Caesarean section and subsequent fertility in sub‐Saharan Africa

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