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 > or =3 versus