If the list of cesarean harms weren’t long enough already, Consumer Reports points to another one: women who have hysterectomies are more likely to experience complications if they have previously had cesareans. Let’s take a look at the study.

Investigators identified a population of 7685 Danish women who had given birth and who subsequently had a hysterectomy for noncancerous reasons when they weren’t pregnant and were more than 45 days past giving birth. They then looked at the association between mode of birth and need for re-operation after the hysterectomy as well as other complications according to whether the women had no, one, or multiple prior cesareans.

After adjusting for factors that might influence both the need for cesarean and the likelihood of hysterectomy complications, they found that one prior cesarean increased the likelihood of needing re-operation by 30% and two or more increased need by 35% compared with women with no prior cesarean. With 4% of women with only vaginal births needing re-operation, this amounted to 2 more women with at least one prior cesarean per 100. Women with 2 or more prior cesareans were also 30% more likely to experience surgical complications (primarily bleeding or infection), which, at a baseline rate of 12% among women with no prior cesarean, amounted to 4 more women per 100. Finally, women with 2 or more prior cesareans were 93% more likely—nearly double the odds—to need a blood transfusion. With 2.5% of women with no prior cesarean needing transfusion, this amounted to 2.5 more women per 100. Both the study authors and the Consumer Reports commenters think the probable cause for the increased complication rates is that adhesions (internal scar tissue) formed consequent to cesarean surgery make further surgery more complex and more likely to result in injury.

In addition, women with prior cesareans were more likely to have an abdominal hysterectomy (42% no prior cesarean; 60% 1 prior cesarean; 68% multiple prior cesareans) as opposed to the less invasive vaginal or laparoscopic hysterectomy. Study authors observe that this is probably because of concern that adhesions could increase the potential for bladder injury or difficulty removing the uterus via these other routes. Minimally invasive surgery, they note, results in shorter recovery time, less pain, and a smaller incision.

Study authors also note that while the overall Danish cesarean rate is 21%, it was 32% in women having a future hysterectomy. This could be because women who have cesareans have health or gynecologic problems that increase their risk of needing a hysterectomy, but it could also be because cesarean surgery increases the likelihood of complications leading to the need for later hysterectomy (chronic pain, bleeding disorders, adenomyosis, and adhesions).

The Consumer Reports article adds that hysterectomies down the road aren’t the only drawback. Women with prior cesareans are also more likely to require a hysterectomy or experience serious complications in conjunction with subsequent births, whether they are planned VBACs or repeat cesareans.

The Take-Away: The excess in rates of re-operation and other complications with downstream hysterectomy may be small, but they add to the reasons why cesareans shouldn’t be undertaken lightly. Worrisome too, the study raises the possibility that cesarean surgery may increase the need for hysterectomy in the future.