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Hum. Reprod. Advance Access originally published online on January 23, 2008
Human Reproduction 2008 23(3):543-547; doi:10.1093/humrep/dem428
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© The Author 2008. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Pregnancy after Caesarean section: fewer or later?

J.J.H. Eijsink1,2, L. van der Leeuw-Harmsen1 and P.J.Q. van der Linden1,3

1 Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, PO Box 5001, Deventer 7400 GC, The Netherlands 2 Present address: Department of Obstetrics and Gynaecology, University Medical Centre Groningen, PO Box 30.001, Groningen 9700 RB, The Netherlands

3 Correspondence address. Tel: +31-570-646741; Fax: +31-570-646746; E-mail: p.j.q.vanderlinden{at}dz.nl


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Authors contribution
 Reference
 
BACKGROUND: It is unclear whether having a Caesarean section results in fewer subsequent pregnancies with longer intervals between pregnancies, an effect which may impact on the reproductive performance of a population. Our aim was to determine the implications of a Caesarean section on the subsequent fecundity and interpregnancy interval.

METHODS: This is a cohort study. The obstetric follow-up of primiparous women who delivered by a Caesarean section of a singleton infant in breech presentation is compared with the follow-up of women who delivered vaginally of a singleton infant after a physiological, uncomplicated pregnancy.

RESULTS: A total of 279 women delivered a singleton infant in breech presentation at term. From these women, 165 (59.1%) had a Caesarean section. In this group, 131 (79.4%) women had a subsequent pregnancy. In the reference group of 268 women who delivered vaginally, 208 (77.6%) became pregnant again. The median interval between birth of the first child and the beginning of the next pregnancy was 20 months for the Caesarean section group and 18 months for the reference group. No significant difference in interpregnancy interval between the different groups was found.

CONCLUSIONS: Women who delivered by Caesarean section at term in their first pregnancy do not have fewer second pregnancies compared with women who delivered vaginally. The interpregnancy interval between first and second pregnancy was not prolonged.

Key words: Caesarean section/interpregnancy interval/subsequent pregnancy/mode of delivery/fecundity


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Authors contribution
 Reference
 
It has been shown that Caesarean section is associated with fewer subsequent pregnancies and births (Hemminki, 1996Go; Jolly et al., 1999Go; Mollison et al., 2005Go). Women with a Caesarean section in their first pregnancy seem to have a lower subsequent pregnancy rate compared with women who have had a vaginal delivery in their first pregnancy (Albrechtsen et al., 1998Go; Bahl et al., 2004Go). Also, delivery by Caesarean section has been shown to lead to a prolonged time to next conception (Murphy et al., 2002Go; Mollison et al., 2005Go; Smith et al., 2006Go).

If the consequence of a Caesarean section is that women have fewer subsequent pregnancies or that the interval between pregnancies is longer, than in the long term a Caesarean section could have impact on fertility and hence on the reproductive performance in a population. Delaying a pregnancy could lead to lower fecundity due to relative older age. Furthermore, this can lead to more subsequent pathology during pregnancy related to an older age.

A possible explanation for delay of a next pregnancy could be serious obstetrical or other pathology during pregnancy that has made a Caesarean section necessary (Oral and Elter, 2007Go). Furthermore, a prolonged delivery ending in a Caesarean section could result in a longer interval between pregnancies (Murphy et al., 2003Go). A prolonged or painful vaginal delivery, however, could also influence the moment of a next pregnancy. Gottvall and Waldenström (2002)Go reported that women who had a negative experience of their first birth, had fewer subsequent children and a longer interpregnancy interval. Gamble (2001)Go showed that despite having negative views of their first Caesarean section, women requested another Caesarean section because of fears relating to current or previous obstetric complications. An elective Caesarean section followed by an uncomplicated post-partum period could perhaps be a reason to have a next pregnancy sooner. In the previous investigated populations the indication for a Caesarean section is a non-considered factor. The underlying pathology for performing a Caesarean section is not at all clear in several studies concerning this issue and hence could have influenced the moment and time of the next pregnancy (Mollison et al., 2005Go; Bhattacharya et al., 2006Go). In all prior studies no distinction was made between patients that have had an elective Caesarean section and those who have had an emergency Caesarean section (Albrechtsen et al., 1998Go; Murphy et al., 2002Go). The role of undergoing a Caesarean section per se on a next pregnancy is therefore not quite clear.

