Scars of birth: caesarean delivery and fertility intentions among women of reproductive age in sub-Saharan Africa

A single multi-country study in sub-Saharan Africa (SSA) conducted nearly two decades ago reported that caesarean section (C-section) delivery was associated with reduced subsequent childbearing. To address the gap created by the lack of recent regionally representative evidence that reflects changes in access to surgical delivery, maternal health systems, and fertility-related attitudes, we assessed the association between having ever had a C-section and subsequent fertility outcomes. The study used the most recent data from the Demographic and Health Surveys (DHS) of 30 countries in SSA conducted between 2013 and 2024 (n = 790,139). The study used two outcome variables: (i) the number of children ever born and (ii) the desire/preference for another child. The independent variable is whether the respondent has ever had a C-section birth. The first analysis applied a negative binomial regression to examine the association between C-section births and the number of children born. The second analysis applied multivariable binary logistic regression to analyse the association between C-section births and the desire to have more children. The mean number of children for each woman is 3.60 (95% CI:3.56–3.61). Chad had the highest mean number of children born (4.61, 95% CI:4.56–4.66) whereas Lesotho had the lowest mean number of children born (2.09, 95% CI:2.02–2.16). The results show that women who have ever had a C-section birth are 8% less likely to have more children compared to those who have not had a C-section birth (IRR = 0.92, 95% CI: 0.91–0.93). Also, higher levels of education are associated with a lower likelihood of having more children, particularly for those with higher education (IRR = 0.51, 95% CI: 0.50–0.52) compared to those with no education. These findings highlight the need for focused and practical interventions to offer counselling to mothers during perioperative, pre-operative, and post-operative periods to enhance understanding of C-section and their potential implications on future fertility. Providing women with clear and practical information during prenatal and antenatal visits can help them better understand the medical reasons for C-sections, as well as the potential risks associated with having many children.