’s for running a team on labor and delivery, a hospital committee, or a private practice, this course will prepare young physicians to be more effective leaders. It includes a self-assessment to understand how participants are wired and how to interact with others who have different leadership styles
  • Personalized Case List Review, Saturday, September 28, 12 to 1 pm: Junior Fellows taking or preparing for their oral board examination (whether they have completed their case list or not) can preregister for this course. Please email me at for additional instructions
  • Junior Fellow Trivia Challenge, Saturday, September 28, 8 to 9 am
  • Junior Fellow Prize Paper Presentations, Friday, September 27, 2 to 2:30 pm, and Saturday, September 28, 9 to 9:30 am
  • Scavenger Hunt FUNraiser: Help raise money for the District VIII Junior Fellow Central American Education Project (donations are tax deductible!). Embark on a photo scavenger hunt with medical students, Junior Fellows, and Fellows. Sign up in advance with LaShawn Jordan, District VIII project manager, at, or sign up at the ADM at the registration table. You’ll take pictures of your team’s success throughout the meeting. Entries will be due on Friday, September 27, at 6 pm

I hope to see you there!


Young physician update

Dr. Nicole E. MarshallDr. Sarah W. PragerNicole E. Marshall, MD, and Sarah W. Prager, MD, District VIII young physicians

We attended an interesting Young Physician Leadership Council Meeting on May 5 as part of the Annual Clinical Meeting in New Orleans. While there were many agenda topics, one of the most surprising was a discussion regarding the mentorship survey (thanks to all of you who completed it several months ago!). The majority of young physicians who responded are happy with their current level of mentorship and do not feel ACOG national or their district young physician representatives can help them find mentorship. This issue had been a primary focus for leadership over the last few years, so the survey results sparked a discussion about other areas that are potentially more important for new Fellows starting out in practice. Other areas discussed include maintenance of certification, medical liability, financial protection, and work-life balance.

Some interesting data presented at the meeting indicated that the number of ob-gyns who report having substance abuse issues has increased recently. It is unclear if the data represent a true increase in incidence or if reporting has simply improved. There is some discussion about exploring the extent to which substance abuse is a problem with young physicians. We welcome your input as to whether or not you see this as a critical issue.

We would love to hear your thoughts on what would be most helpful to you in your first eight years as Fellows and ways we can help your professional and personal development. As your District VIII representatives, we are focused on making ACOG as career- and family-friendly as possible. We’re working to minimize time away from practice and family by streamlining meetings and making sure they are family-friendly. What would make it easier for you to attend ACOG meetings? What has kept you from becoming more involved in ACOG?  

The Fourth Annual Young Physician Luncheon will be held on Friday, September 27, as part of the Annual District Meeting in Maui, HI. Ralph W. Hale, MD, past ACOG executive vice president, will present a condensed version of his popular “Future Leaders of Obstetrics and Gynecology” course, which will provide practical tips for different leadership styles. These tips will be helpful as we take on new challenges in our practices.

Informal gatherings are also planned for the ADM, including kid time by the pool and a happy hour for young physicians to network and build support systems. We should support one another as we are shaping our practices. As always, we welcome suggestions for additional gatherings and future meetings.

As a reminder, please check out the young physician website for additional helpful resources. We hope to see you in Maui!


Opportunities to advocate for women’s health

Dr. Tony OgburnTony Ogburn, MD, District VIII legislative chair

I hope everyone is having a great summer. Mixed in with all your summer activities, I encourage you to meet with legislators at the state and federal levels. The US House and Senate are in recess for most of August, and most members of Congress will be home for much of this time. Many of us have experience with brief meetings with legislators in Washington, DC, thanks to the Congressional Leadership Conference, The President’s Conference (CLC), and other opportunities. Local meetings are often much more relaxed, meaningful experiences. They’re a great time to build relationships and get to know local staff members. Local meetings are also more likely to include representatives or senators, not just members of their staff.

Most state legislatures are not in session right now, but members continue to meet with constituents and attend interim committee meetings. State medical societies will often host legislative events in the summer or early fall. These events provide great opportunities to speak with legislators and talk about women’s health issues. The ACOG Government Affairs staff will be happy to assist you in preparing for local meetings.

As you know, there are many issues in women’s health that need our attention. Two timely areas are implementation of health care reform and legislative interference with the doctor-patient relationship. As health care reform is implemented at the state level, there will be variation among the states (depending on their participation in Medicaid expansion) with the design of their exchanges and more. Legislators and other agencies will need our assistance at the state level to ensure women’s health services are optimized under the new programs. 

