title: Forceps delivery volumes in teaching and nonteaching hospitals: are volumes sufficient for physicians to acquire and maintain competence?
abstract: OBJECTIVE
  The decline in the use of forceps in operative deliveries over the last two decades raises questions about teaching hospitals' ability to provide trainees with adequate experience in the use of forceps. The authors examined (1) the number of operative deliveries performed in teaching and nonteaching hospitals, and (2) whether teaching hospitals performed a sufficient number of forceps deliveries for physicians to acquire and maintain competence.
  
  
  METHODS
  The authors used State Inpatient Data from nine states to identify all women hospitalized for childbirth in 2008. They divided hospitals into three categories: major teaching, minor teaching, and nonteaching. They calculated delivery volumes (total operative, cesarean, vacuum, forceps, two or more methods) for each hospital and compared data across hospital categories.
  
  
  RESULTS
  The sample included 1,344,305 childbirths in 835 hospitals. The mean cesarean volumes for major teaching, minor teaching, and nonteaching hospitals were 969.8, 757.8, and 406.9. The mean vacuum volumes were 301.0, 304.2, and 190.4, and the mean forceps volumes were 25.2, 15.3, and 8.9. In 2008, 31 hospitals (3.7% of all hospitals) performed no vacuum extractions, and 320 (38.3%) performed no forceps deliveries. In 2008, 13 (23%) major teaching and 44 (44%) minor teaching hospitals performed five or fewer forceps deliveries.
  
  
  CONCLUSIONS
  Low forceps delivery volumes may preclude many trainees from acquiring adequate experience and proficiency. These findings highlighted broader challenges, faced by many specialties, in ensuring that trainees and practicing physicians acquire and maintain competence in infrequently performed, highly technical procedures.
authors.affiliation: Dr. Kyser is a perinatologist, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland. Ms. Lu is a data analyst, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Donna Santillan is research assistant professor, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Mark Santillan is assistant professor, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Caughey is professor and chair, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon. Dr. Wilson is professor and associate dean of graduate medical education, University of Iowa Hospitals and Clinics and University of Iowa Carver College of Medicine, Iowa City, Iowa. Dr. Cram is professor, University of Toronto, and director, Division of General Internal Medicine, Mt. Sinai/UHN, Toronto, Ontario, Canada.
authors.forename: Kathy L
authors.initials: KL
authors.lastname: Kyser
authors.forename: Xin
authors.initials: X
authors.lastname: Lu
authors.forename: Donna
authors.initials: D
authors.lastname: Santillan
authors.forename: Mark
authors.initials: M
authors.lastname: Santillan
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Caughey
authors.forename: Mark C
authors.initials: MC
authors.lastname: Wilson
authors.forename: Peter
authors.initials: P
authors.lastname: Cram
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data; D002983:Clinical Competence; D036861:Delivery, Obstetric / Q000295:instrumentation / Q000706:statistics & numerical data*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D009772:Obstetrical Forceps / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011247:Pregnancy; D014481:United States