PURPOSE: This study aims to investigate trends in birth and cesarean section (CS) rates among women with epilepsy (WWE) in Korea. METHODS: We conducted a nationwide, population-based, repeated cross-sectional study using data from the Korean National Health Insurance Service database. We evaluated the annual childbirth rate and proportion of CS among all deliveries for WWE and the entire female population aged 15-49 years from 2004 to 2019. RESULTS: The annual childbirth rates declined more sharply for WWE than those for the general population, with an average annual percent change (AAPC) of -3.5 % for WWE compared to -1.3 % for general women. The CS rate was higher in WWE (51.2 %) than in general population (38.9 %), with increasing trends observed in both groups (AAPC = 2.2 % for WWE vs. AAPC = 1.8 % for general women). Among WWE under monotherapy, without emergency room visits related to epilepsy, and without both central nervous system and psychiatric diseases, the CS rates were 47.8%, 50.6%, and 48.3%, respectively. After adjusting for age and obstetric comorbidities, factors associated with increased CS risk included the use of four or more antiseizure medications (adjusted odds ratio (aOR) 1.74 [1.06-2.87]), emergency room visits (aOR 5.64 [2.83-11.24]), and an Epilepsy-Specific Comorbidity Index of ≥2 (aOR 1.45 [1.05-2.01]). CONCLUSIONS: The annual decline in childbirth and increase in CS rates were more prominent in WWE. While epilepsy severity and comorbidities were associated with CS deliveries, the persistently high CS rates in WWE even under favorable maternal conditions suggest the potential for unnecessary CS procedures.