This is a tale of two hospitals.

One has the highest rate of Caesarean sections in the city, the other the fourth lowest. They represent some of the city’s obstetric extremes, yet they sit just five miles apart on Staten Island, serving similar populations.

So what accounts for the difference?

In large part, determination, which Dr. Mitchell A. Maiman, the chairman of the obstetrics and gynecology department at one of the two, Staten Island University Hospital, has in ample supply. As New York City’s C-section rate has soared in recent years — by 36 percent, between 2000 and 2007, according to the New York State Department of Health — Dr. Maiman has kept his hospital’s rate around 23 percent of all births.

In 2008, according to numbers released by Choices in Childbirth, an advocacy group for pregnant women, working with state statistics, Staten Island University Hospital’s rate went down, while the rate at the other hospital, Richmond University Medical Center, went up again, to 48.3 percent. That made it, for the fifth consecutive year, the hospital with the highest C-section rate in the city. (The National Center for Health Statistics reported that the Caesarean rate reached 32 percent in 2007.)

Caesarean births are generally considered more prone to complications than natural births, so most hospitals at least pay lip service to their devotion to reducing them. But very few have pulled it off. What seems to have made the difference for Dr. Maiman’s department is building that goal into policy, even when it is unpopular with doctors — even, sometimes, when it may be unpopular with patients.