Alternative strategies for controlling rising cesarean section rates.

Cesarean section rates in the United States have increased from 5.5% in 1970 to 24.4% in 1987. This dramatic increase has generated considerable concern, leading to a variety of proposals to control rising use of cesarean section. Six strategies have been adopted or proposed to reduce cesarean section use: (1) education and peer evaluation, (2) external review, (3) public dissemination of cesarean section rates, (4) changes in physician payment, (5) changes in hospital payment, and (6) medical malpractice reform. These strategies differ in their specific assumptions regarding the process of clinical decision making, implications for physician autonomy, and methods of implementation. Educational efforts have been the most widely promoted. Of these, formal programs aimed at modifying practices within individual hospitals appear to be the most successful. However, insufficient research has been conducted to compare conclusively the impact and feasibility of these six strategies, pointing to the need for further study.