Objective To determine the impact of caesarean section on fertility among women in sub-Saharan Africa.
Design Analysis of standardised cross-sectional surveys (Demographic and Health Surveys).
Setting Twenty-two countries in sub-Saharan Africa, 1993–2003.
Sample A total of 35 398 women of childbearing age (15–49 years).
Methods Time to subsequent pregnancy was compared by mode of delivery using Cox proportional hazards regression models.
Main outcome measures Natural fertility rates subsequent to delivery by caesarean section compared with natural fertility rates subsequent to vaginal delivery.
Results The natural fertility rate subsequent to delivery by caesarean section was 17% lower than the natural fertility rate subsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73–0.96, P < 0.01; controlling for age, parity, level of education, urban/rural residence and young age at first intercourse). Caesarean section was also associated with prior fertility and desire for further children: among multiparous women, an interval ≥3 versus <3 years between the index birth and the previous birth was associated with higher odds of caesarean section at the index birth (OR = 1.4, 95% CI 1.1–1.7, P= 0.005); among all women, the odds of desiring further children were lower among women who had previously delivered by caesarean section (OR = 0.67, 95% CI 0.54–0.84, P < 0.001). Caesarean section did not appear to increase the risk of a subsequent pregnancy ending in miscarriage, abortion or stillbirth.
Conclusions Among women in sub-Saharan Africa, caesarean section is associated with lower subsequent natural fertility. Although this reflects findings from developed countries, the roles of pathological and psychological factors may be quite different because a much higher proportion of caesarean sections in sub-Saharan Africa are emergency procedures for maternal indication.