The influence of a Caesarean section on a next pregnancy should ideally be investigated in a population without pregnancy related problems. Women with an uncomplicated pregnancy and a non-malformed child in breech presentation in a non-malformed uterus at term can be considered healthy, although we cannot rule out they are a priori totally problem-free. A substantial number of patients in these circumstances will have a Caesarean section just for the breech position. Comparing results of this population with a population of women who deliver vaginally after an uneventful pregnancy, can contribute to an answer on the question if delivery by Caesarean section influences the subsequent obstetric performance and the interpregnancy interval.

The aim of our study is to investigate the implications of a Caesarean section in the first pregnancy for the reproductive performance and subsequent interpregnancy interval. To this end, we first want to establish the obstetrical performance and the interpregnancy interval in a population with an uneventful first pregnancy and delivery. Secondly, we will compare the obstetrical performance and the interval between first and next pregnancy of patients having a Caesarean section after an uncomplicated first pregnancy. Comparing the results of these two groups will give more information about the role of the Caesarean section itself on the reproductive career of women.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Authors contribution
 Reference
 
In this cohort study, one of the study groups included all primiparous women with a non-malformed singleton infant in breech position after the 36th week of an uneventful pregnancy between January 1998 and December 2002 (n = 279). All these women were planned to give birth at home but only because of the breech position they were sent to the hospital. We collected data from their first pregnancy and delivery and followed-up each patient until 31 December 2005. Hence, follow-up was at least 36 months. We established if the patient had a second pregnancy during this period and collected data from that pregnancy too.

Women with spontaneous or induced abortion or a history of infertility before the first ongoing pregnancy were not excluded from the study. Women with a known uterine anomaly were excluded.

We created a reference group of patients with an uneventful pregnancy that ended in a spontaneous birth of a non-malformed child in vertex position at home in the same period (n = 268). The Dutch obstetrical system, where healthy women with uncomplicated pregnancies give birth at home, gives us an opportunity to select patients for the reference group. In 2001–2002, 30% of the deliveries in the Netherlands took place at home (Anthony et al., 2005Go). Furthermore, in the Netherlands no recommendations are given with respect to the interpregnancy interval after Caesarean section. All the patients in this study are from the same geographical area around the teaching hospital of Deventer, in the eastern part of the Netherlands.

Each patient in the breech presentation group was matched with a patient from the reference group. We matched for date of delivery ± 6 months and for age of the mother ± 1 year. Data were retrieved from the local obstetrical database. This obstetrical database is used in our hospital and an identical database is used by midwives and general practitioners who are responsible for the obstetrical care at home. Obstetrical data of subsequent pregnancies in these databases are registered in a longitudinal way. Every patient has a unique number in these databases. From all patients in the region around the hospital data concerning pregnancy are stored in these databases. To put data together from the databases of the hospital, the midwives and the general practitioners we used deterministic joining, based on the unique patient number. Thereafter, we have made a copy of the complete database and we removed all the identifying characteristics of the patients.

The total population was divided into four groups: breech presentation and elective Caesarean section, breech presentation and emergency Caesarean section, breech presentation and vaginal delivery and vertex position and vaginal delivery.

