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Cesarean sections and subsequent fertility

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Cesarean sections are rising all over the world and may, in some countries, soon become the most common delivery mode. A growing body of medical literature documents a robust fact: women undergoing cesarean sections end up having less children. Unlike most of the medical literature, which assumes that this association is mostly working through a physiological channel, we investigate a possible channel linking c-section and subsequent fertility through differences in maternal behavior after a c-section. Using several national and cross-national demographic data sources, we find evidence that maternal choice is playing an important role in shaping the negative association between cesarean section and subsequent fertility. In particular, we show that women are more likely to engage in active contraception after a cesarean delivery and conclude that intentional avoidance of subsequent pregnancies after a c-section seems to be responsible for part of the negative association between c-sections and subsequent fertility.

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  1. See Stanton and Holz (2006)

  2. See Menacker and Hamilton (2010) and Osterman and Martin (2014)

  3. The World Health Organization (WHO) at some point stated that cesarean section rates above 15 % may do more harm than good. See Althabe and Belizan (2006). In 2010, WHO withdrew its recommendation regarding c-section rates not to exceed 15 % citing inconclusive evidence. In March 2014, the American College of Obstetricians and Gynecologists (ACOG) issued a consensus report on seeking to reduce the overall number of unnecessary c-sections by reducing the number of primary c-sections.

  4. See, however, Currie and MacLeod (2013) who find that while many cesarean sections are medically unnecessary, some are not performed when they are indeed medically needed.

  5. See also AHRQ (2005) and Steer and Modi (2009)

  6. See LaSala and Berkeley (1987), Hemminki (1996), Leitch and Walker (1998), Jolly et al. (1999), Porter et al. (2003), Collin et al. (2006), Smith et al. (2006) and Tollanes et al. (2007)

  7. See Hurry et al. (1984), Amu et al. (1998), and Alpay et al. (2008)

  8. See Nielsen et al. (1989), Ananth et al. (1997), Ananth and Vintzileos (2007), Lydon-Rochelle et al. (2001), and Lydon-Rochelle et al. (2010)

  9. See McMahan (1998) and Landon (2010)

  10. See Lieberman (1997) and Basso and Baird (2003)

  11. See Hannah et al (2004) and Smith et al. (2006)

  12. See Roberts et al. (2007).

  13. See Reader and Savage (1983), Garel et al. (1988), Garel et al. (1990), Mutryn (1993), and Jolly et al. (1999).

  14. See de Gregorio et al. (1988).

  15. See Bettegowda et al. (2008).

  16. See, for example, Rowe-Murray and Fisher (2001).

  17. See also Keeler and Brodie (1993), Gruber et al. (1999), Brown (1996), Dubay et al. (1999), and Johnson and Rehavi (2015)

  18. Index pregnancy and index births are often our units of observation in the econometric analysis. More details below.

  19. Of course if the woman has health insurance, these differential monetary costs are less relevant in her decision making.

  20. We only use cycles from 1982 to 2008. Earlier NSFG cycles from 1973 and 1976 do not include delivery mode information

  21. A similar logit specification delivers an odds ratio of 0.80 for subsequent birth following a cesarean section at first births, and an odds ratio of 0.68 for subsequent birth following cesarean section at a higher order index birth.

  22. Results are not fully comparable between panels A and B because we only allow a 3-year window in the DHS samples. This is because delivery mode information in DHS is only available for births in the 5 years preceding the interview.

  23. See, for example, Lydon-Rochelle et al. (2001) and Lydon-Rochelle et al. (2010) who document increased odds of uterine rupture among women attempting a VBAC. In addition to the health risks for the mother, uterine rupture leads to fetal death on one third of these cases. See Douglas et al. (1963). Moreover, it is also possible that a c-section reduces the woman’s ability to conceive further children. Essentially, there are three steps of interest, physiologically, which are hard to distinguish in practice: (a) conception: the merging of genetic material from sperm and egg, (b) implantation: the establishment of an attachment between fertilized egg and mother’s body, and (c) gestation: the nurturing of implanted embryo for long enough to produce a surviving newborn ready to cope with the outside world. Several reports have speculated about the mechanism by which a cesarean could lead to infertility or subfertility (a term used to describe varying degrees of difficulty in producing a subsequent child). For example, Murphy et al. (2002) suggest that women who had their first child by cesarean might have more difficulty producing another child because of pelvic adhesions (which can lead to problems with travel of sperm or egg along the fallopian tubes, and therefore problems with conception or implantation), or placental bed problems (which can lead to problems with implantation or gestation).

  24. See Lieberman (1997) and Basso and Baird (2003)

  25. The indicator is equal to one if at the time of interview the woman reports being sterile for non-surgical reasons.

  26. The indicator is equal to one if any subsequent pregnancy ended without a live birth.

  27. Unfortunately, we do not have the relevant information on infertility and failed pregnancies to estimate these models with the DHS surveys.

