Skip to main content

Cesarean sections and subsequent fertility


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.

This is a preview of subscription content, access via your institution.


  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.


  • AHRQ (2005) U.S. Agency for Health Care Research and Quality. HCUPnet. Healthcare Cost and Utilization Project: Rockville, MD. AHRQ 2005 [DRGs 370-3]

  • Alpay Z, Saed GM, Diamond MP (2008) Postoperative adhesions: from formation to prevention. Semin Reprod Med 26(4):313–321

    CAS  Article  PubMed  Google Scholar 

  • Althabe F, Belizan JF (2006) Caesarean section: the paradox. Lancet 368:1472–1473

    Article  PubMed  Google Scholar 

  • Amu O, Rajendran S, Bolaji II (1998) Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. Br Med J 15;317(7156):463–465

    Google Scholar 

  • Ananth CV, Smulian JC, Vintzileos AM (1997) The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Am J Obstet Gynecol 177(5):1071–8

    CAS  Article  PubMed  Google Scholar 

  • Ananth CV, Vintzileos AM (2007) Maternal-fetal conditions necessitating a medical intervention resulting in preterm birth. Am J Obstet Gynecol 195(6):1557–63

    Article  Google Scholar 

  • Angrist J, Evans W (1998) Children and their parents’ labor supply: evidence from exogenous variation in family size. Am Econ Rev 88(3):450–477

    Google Scholar 

  • Baicker K, Buckles KS, Chandra A (2006) Geographic variation in the appropriate use of cesarean delivery. Health Aff 25(5):w355–367

    Article  Google Scholar 

  • Basso O, Baird DD (2003) Infertility and preterm delivery, birthweight, and Caesarean section: a study within the Danish National Birth Cohort. Hum Reprod 18(11):2478–2484

    Article  PubMed  Google Scholar 

  • Bettegowda VR, Dias T, Davidoff MJ, Damus K, Callaghan WM, Petrini JR (2008) The relationship between cesarean delivery and gestational age among us singleton births. Clin Perinatol 35(2):309–323

    Article  PubMed  Google Scholar 

  • Brown HS (1996) Physician demand for leisure: implications for cesarean section rates. J Health Econ 15(2):233–242

    Article  PubMed  ADS  Google Scholar 

  • Collin S, Marshall T, Filippi V (2006) Caesarean section and subsequent fertility in sub-Saharan Africa. Br J Obstet Gynecol 113:276–283

    CAS  Article  Google Scholar 

  • Currie J, MacLeod B (2008) First Do No Harm? tort reform and birth outcomes. Q J Econ 123(2):795–830

    Article  Google Scholar 

  • Currie J, MacLeod B (2013) Diagnosis and unnecessary procedure use: Evidence from C-Section. NBER working paper

  • Daltveit AK, Tollanes MC, Pihlstrø mH, Irgens LM (2008) Cesarean delivery and subsequent pregnancies. Obstet Gynecol 111(6):1327–34

    Article  PubMed  Google Scholar 

  • De Gregorio G, Hillemanns H, Quaas L, Mentzel J (1988) Late morbidity following cesarean section : a neglected factor. Geburtshilfe Frauenheilkd 48(1):16–19

    Article  PubMed  Google Scholar 

  • Douglas RG, Birnbaum SJ, MacDonald FA (1963) Pregnancy and labor following cesarean section. Am J Obstet Gynecol 86:961–971

    CAS  PubMed  Google Scholar 

  • Dubay L, Kaestner R, Waidmann T (1999) The impact of malpractice fears on cesarean section rates. J Health Econ 18(4):491–522

    CAS  Article  PubMed  Google Scholar 

  • Garel M, Lelong N, Kaminski M (1988) Follow-up study of psychological consequences of caesarean childbirth. Early Hum Dev 16(2-3):271–82

    CAS  Article  PubMed  Google Scholar 

  • Garel M, Lelong N, Marchand A, Kaminski M (1990) Psychosocial consequences of caesarean childbirth: a four-year follow-up study. Early Hum Dev 21(2):105–14

    CAS  Article  PubMed  Google Scholar 

  • Gruber J, Owings M (1996) Physician financial incentives and cesarean section delivery. RAND J Econ 27(1):99–123

    CAS  Article  PubMed  Google Scholar 

  • Gruber J, Kim J, Mayzlin D (1999) Physician fees and procedure intensity: the case of cesarean delivery. J Health Econ 18(4):473–490

    CAS  Article  PubMed  Google Scholar 

  • Hall MH, Campbell DM, Fraser C, Lemon J (1989) Mode of delivery and future fertility. Br J Obstet Gynecol 96(11):1297–1303

    CAS  Article  Google Scholar 

  • Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collab Group Lancet 356:1375–1383

    CAS  Google Scholar 

  • Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, Hutton E, Kung R, McKay D, Ross S, Saigal S, Willan A (2004) Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 191(3):917–927

    Article  PubMed  Google Scholar 

  • Hemminki E (1996) Impact of caesarean section on future pregnancy: a review of cohort studies. Paediatr Perinat Epidemiol 10:366–379