Legislative interference seems to be increasing in many states. The issue touches many aspects of the care we provide. Many bills focus on reproductive rights, including abortion, but they also include a wide variety of other issues, such as mammography and dense breasts, elective deliveries, and informed consent. Often these bills are based on personal beliefs, emotion, and politics—not science. Be diligent in identifying these bills, and work with your legislators to defeat them.

Please consider attending the 2014 CLC next year on March 2–4 and the District VIII legislative meeting on the morning of March 2. All District VIII Fellows and Junior Fellows are welcome! The current ACOG president leads the development of the CLC program each year, and Immediate Past ACOG President James T. Breeden, MD, past District VIII chair, did a fabulous job putting together a provocative lineup of speakers and topics in 2013. Next year’s CLC, with direction from ACOG President Jeanne A. Conry, MD, PhD, and the growing influence of ACOG, promises to be even better. Contact your section officers for more information.

Finally, I would encourage you to donate to Ob-Gyn PAC, ACOG’s federal political action committee. (You will not be favored or disadvantaged by reason of the amount of your contribution or a decision not to contribute. Contributions from foreign nationals are not permitted.) ACOG continues to have great success with legislative issues, and the support of our members is crucial for this success to continue.

It’s an honor and a pleasure to be your District VIII legislative chair. Please don’t hesitate to contact me at if I can be of assistance.


Proposing bills: 10 lessons learned in Hawaii

Hawaii Expedited Partner Therapy Bill Signing         

Lori E. Kamemoto, MD, MPH, Hawaii Section chair;
Hawaii Gov. Neil Abercrombie; and Cynthia J. Goto,
MD, past Hawaii Section chair, at the signing of a
bill proposed by the Hawaii Section to allow
expedited partner therapy for sexually transmitted

Lori E. Kamemoto, MD, MPH, Hawaii Section chair 

The Hawaii Section recently increased its state legislative activities with some success. We proposed our first two bills this legislative session. One bill, allowing expedited partner therapy for sexually transmitted diseases such as chlamydia, was signed into law by the governor on July 1. The other bill, regarding the establishment of a maternal mortality review committee in Hawaii, accelerated discussion with stakeholders. We think this bill will have a good chance of passing next session. We also assisted with another bill that passed this year, requiring hospitals to offer emergency contraception (EC) to all rape victims in Hawaii and to have EC readily available on site. It took 17 years for this bill to finally pass.

We discovered that the best way to learn about the legislative process is to jump right in and do it! For those interested in proposing bills, we hope the following lessons we learned are helpful:


  1. Develop a small and interested section legislative committee. Update the committee frequently via email
  2. Discuss legislative work at all your section meetings. You will be surprised by how many of your colleagues are interested and willing to write letters to, call, or email legislators. Because testimony is often required on very short notice, provide draft samples of testimonies, emails, and/or call scripts with instructions on how to submit them. Legislators do compare the stacks of testimonies in support of legislation to those against it
  3.           Women’s Health Legislator of the Year Award

    Hawaii Section leaders present State Sen. Josh
    Green (D-Kona), who was a primary sponsor of the
    bill allowing expedited partner therapy, with the
    2013 ACOG Women’s Health Legislator of the Year
    Award. Pictured left to right: Harry N. Yoshino, MD,
    past Hawaii Section chair; Lori E. Kamemoto, MD,
    MPH, Hawaii Section chair; State Sen. Green;
    Greigh I. Hirata, MD, Hawaii Section vice chair;
    and Raydeen M. Busse, MD, immediate past
    Hawaii Section chair


    Develop relationships with other stakeholder organizations. Nurse practitioners, certified nurse-midwives, and pediatricians were some of our biggest supporters. Find out if your state has a coalition of other organizations interested in women’s legislative issues. These organizations can be great supporters of bills. Hawaii also has a women’s caucus composed of women legislators. If your state has such a caucus, this is a good place to start to gain support for your bill
  4. There are so many legislative issues to consider. For our first bills, we tried to work on issues we thought were less controversial. However, you should understand that there will always be someone against your bill
  5. Prior to the start of the session, when discussing your proposed bill with supportive legislators, bring them good examples of other states’ bills. Determine if their office is willing to help write the bill, and collaborate with their staff. Make sure to meet the deadline for submitting bills and inquire about timelines
  6. Deadlines in the legislative process are strict. Be sure to determine what they are. Hawaii has an excellent Public Access Room, which we called many times to ask about deadlines and other nuances in the legislative process
  7. Be prepared to attend all committee hearings on your bill. Your oral testimony is usually short (three minutes or less), and showing up for these hearings is important to show your interest and support and to answer any questions. It is also important to be present to hear any opposing testimony for future strategy
  8. Be prepared to counter opposing testimony in your oral and written testimonies
  9. National ACOG is an invaluable resource and sounding board for issues that come up during the process. Do not hesitate to email or call ACOG staff
  10. Perseverance is the key to success


2013 ACM: Medical student perspective

Dr. Leslie K. Palacios-HelgesonLeslie K. Palacios-Helgeson, second-year medical student, University of Colorado, Denver

I was honored to represent Colorado at this year’s Annual Clinical Meeting in beautiful New Orleans. Having done research in ob-gyn for three years at the University of Colorado, pursuing ob-gyn as a career was definitely on my radar. I was initially apprehensive about attending the conference as a first-year medical student. Was it too early to attend clinical meetings? Would the student attendee benefits be lost on me? In fact, I cannot emphasize enough how beneficial the ACM was for me.