All data were analysed with the Statistical Package for the Social Sciences (SPSS) 14.0 (SSPS, Inc., Chicago, IL, USA). For analysis of differences between groups, we used the student's t-test, chi-squared test, Mann–Whitney U-test or Kaplan–Meyer curves, when appropriate. Statistical significance was assumed if the P-value was <0.05.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Authors contribution
 Reference
 
Between January 1998 and December 2002, 5515 women at term gave birth in our hospital. In 659 cases the child was in breech position. From these cases, a total of 279 primiparous women were sent to the hospital in this period because of a non-malformed singleton infant in breech presentation after the 36th week of the pregnancy or during delivery. From these 279 women, 165 (59.1%) delivered by Caesarean section and 114 women delivered vaginally (40.9%). In the reference group, 268 women were included who delivered vaginally of their first child in vertex position at home. We were not able to find a matching patient for appropriate birth date or age for 11 women. Epidemiological and obstetrical characteristics of the women who delivered of a singleton infant in breech presentation and the women from the reference group are presented in Table I. All women were followed-up for a period with a median duration of 5 years (range 3.36–8.31).


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  		Table I. Epidemiologic and obstetric characteristics of primiparas who delivered a singleton non-malformed infant in breech presentation and of primiparas who delivered a singleton non-malformed infant in vertex position vaginally (= reference group).

 
Table II shows that there is no difference in number of subsequent pregnancies between the total Caesarean section group and the reference group (P = 0.800). There was also no difference for having a second pregnancy between the vaginal group, the elective Caesarean section group and the emergency Caesarean section group (P = 0.433).


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  		Table II. Mode of first delivery and subsequent pregnancy.

 
We retrieved information from our database about the interval between the date of birth of the first child and the date of the last period of the next pregnancy for 205 women in the breech group and 204 in the reference group (Table III). From nine women of the breech group and four women of the reference group, the data of the next pregnancy were not complete in the database. Only the fact of pregnancy was known, but unfortunately reliable data concerning the estimated date of delivery were missing in our database. No difference in interpregnancy interval has been found.


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  		Table III. Interval between date of birth of the first child and first day of the next pregnancy.

 
The presentation of the child at next delivery is shown in Table IV. From the 214 women in the breech group, 172 had a next delivery, 23 women had a spontaneous abortion, 1 woman had an induced abortion and 3 women had an ectopic pregnancy. From 15 women, it is known that they have had a subsequent ongoing pregnancy, but the information in the database about the delivery is incomplete in this respect. From the 208 women in the reference group, 165 had a next delivery, 23 women had a spontaneous abortion, 1 woman had an induced abortion and 1 woman had a stillbirth. From 18 women, it is known that they have had a subsequent pregnancy, but the information in the database about the delivery is incomplete in this respect. From all these women in both groups, only the estimated date of delivery was known. The details about the delivery were missing due to departure from the region during pregnancy. When the first child was in breech position, in the next pregnancy 15.7% of the cases had another child in breech position. In the reference group only one child was in breech position at the next delivery.


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  		Table IV. Presentation of infant at first delivery and presentation at next delivery.

 
Table V shows that most of the women from the breech group delivered vaginally in the next pregnancy (86.1%), with 68.9 and 83.7% for women who had undergone elective or emergency Caesarean section, respectively. We compared the reference group with the Caesarean section group for the mode of the next delivery divided in vaginal delivery and Caesarean section. In the Caesarean section group, 87 women delivered vaginally and 22 women delivered by Caesarean section again. There was a significant difference between the reference group and the Caesarean section group for mode of delivery for the next delivery (P < 0.001).


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  		Table V. Mode of first delivery versus mode of next delivery for the breech presentation group and the reference group.

 
The association between a Caesarean section and subsequent pregnancy was also studied by means of Kaplan–Meier curves, which take into account not only whether a woman has one more pregnancy or not, but also the interpregnancy interval. Kaplan–Meier curves estimate the time to an event as survival time which in this context corresponds with the interval between the first birth and the next pregnancy. The estimated mean time to the next pregnancy was 21.257 months [95% confidence interval (CI) 18.435–24.078] for the reference group and 22.801 months (95% CI 19.509–26.093) for the Caesarean group (Log Rank 1). Women who did not have another pregnancy during the observation period were censored observations (Fig. 1). Exclusion of the patients in the study group, for whom no matching patient was found, did not alter the results.