    CAS  Article  PubMed  Google Scholar 

  • Hurry DJ, Larsen B, Charles D (1984) Effects of postcesarean section febrile morbidity on subsequent fertility. Obstet Gynecol 64:256–260

    CAS  PubMed  Google Scholar 

  • Johnson E, Rehavi MM (2015) Physicians Treating Physicians: Information and Incentives in Childbirth, forthcoming American Economic Journal: Economic Policy

  • Jolly J, Walker J, Bhabra K (1999) Subsequent obstetric performance related to primary mode of delivery. Br J Obstet Gynecol 106:227–232

    CAS  Article  Google Scholar 

  • Keeler EB, Brodie M (1993) Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q 71(3):365–404

    CAS  Article  PubMed  Google Scholar 

  • Landon MB (2010) Predicting uterine rupture in women undergoing trial of labor after prior cesarean delivery. Semin Perinatol 34(4):267–271

    Article  PubMed  Google Scholar 

  • LaSala AP, Berkeley AS (1987) Primary cesarean section and subsequent fertility. Am J Obstet Gynecol 157:379–383

    CAS  Article  PubMed  Google Scholar 

  • Leitch CR, Walker JJ (1998) The rise in caesarean section rate: the same indications but a lower threshold. Br J Obstet Gynaecol 105(6):621–626

    CAS  Article  PubMed  Google Scholar 

  • Lieberman E (1997) Predictors of Cesarean delivery. Curr Probl Obstet Gynecol Fertil 20:98–131

    Google Scholar 

  • Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP (2001) Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 345:3–8

    CAS  Article  PubMed  Google Scholar 

  • Lydon-Rochelle M, Cahill AG, Spong CY (2010) Birth after previous cesarean delivery: short-term maternal outcomes. Semin Perinatol 34(4):249–257

    Article  PubMed  Google Scholar 

  • McMahan MJ (1998) Vaginal birth after cesarean. Clin Obstet Gynecol 41(2):369–81

    Article  Google Scholar 

  • Menacker F, Hamilton BE (2010) Recent trends in cesarean delivery in the United States NCHS Data Brief No 35

  • Murphy DJ, Stirrat GM, Herron J (2002) ALSPAC study team (2002) The relationship between cesarean section and subfertility in a population based sample of 14541 pregnancies. Hum Reprod 17(7):1914–1917

    CAS  Article  PubMed  Google Scholar 

  • Mutryn CS (1993) Psychosocial impact of cesarean section on the family: a literature review. Soc Sci Med 37(10):1271–81

    CAS  Article  PubMed  Google Scholar 

  • Nielsen TF, Hagberg H, Ljungblad U (1989) Placenta previa and antepartum hemorrhage after previous cesarean section. Gynecol Obstet Invest 27(2):88–90

    CAS  Article  PubMed  Google Scholar 

  • Norberg K (2004) Partnership status and the human sex ratio at birth. Proc Biol Sci 271(1555):2403–2410

    PubMed Central  Article  PubMed  Google Scholar 

  • Osterman MJK, Martin JA (2014) Primary cesarean delivery rates, by state: results from the revised birth certificate, 2006-2012. Nat Vital Stat Rep 63(1)

  • Porter M, Bhattacharya S, Teijlingen VE, Templeton A (2003) Does caesarean section cause infertility Hum Reprod 18:1983–1986

    Article  PubMed  Google Scholar 

  • Price J, Simon K (2009) Patient education and the impact of new medical research. J Health Econ 28(6):1166–1174

    Article  PubMed  Google Scholar 

  • Reader F, Savage W (1983) Coping with caesarean and other difficult births. Macdonald Publishers, Edinburgh, UK

    Google Scholar 

  • Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ (2007) Changing policies on vaginal birth after cesarean: impact on access. Birth 34:316–322

    Article  PubMed  Google Scholar 

  • Rowe-Murray HJ, Fisher JR (2001) Operative intervention in delivery is associated with compromised early mother-infant interaction. Br J Obstet Gynaecol 108(10):1068–1075

    CAS  Google Scholar 

  • Smith GCS, Wood AM, Pell JP, Dobbie R (2006) First cesarean birth and subsequent fertility. Fertil Steril 85(1):90–95

    Article  PubMed  Google Scholar 

  • Stanton CK, Holtz SA (2006) Levels and trends in cesarean birth in the developing world. Stud Fam Plann 37(1):41–48

    Article  PubMed  Google Scholar 

  • Steer PJ, Modi N (2009) Elective caesarean sections-risks to the infant. Lancet 374(9691):675–676

    Article  PubMed  Google Scholar 

  • Tollanes MC, Thompson JM, Daltveit AK, Irgens LM (2007) Cesarean section and maternal education. secular trends in norway 1967-2004. Acta Obstet Gynecol Scand 86(7):840–848

    Article  PubMed  Google Scholar 

Download references


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.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Juan Pantano.

Additional information

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

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Fertility
  • Infertility
  • C-Sections
  • Reproductive Health

JEL Classification

  • J11
  • J13
  • I10