The Impact of Legislatively Imposed Practice Guidelines on Cesarean Section Rates: The Florida Experience

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Abstract
Florida legislation implemented in the fall of 1992, unique in the nation, mandated that practice guidelines regarding cesarean section deliveries be disseminated to obstetric physicians. The law also required that peer review boards at hospitals be established to review ce sarean deliveries and that the exact dates of implemen tation of the guidelines be reported to a state agency. To determine the impact of the legislation, we conducted a retrospective analysis of 366,246 total live births oc curring in Florida hospitals during 1992 and 1993, be fore and after formal hospital certification of the implementation of the guidelines. Changes in primary and repeat cesarean rates were analyzed for 108 inde pendent groups of births, controlling for the mother's age, race, payment source, and the timing of the imple mentation of the guidelines at hospitals. The guideline certification program did not accelerate the consistent but gradual downward trend in cesarean births which had already been evident in the three prior years. The data do suggest that the guideline program may have af fected repeat cesareans more than primary cesareans, especially in the first quarter of 1993, immediately after the hospital certification period. Reductions in repeat cesareans involved both Medicaid and commercially in sured births, whereas reductions in primary cesareans were found almost exclusively within commercially in sured mothers, where the existing rates are highest. Although births with a prior cesarean represent only 12.5% of all births, significant decreases in repeat ce sareans were found in groups representing 72.6% of this population. By comparison, significant decreases in pri mary cesareans were found in groups representing only 36.5% of the births without a prior cesarean. The date of guideline implementation reported by hospitals was not related to any systematic change in observed ce sarean section rates. We concluded that the mere dis semination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit and thorough guideline implementation program. Blunt legislative man dates may be ineffective when multiple initiatives are already achieving desired outcomes.