  28. We only use NSFG cycles starting in 1995 as no comparable information on infertility was collected in previous cycles.

  29. We then exclude births that happen to be the last birth reported in the fertility histories from the analysis sample for this particular outcome.

  30. To define “active contraception”, we first assign a missing value to those who cannot become pregnant (i.e., postpartum and sterile for non-contraceptive reasons) For those females who can get pregnant, we define “active contraception” to equal 1 if they report either using any method for contraception or having no intercourse in the last 3 months. Active contraception is set to equal 0 if they are (at the time of interview) currently pregnant, seeking pregnancy, or using no contraception method despite having intercourse in the last 3 months prior to interview. Contraceptive methods include Implants, Injectables, Pill, Patch, Ring, Morning-after pill, IUD, Diaphragm, Condom, Foam, Sponge, Jelly, temperature and calendar rhythms, Withdrawal and Male (vasectomy) or Female (tubal ligation) Contraceptive Sterilizations.

  31. We are thankful to a referee for this insight.

  32. A third line of evidence against this channel comes from the fact that the relationship between c-section at index birth and low subsequent fertility holds for index births far back in time, when the c-section rate was much lower.

  33. However, see Norberg (2004) for a caveat on the use of sex as randomly assigned.

  34. The two elicitations are such that (a) the first was at least 9 months before the birth of baby b and the second was after the birth of baby b.

  35. To identify the effect of the 1999 change in ACOG guidelines, we control for linear or quadratic year of birth trends rather than unrestricted year of birth effects as in previous specifications.

  36. In order to have enough births after 1999 to identify the potential effects, we use a 3-year back-window. We cannot use a 7-year back-window relative to the 2006-2008 NSFG cycle. Doing so would essentially leave us with almost no births available after 1999.

  37. Our data does not allow us to test how potentially changing perceptions of the risks associated with the two delivery modes might affect the choice of delivery mode for a given birth and the choice of subsequent fertility after that birth. For example, women may increase their perception of the risks involved in having additional children after a c-section, regardless of how those subsequent children might be eventually delivered. If those perceptions of risk happen to increase significantly before and after 1999, one would also see the pattern we find in Table 8.

  38. If tubal ligation was more reliable than reversible methods of contraception, then a reduction in the net cost of voluntary sterilization could lead to a negative association between cesarean section and the occurrence of unwanted subsequent births. However, tubal may reduce wanted subsequent births as well, by eliminating the option value of remaining fertile.

  39. The small difference in magnitude is due to the fact that estimates in Table 4 come from a linear probability model whereas those in Table 11 are relative risk ratios for the three outcome multinomial logit model which we use to derive the appropriate marginal effects.

  40. The sample used to estimate the multinomial logit model excludes women who cannot get pregnant (postpartum, male, or female sterilility for non-contraceptive reasons) and those who are not sexually active. Similar results are obtained if we treat sexual inactivity as a form of active contraception.

  41. This is starting to change as procedures are spreading to “undo” the tubal ligation, effectively transforming sterilization into another reversible or temporary contraceptive method.

  42. Results from DHS cannot be taken at face value given that a substantial number of observations have missing information on pregnancy wantedness. This biases the results from the multinomial logit as it artificially inflates the number of women with no subsequent birth.


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We thank Qi (Clare) Li for truly outstanding research assistance. We also thank Kate Ambler, Marianne Bitler, Hoyt Bleakey, Kasey Buckles, Paul Gertler, Joe Hotz, Adriana Lleras-Muney, Bob Pollak, Seth Sanders, Lucie Schmidt, Michela Tincani, and participants at the Workshop on Work, Family and Public Policy at Washington University in St. Louis, the 2011 Meetings of the Midwest Economics Association in St. Louis, the Economic Demography Workshop at the 2011 PAA Meetings in Washington D.C., the 2011 joint meetings of LACEA and the Econometric Society in Santiago, Chile and the Economics and Biodemography of Aging and Health Workshop at the University of Chicago (2011). We also thank two anonymous referees for their helpful and insightful comments. All errors remain ours. We are grateful to the Center for Health Policy at Washington University in St. Louis as a source of support for Norberg during the writing of this paper. In addition, we gratefully acknowledge funding from the Weidenbaum Center at Washington University in St. Louis.

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Correspondence to Juan Pantano.

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Responsible editor: Junsen Zhang



Fig. 1
figure 1

Effect of C-Section on subsequent fertility (DHS, first births)

Fig. 2
figure 2

Effect of C-Section on subsequent fertility (DHS, higher order births)

Fig. 3
figure 3

Effect of C-Section on active contraception (DHS, first births)

Fig. 4
figure 4

Effect of C-Section on active contraception (DHS, higher order births)

Table 11 Descriptive statistics NSFG
Table 12 Descriptive statistics DHS
Table 13 Descriptive statistics NLSY79

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Norberg, K., Pantano, J. Cesarean sections and subsequent fertility. J Popul Econ 29, 5–37 (2016).

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