Figure 1
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  		Figure 1: Second pregnancy and interpregnancy interval for primiparous women who had a first singleton infant in breech presentation by Caesarean section (n = 165), or in vertex presentation by vaginal delivery after an uncomplicated pregnancy (n = 268)

 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Authors contribution
 Reference
 
In our study, we saw no differences in the proportion and timing of a following pregnancy between women undergoing a Caesarean section and women giving birth vaginally after uncomplicated pregnancies.

In our reference group of women with an uneventful first pregnancy and delivery 77.6% became pregnant again. Their median interpregnancy interval was 18 months. When an uneventful pregnancy did end in a Caesarean section, we did not see fewer subsequent pregnancies, nor did we see a longer interpregnancy interval. Although the number of patients in the elective Caesarean group is only 35 (with a median interpregnancy interval of 22 months), a trend towards a prolonged interval compared with the reference group of 204 patients (with a median interpregnancy interval of 18 months) cannot be denied.

These results seem to be in contrast with results from the literature. Porter et al. (2003)Go started a debate about this subject: does Caesarean section cause infertility? They concluded that Caesarean section does cause infertility and stated that as yet it is unclear whether reproductive potential is compromised by the effect of pelvic surgery or whether women are deliberately limiting their fertility following Caesarean section. Recently, Oral and Elter (2007)Go suggested that the surgical impact of Caesarean delivery on subsequent delivery is negligible. An important indication for their proposition is the finding of Hannah et al. (2004)Go that the fecundity rate of women from the randomized controlled Term Breech Trial two years post-partum shows no difference between the Caesarean and the vaginal group.

In most studies information about the indications for a Caesarean section is limited. It is not unthinkable that pregnancy or delivery-related problems leading to a Caesarean section differ considerably in literature. But this underlying pathology in pregnancy or delivery could have serious consequences and can lead to a negative birth experience with obvious impact on fertility and interpregnancy interval. The strength of our study is that it includes a well-defined cohort of healthy women with an uncomplicated pregnancy in a well-defined area of the Netherlands during a recent 5-year period. In this cohort, it is possible to establish the pattern of fecundity and interpregnancy interval after an uncomplicated pregnancy and vaginal birth. It is also possible to compare this with the fecundity and interpregnancy interval after an uncomplicated pregnancy ending in a Caesarean section. Our study at least suggests that in our region women do not limit their fertility because of a Caesarean section in their past.

LaSala and Berkely (1987)Go found a small excess of infertility following Caesarean section and speculate that surgery may be the crucial factor which pushes some less fertile women into the infertile zone. Although in our study only a few women with fertility problems before the first pregnancy are included, we did not find an indication for fertility problems because of the pelvic surgery. In our breech presentation group there are more women with a history of infertility than in the reference group. These women who were aware of being subfertile may have started therefore trying for another child earlier than those in the reference group. In our database we do not have information on the start date of trying to become pregnant, so the impact of this phenomenon in our region is beyond our scope. We recognize the fact that there are many possible other determinants of the interpregnancy interval that we do not have data on, like the desire for obtaining a given family size, the use of contraceptive methods and so on. However, due to the nature of our study and the selection of patients a priori differences are not to be expected in these groups in this respect.

A second outcome of our study was that if a first child is born in a vertex position, there is only a minimal chance of birth in breech position during a subsequent pregnancy. However, when a first child is born in breech position the chance of recurrence is 15.7%. Furthermore, if a first child is born after an uneventful pregnancy and vaginal delivery, the chance of an uneventful vaginal delivery during the subsequent pregnancy is very high (99.4%). If a first child is born by Caesarean section due to breech position, the chance of a normal vaginal delivery in the next pregnancy remains fairly high (79.8%), irrespective of the child’s position. These figures could be reassuring when counselling a patient after her first pregnancy with respect to her obstetrical outcome in future. The obstetrical concerns with respect to risks related to a Caesarean section for the subsequent pregnancies remain present, such as an enhanced risk of uterine rupture and retained placenta due to placenta increta, but were not the subject of our study.

