Abstract
As obstetric services disappear from rural communities, family physicians are increasingly asked whether operative maternity care remains part of their role. This reflection argues that maintaining cesarean delivery capacity is not an expansion of scope, but a commitment to continuity and to remaining present for patients at moments of greatest vulnerability. Drawing on rural clinical experience, this essay explores how trust, built over time, extends into the operating room, where continuity takes on a different but no less essential form. It also considers the ethical implications of physicians stepping away from operative obstetrics, as individual decisions accumulate into system-level loss for communities with limited alternatives. In this context, operative obstetrics emerges not only as a technical skill, but as a means of preserving access, accountability, and relational care within family medicine.
Key words:
There is a persistent assumption in modern medicine that surgery represents a rupture in continuity, a transfer of care from relationship-based practice to technical intervention, from the familiar to the specialized. In rural underserved communities, however, I have learned the opposite. There, cesarean delivery can be one of the clearest expressions of continuity a family physician can offer: the extension of trust built over time into a moment of vulnerability and risk. The decision to provide or step away from this care carries ethical weight, not only for the clinician, but for the communities whose access depends on that presence.
I chose to perform cesarean deliveries as part of my family medicine practice not to pursue technical breadth for its own sake, but because full-spectrum maternity care is foundational to how family medicine serves communities. In settings where access is fragile and systems frequently withdraw, the ability to provide comprehensive obstetric care, including cesarean delivery, is not an expansion of scope. It is an ethical response to absence.
Family medicine has long defined itself by continuity, comprehensiveness, and accountability to community.1,2 Maternity care embodies all three. In many rural and underserved settings, family physicians are not one option among many; they are the maternity care workforce. National data demonstrate that family physicians provide a substantial proportion of obstetric care in rural hospitals and, in many communities, are the only clinicians offering operative obstetric services.3-5 When that capacity disappears, communities do not seamlessly transition to alternative care. Instead, they experience longer travel, delayed intervention, fragmented care, and heightened risk.6-7
I entered residency knowing I wanted to practice full-spectrum family medicine. I had not planned to pursue additional training in high-risk or surgical obstetrics, but I trained in a setting where both were simply part of what family physicians did, where cesarean deliveries were not exceptional but expected. It felt natural to be there. I was drawn in gradually by signing up to assist whenever I could, staying late when my patients were in labor, coming in when they needed a cesarean delivery, and then continuing to care for them and their families afterward.
In those moments, I began to understand what operative obstetrics made possible. I saw family physicians care for entire communities across generations. I saw continuity not just encouraged but protected. And I realized that learning to perform cesarean deliveries was not about expanding my scope; it was about becoming the kind of physician my community needed.
That understanding was reinforced by the growing number of US counties without obstetric services, the steady closure of rural labor and delivery units, and the widening distances pregnant patients are asked to travel.6,7 These challenges have intensified in the evolving policy landscape following the Dobbs v. Jackson Women’s Health Organization decision, which has accelerated shifts in the maternity care workforce and influenced where clinicians choose, or are able, to practice.8,9 In many regions, these pressures have compounded existing access barriers, particularly in rural and underserved communities. In this context, operative maternity care becomes less about professional identity and more about whether continuity of care can survive structural retreat.
Trust is often described as a byproduct of continuity. In practice, it is a skill, one that must be earned, repaired, and sustained. Few clinical encounters test trust more than childbirth, and few events fracture it more profoundly than a traumatic delivery.
I first met one patient 2 weeks postpartum. Her chart documented a devastating course: induction of labor at a distant tertiary care center for severe preeclampsia, cesarean delivery for failure to dilate, and neonatal death of unclear etiology despite extensive evaluation and autopsy. The electronic record was detailed—and profoundly incomplete.
I paused before entering the room, uncertain how to begin. How does one step into grief that deep, mediated only by templated notes and laboratory values?
She cried as soon as we began. I reached across the exam table, held her hand, and listened. What she shared was absent from the chart: confusion, unanswered questions, anger, guilt, and the erosion of trust in a system that felt distant and opaque. Her physical healing was visible. Her emotional wounds were not.
I continued to care for her, managing chronic hypertension, treating postpartum depression, and listening. Over time, trust returned, not because I could undo what had happened, but because I remained present and accountable. I did not disappear after the complication. I stayed.
