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In Germany, the majority of departments integrate obstetric and gynecological care within a single department.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>The analysis utilized quality reports from German hospitals spanning 2015 to 2019. The outcome variable was the annual risk-adjusted cesarean section ratio\u2014a metric comparing expected to observed cesarean sections. Explanatory variables included annual counts of physicians, midwives, and births. To account for case number-related staffing variations, full-time equivalent midwife and physician staff positions were normalized by the number of deliveries. Uni- and multivariate panel models were applied, complemented by multiple instrument variable analyses, including two-stage least square and generalized method of moments models.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Incorporating data from 509 integrated obstetric departments and 2089 observations, representing 2,335,839 deliveries with 720,795 cesarean sections (over 60% of all inpatient births in Germany), multivariate model with fixed effects revealed a statistically significant positive association between the number of physicians per birth and the risk-adjusted cesarean section ratio (0.004, p\u2009=\u20090.004). Two-stage least square instrument variable analysis (0.020, p\u2009&lt;\u20090.001) and a system GMM estimator models (0.004, p\u2009&lt;\u20090.001) validated these results, providing compelling evidence for a causal relationship.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>The study established a robust connection between the number of physicians per birth and the risk-adjusted cesarean section ratio in integrated obstetric and gynecological departments in Germany. While the cause of the effect remains unclear, one possible explanation is a lack of specialization within these departments due to the combined provision of both obstetric and gynecological care.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1007\/s10198-024-01749-0","type":"journal-article","created":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T23:03:17Z","timestamp":1737414197000},"page":"987-1022","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Exploring the influence of medical staffing and birth volume on observed-to-expected cesarean deliveries: a panel data analysis of integrated obstetric and gynecological departments in Germany"],"prefix":"10.1007","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7685-2731","authenticated-orcid":false,"given":"Arno","family":"St\u00f6cker","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Holger","family":"Pfaff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nadine","family":"Scholten","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ludwig","family":"Kuntz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,1,21]]},"reference":[{"key":"1749_CR1","doi-asserted-by":"publisher","first-page":"1341","DOI":"10.1016\/S0140-6736(18)31928-7","volume":"392","author":"T Boerma","year":"2018","unstructured":"Boerma, T., Ronsmans, C., Melesse, D.Y., et al.: Global epidemiology of use of and disparities in caesarean sections. 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