Attending the conference late in my first year was an advantage. Medical students at the University of Colorado complete Step 1 in April of their second year, so attending my second year was not an option. As someone seriously considering ob-gyn, attending right before my fourth year would have been late for me, personally. I now have an idea of how to frame my next three years, the types of programs to which I would actually be interested in applying, whether or not I will prioritize research, and the electives I would like to take to enhance my candidacy for residency.

The medical student activities at the ACM were well organized, relevant, and informative. I truly appreciate the people who put them together. Skills night was well received by every student I met, and it certainly brought a tangible excitement to those of us serious about ob-gyn. Panelists were honest, open, and answered questions thoroughly—especially those best answered by physicians working in different specialties and types of practice. I learned so much about practice options in general that I am now more self-reflective about the type of ob-gyn I want to be.

I also made a network of friends from other medical schools at the ACM. Many of us have already offered our couches to people we met at the meeting should we have the opportunity to interview in each other’s cities. The ACM served as the very beginning of a future of networking within the medical community.

Featured speakers at the general meeting were phenomenal. I enjoyed the talk “Sex, Ideology, and Religion: How Family Planning Frees Women and Changes the World” by Malcolm Potts, MD, so much that I purchased several of his books to read this summer. The lectures I attended were inspiring and empowering and have motivated me to become a patient advocate in addition to being a physician. My experience at the ACM has only strengthened my resolve to become an ob-gyn, and perhaps one day I may have a more active role in ACOG as well. I am grateful to the Colorado Section for the opportunity. 


ACOG encourages everyone to ‘choose wisely’

Dr. Sandra KochSandra Koch, MD, ACOG Committee on Patient Safety and Quality Improvement vice chair

Choosing Wisely is a campaign to help physicians, patients, and other health care stakeholders think and talk about overuse of health care resources in the US. Given the enormous financial investment America makes in its health care delivery system, it is laudable to be participating in a project where the aim is to improve the quality of health care while simultaneously decreasing the costs.

ACOG has joined more than 50 medical specialties, as well as Consumer Reports and a number of consumer-focused organizations, in working with the American Board of Internal Medicine Foundation on this project. 

In February, ACOG released a list of the top five tests and procedures to question in ob-gyn as part of the Choosing Wisely campaign:

  • Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age
  • Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable
  • Don’t perform routine annual Pap tests in women 30 to 65 years of age
  • Don’t treat patients who have mild dysplasia of less than two years in duration
  • Don’t screen for ovarian cancer in asymptomatic women at average risk

Lists from other specialties are available on the Choosing Wisely website. Please take the time to read through the lists, and promote their adoption within your health care system. If you have recommendations for the next list regarding ob-gyn, please email me at


Arriving at the appropriate cesarean delivery rate

Dr. W. Lawrence WarnerW. Lawrence Warner, MD, Utah Section vice chair

When I began medical school in 1970, the overall cesarean delivery rate was 5.5%. After 36 years of practice, the rate has risen to the present level of 31.3%. I practice in Utah, where the rate is 22.2%, the lowest in the country. In New Jersey, the rate is 38.3%, the highest in the country. There are some individual hospitals with rates well over 50%. Many factors have led to this rising rate, but interestingly enough, most are not evidence-based. Maternal mortality has actually risen with the cesarean delivery rate—from 10 per 100,000 births in 1998 when the cesarean delivery rate was 21.2% to 14 per 100,000 in 2004 when the rate had reached 29.1%. The consequences of the increased cesarean delivery rate have been increased risk and cost for current delivery and increased risk for future pregnancies. 

Is there an ideal cesarean delivery rate? In 1998, the US Public Health Service Commissioned Corps set forth public health goals in Healthy People 2010, including a cesarean delivery rate of 15%. The year 2010 came and went with double that rate. The new goal for 2020 has been set at 23.9%. Some major health care systems have attempted to set what they determine as an acceptable rate, including Intermountain Healthcare in Utah, which set the rate at 15%. The reaction from the physicians in the system was significant criticism and pushback.  

