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Likelihood of Continued Childbearing After Cesarean Delivery in the United States

Masinter, Lisa M. MD, MPH; Feinglass, Joe PhD; Grobman, William A. MD, MBA; Simon, Melissa A. MD, MPH

doi: 10.1097/AOG.0000000000000294
Contents: Original Research

OBJECTIVE: To estimate the likelihood of continued childbearing as a function of mode of delivery and number of cesarean deliveries and to explore whether it varies by sociodemographic characteristics.

METHODS: Cross-sectional data from the 2006–2010 National Survey of Family Growth were used to conduct an analysis of U.S. childbearing women. The birth trajectory for respondents who identified a live, singleton, first birth was assessed through four births. Population-weighted analyses were performed to test the association between route of delivery and sociodemographic characteristics with the likelihood of subsequent birth.

RESULTS: Among 6,526 respondents, cesarean delivery, regardless of birth order, was associated with a lower likelihood of future birth, which decreased in a dose–response fashion as the number of cesarean deliveries increased. Among women with three births, those with two or three cesarean deliveries were 37% and 59% less likely (P<.05), respectively, to have a fourth birth when compared with women with three vaginal deliveries, adjusting for confounders. When interaction terms were added to the model, lower income women were significantly more likely to have a fourth birth after undergoing two or three cesarean deliveries than women with higher incomes (adjusted incidence rate ratio 2.50, 95% confidence interval [CI] 1.23–5.05 and adjusted incidence rate ratio 2.39, 95% CI 1.01–5.65, respectively).

CONCLUSIONS: U.S. women who have cesarean deliveries are less likely to continue childbearing, especially because they undergo higher numbers of cesarean deliveries; however, this relationship is attenuated among low-income women. Given the risks associated with multiple cesarean deliveries, these findings underscore the need to further examine this relationship and what factors may be driving the income-based difference in childbearing after cesarean deliveries.


Although childbearing progressively decreases with increasing numbers of cesarean deliveries for the U.S. childbearing population, the trend is significantly attenuated in women from lower income backgrounds.

Departments of General Internal Medicine and Obstetrics and Gynecology–Maternal-Fetal Medicine, Center for Healthcare Studies–Institute for Public Health and Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Corresponding author: Lisa M. Masinter, MD, MPH, Postdoctoral Research Fellow, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, 420 E. Superior Street, 10th Floor, Chicago, IL 60611; e-mail:

Supported by an institutional award for postdoctoral training to the Northwestern University Feinberg School of Medicine Center for Healthcare Studies from the Agency for Healthcare Research and Quality, T-32 HS 000078, and by grant number P01HS021141 from the Agency for Healthcare Research and Quality.

The authors thank Jane Holl, MD, MPH, for her editorial assistance and Jungwha Lee, PhD, for her assistance with statistical analysis and variable manipulation.

Presented as a poster at the American College of Obstetricians and Gynecologists Annual Clinical Meeting, April 28, 2014, Chicago, Illinois.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.