Remarkable is the high age of our study population, however, the mean age of our patient group (29.6–30.0 years) is representative of the mean age of the women giving birth to their first child in the Netherlands.

The weakness of our study is the restricted size. We would, therefore, strongly suggest to carryout this study again in another and larger population to see if the impact of a Caesarean section on fertility and interpregnancy interval is comparable with our findings.

Our study sheds new light upon the contention that a Caesarean section per se has a negative influence on the subsequent pregnancy with respect to number and interpregnancy interval.


   Authors contribution
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Authors contribution
Reference
 
All authors equally contributed to design, data analysis and interpretation, and writing of the article.


   Reference
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Authors contribution
 Reference
 
Albrechtsen S, Rasmussen S, Dalaker K, Irgens LM. Reproductive career after breech presentation: Subsequent pregnancy rates, interpregnancy interval, and recurrence. Obstet Gynecol (1998) 92:345–350.[CrossRef][Web of Science][Medline]

Anthony, Amelink-Verburg MP, Jacobusse GW, van der Pal-de Bruin KM. De thuisbevalling in Nederland. Rapportage over de jaren 2001–2002. (2005) PRN-TNO-rapport KvL/JPB 2005.083.

Bahl R, Strachan B, Murphy DJ. Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study. BMJ (2004) 328:311–314.[Abstract/Free Full Text]

Bhattacharya S, Porter M, Harrild K, Naji A, Mollison J, Van TE, Campbell DM, Hall MH, Templeton A. Absence of conception after Caesarean section: voluntary or involuntary? BJOG (2006) 113:268–275.[CrossRef][Web of Science][Medline]

Gamble JA, Health M, Creedy DK. Women's preference for cesarean section: incidence and associated factors. Birth (2001) 28:101–110.[CrossRef][Web of Science][Medline]

Gottvall K, Waldenström U. Does a traumatic birth experience have an impact on future reproduction? Int J Obstet Gynecol (2002) 109:254–260.

Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, et al. Maternal outcomes at 2 years after planned Caesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol (2004) 191:917–927.[CrossRef][Web of Science][Medline]

Hemminki E. Impact of Caesarean section in future pregnancy—a review of cohort studies. Paediatric and perinatal. Epidemiology (1996) 10:366–379.

Jolly J, Walker J, Bhabra K. Subsequent obstetric performance related to primary mode of delivery. BJOG (1999) 106:227–232.[CrossRef]

LaSala AP, Berkeley AS. Primary cesarean section and subsequent fertility. Am J Obstet Gynecol (1987) 157:379–383.[Web of Science][Medline]

Mollison J, Porter M, Campbell D, Bhattacharya S. Primary mode of delivery and subsequent pregnancy. BJOG (2005) 112:1061–1065.[Web of Science][Medline]

Murphy DJ, Stirrat GM, Heron J. The relationship between Caesarean section and subfertility in a population-based sample of 14,541 pregnancies. Hum Reprod (2002) 17:1914–1917.[Abstract/Free Full Text]

Murphy DJ, Pope C, Frost J, Liebling R. Womens view on the impact of operative delivery in the second stage of labour: qualitative interview study. BMJ (2003) 327:1132–1136.[Abstract/Free Full Text]

Oral E, Elter K. The impact of Caesarean birth on subsequent fertility. Curr Opin Obstet Gynecol (2007) 19:238–243.[Web of Science][Medline]

Porter M, Bhattacharya S, van Teijlingen E, Templeton A. Does Caesarean section cause infertility? Hum Reprod (2003) 18:1983–1986.[Abstract/Free Full Text]

Smith GC, Wood AM, Pell JP, Dobbie R. First cesarean birth and subsequent fertility. Fertil Steril (2006) 85:90–95.[CrossRef][Web of Science][Medline]

Submitted on June 27, 2007; resubmitted on December 6, 2007; accepted on December 13, 2007.


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This Article
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