Two years later, she came in without a stated chief complaint. When I entered the room, she cried again, this time with joy, and told me she was pregnant. She wanted care close to home. She wanted continuity with someone she trusted. She wanted me to care for her throughout pregnancy and perform her repeat cesarean delivery.
In that moment, I felt both the weight of responsibility and the privilege of continuity. She delivered a healthy infant surrounded by her family and community. Today, I care for her, her child, and other members of her family.
That trust was not built in the operating room. But it was honored there. In the operating room, continuity becomes something quieter, but no less profound. It is no longer the slow accumulation of visits and conversations, but the simple, steady presence of someone who knows her story when the room grows tense and the stakes are highest. Had her care been handed off in that moment, the surgery itself may have unfolded the same. The same incision, the same steps, but the experience would have been different. Because what continuity carries into that room is not just clinical information, but shared memory. It is the recognition of what she has endured, what she fears, and what she hopes for. It is the reassurance, often unspoken, that she is not just another patient on the table and that her story has not been left behind.
There were many moments when I considered walking away from operative obstetrics altogether. The barriers were not subtle: privileging challenges, professional isolation, call burden, liability anxiety, and the persistent message, spoken or implied, that this work was outdated or unnecessary. The message that this work did not belong within family medicine surfaced in different ways, through institutional policies that restricted privileges, referral patterns that bypassed local care, and subtle signals within interdisciplinary teams about who was expected to be in the operating room.10 For the patients I serve, largely rural and underserved, these same structures translated into delayed care, long travel, and repeated experiences of being told to go elsewhere.
It is tempting, in such environments, to frame leaving as self-preservation. For many clinicians, it is. But I came to see that each individual departure accumulates into collective abandonment. What feels like an individual recalibration of scope rarely remains individual. In rural communities, where maternity care already rests on a thin margin, each departure quietly reshapes what is possible. Call schedules thin. The burden shifts. The question emerges: can this still be sustained? Over time, these decisions accumulate into something larger: fewer services, lost operative capacity, and, eventually, closure.
For patients, this is not abstract. It is distance. It is delay. It is the quiet loss of care close to home.
This tension does not exist apart from considerations of safety. Regionalized systems are designed to match patients with facilities equipped for their level of risk, and referral remains essential when higher-level resources are required.11 At the same time, in many rural settings, the absence of local operative capacity does not eliminate risk, it redistributes it, often through delay and distance at critical moments. Preserving continuity, in this context, is not an argument for providing care beyond a facility’s capabilities, but for maintaining appropriately resourced local capacity and clear pathways for timely referral. In this way, continuity and safety are not opposing aims, but interdependent conditions for equitable care.
The literature supports what experience makes clear. Comparative studies demonstrate similar maternal and neonatal outcomes when cesarean delivery is performed by well-trained family physicians and obstetricians in rural settings.12 Professional organizations affirm that operative obstetric care is within the scope of family medicine for appropriately trained physicians and is essential for maintaining access in underserved communities.13 When trained family physicians are prevented from maintaining operative obstetric capacity, access suffers without clear evidence that such restrictions improve safety.6,14
In this light, maintaining operative obstetric capacity became, for me, an ethical stance. Not a rejection of collaboration or referral, but a refusal to allow geography, bureaucracy, or professional boundary-drawing to determine whether my patients could receive timely, comprehensive care.
In my practice, surgery has become one of the clearest expressions of primary care. Maintaining operative obstetric capacity allows continuity to extend through crisis rather than fracture at it. It allows the clinician who knows the patient’s story to remain present when the stakes are highest.
Operative obstetric skills, like any skill in family medicine, are not ends in themselves. They are tools—tools for maintaining trust, preserving access, and honoring relationships that begin long before labor and continue long after the incision is closed.
In rural underserved communities, continuity is not sentimental. It is protective.
This is why I chose to maintain operative obstetric capacity within my family medicine practice. Not to expand my scope, but to defend it. Not to be exceptional, but to remain present. Not because surgery defines me as a physician, but because continuity defines the kind of physician I aim to be.
Acknowledgments:
The author is grateful to the patients, mentors, and communities whose experiences and trust have shaped this work.
- Received for publication January 17, 2026.
- Revision received March 20, 2026.
- Accepted for publication April 8, 2025.
- © 2026 Annals of Family Medicine, Inc.