How do you arrive at this predetermined rate? The Hospital Corporation of America (HCA) has taken a different approach to this issue. The organization has stated that the cesarean delivery rate functions poorly as an independent metric of quality of obstetric care and that sustainable reduction in the rate cannot be approached directly but will naturally flow from optimization of care processes that lead to cesarean delivery. HCA’s primary cesarean delivery rate has remained stable since 2005, while the national rate has continued to climb. HCA’s rate stability resulted from the implementation of improvements of each individual component of care.

Primary cesarean deliveries account for 50% of the increasing total cesarean delivery rate. Given its effect on subsequent pregnancies, an understanding of the drivers behind the increase in primary cesarean delivery rates and renewed efforts to reduce them may have a substantial effect on maternal health. The top five contributors to the primary cesarean delivery rate are nonreassuring fetal status, arrest of labor, multiple gestation, preeclampsia, and macrosomia. All five contributors are either subjective or depend on management style. Thus, the decision the patient makes as to whom she will see for her prenatal care and which physician will be on call for her delivery may be major determinants as to whether she will end up with a cesarean delivery or a vaginal birth. 

Complete placenta previa, vasa previa, and cord prolapse represent absolute indications for cesarean delivery. However, most indications depend on the caregiver’s interpretation, recommendation, or action in response to the developing situation, making them a modifiable and likely target to lower the cesarean delivery rate. The potentially modifiable indications fall into three categories: obstetric, fetal, and maternal. The challenge for us as a specialty is to look at each component of care and each indication individually and collectively (as departments) and then evaluate if we are following established evidence-based protocols, policies, and/or checklists.

Continuing efforts to eliminate elective inductions prior to 39 weeks of gestation and inductions in nulliparous patients with an unfavorable cervix have helped reduce the overall cesarean delivery rate. We also need to reconsider our approach to patients with a previous cesarean delivery and strive to overcome the barriers to vaginal birth after cesarean delivery.

At the two hospitals where I practice, the departments have begun a project to move us in the right direction. At a recent department meeting, I gave an introductory presentation that identified all the potentially modifiable contributors to the decision to perform a cesarean delivery. Now, at each monthly department meeting, a short presentation will be made by a staff physician about one of these contributing factors, reviewing the most current evidence. The physician will then lead a discussion about where improvements could be made. By assigning a different physician each month, we hope involvement and buy-in by the entire staff will be maximized. Whenever a cesarean delivery is being considered, staff members are now encouraged, when possible, to arrive at a decision after discussion with peers. 

Care must be taken to not have the unintended consequence of physicians becoming reluctant to proceed with clearly indicated cesarean deliveries because they fear criticism after later review of the care by the quality committee. This same issue occurs with medically indicated inductions of labor prior to 39 weeks of gestation.

In conclusion, this article is focused on arriving at the appropriate cesarean delivery rate rather than just lowering the cesarean delivery rate. The appropriate rate will be realized as we optimize each component of care, more freely seek the opinion of peers, improve our individual knowledge and skills, and educate our patients about the immediate and future consequences of a cesarean delivery.


National Practitioner Data Bank information

Dr. Ralph W. HaleRalph W. Hale, MD, past ACOG executive vice president

The National Practitioner Data Bank (NPDB) is a project of the Health and Human Services Branch of the National Institutes of Health that is responsible for maintaining a database of all licensed practitioners in all states and territories of the US. This database records all adverse actions against any provider or health care practitioner. It is accessible by individual practitioners, hospitals, and other health care facilities that wish to query applicants who have applied for privileges or other activities. 

The NPDB has a staff assigned to oversee the database, perform research on the data, and educate and work with all practitioners, their professional organizations, and facilities that deliver health care, such as hospitals and care centers. The NPDB has an executive committee that oversees NPDB activities that is composed of more than 30 professional organizations. Each of these organizations has a representative on the executive committee.

ACOG is one of the founding members of the NPDB executive committee. The original ACOG representative on the committee was William T. Mixson, MD, past ACOG president. I serve as the current representative and am also chair of the executive committee. The committee meets face-to-face once a year in the fall in Washington, DC, and once again in the spring via a web-based meeting. At the fall meeting, staff members give a detailed report of all activities. In the spring, we have a focused meeting on some aspect of the NPDB.


Calendar of events


Annual District Meeting (with Districts V, VI, and IX)
Grand Wailea
Maui, HI
Contact: Linda Minor, 202-863-2488

Hawaii Section Meeting
Hapuna Beach Prince Hotel
Kohala Coast
Contact: Lori E. Kamemoto, MD, MPH,



30–February 1
Montana Section Meeting
Big Sky
Contact: Kathleen G. Nelson, MD, or 406-752-5252

Congressional Leadership Conference, The President’s Conference
Washington, DC
Contact: Stacie Monroe, 202-863-2505


American Congress of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998