Reducing cesarean delivery rates in managed care organizations

A national consensus has emerged that cesarean delivery (CD) rates are excessive.

To review the subject of CD delivery and to discuss options for reducing CD delivery rates in managed care organizations (MCOs) from the current rate of approximately 22% to a rate of 10% to 15% in 5 years, as proposed by the World Health Organization.

Literature review.

Contracted physicians could be provided with evidence-based clinical practice guidelines for CD as well as data on acuity-adjusted physician-specific CD rates within the MCO and could be offered supplementary fees for performing vaginal deliveries after a previous CD. Administrators and physician leaders of contracted hospitals could also be asked to adopt written criteria for lack of progress in labor, to review all indications for CD for all cases, to encourage use of vaginal delivery after a previous CD, and to require a second opinion for performing all except emergency CDs. Members of MCOs who become pregnant could be mailed an educational pamphlet that encourages vaginal delivery rather than CD.

To facilitate dissemination of information, MCOs should report their experience in implementing, monitoring, and evaluating the effectiveness and outcomes of programs to reduce CD delivery rates. The MCO objective would be to lower CD rates without alienating physicians or attempting to impose a regimented approach that would offend and be counterproductive for consumers.