Contributing to the Modern Cesarean Epidemic: an example of insufficient evidence in my field

Today I was in class trying to follow along in a fast-paced discussion of voice pathologies.  One such pathology discussed was the Human Papilloma Virus which can attack the vocal folds.  Colds and other viral infections can manifest as papillomas (small harmless epithelial tumors) on or near the vocal folds (membranes of the voice box).  This is called Recurrent Respiratory Paillomatosis (RRP).

RRP shows up in children, and the suspected cause is a HPV-infected mother.  When a baby descends through his/her mother’s birth canal, the baby can contract HPV if the mother carries the virus.  Adult onset RRP evidently is becoming more prevalent, possibly due to changing sexual practices.

In the course of teaching us about HPV and the respiratory equivalent, RRP, the instructor stated that pregnant women with HPV should have their babies “delivered” via cesarean section.  The instructor was given this information by . . . you guessed it . . . a DOCTOR!  I couldn’t hold my tongue.  I wanted my colleagues to be sure to know that although a doctor may suggest that a pregnant woman with HPV should have a cesarean, that it’s not a mandate.

I wish I had told my colleagues that uniformly recommending cesarean delivery due to HPV is not an evidence-based practice.  Why is this important?  What if a pregnant woman enters this practitioner’s speech & hearing clinic complaining that her voice is hoarse and weak, and upon further investigation, it is discovered that she has RRP.  This practitioner may tell her that she’ll have to have a cesarean because she has RRP.  That may be one more woman who, heeding the advice of her care providers, would be cut.

Let’s look at some of the literature on the net about both HPV and RRP. (See sources at the bottom of this post.)
Frequency:  According to the RRP Foundation, there are maybe 20,000 active cases of RRP in the U.S., and the CDC estimates that less than 2,000 children contract RRP in a year.  HPV is quite prevalent – approximately 20 million Americans are infected.
Transmission.  Active condyloma during pregnancy or HPV can cause a baby to become infected, but occurrence is deemed RARE.  As stated previously, RRP is becoming more prevalent in the adult population possibly due to changing sexual practices, and HPV has a strong connection to sexual practice.
Childbirth recommendations:  Cesarean delivery is not completely protective from RRP though recommended for consideration when visible condyloma is present in a primaparous pregnant patient.  Cesarean delivery is not protective against RRP in mothers with genital warts.

Well-meaning practitioners from other unrelated fields can and do contribute to the cesarean problem.  However uncomplicated a cesarean may seem when presented antiseptically from a medical provider or behavioral clinician, important questions are not being asked:

  1. How likely is transfer of the presumed pathogen
  2. How is cesarean delivery protective against the transfer of specific STDs and other viral infections
  3. What physical complications can arise for the mother with a cesarean
  4. What physical complications can arise for the baby due to a cesarean
  5. How does cesarean delivery affect the mother-baby dyad
  6. What psychophysical or emotional complications can arise after cesarean delivery (or after traumatic birth experiences); how and when do they manifest
  7. What complications may arise (at birth, in childhood, during puberty, in adulthood) from possible RRP transfer
  8. How should the patient/client prioritize the risks/benefits of vaginal or cesarean birth
  9. What does the mother (and her support team – partner, family members, close friends, etc.) desire
  10. Who is more important – the mother or the baby

This last question is the most perplexing, it seems, for the medical community.  Babies are born innocent and vulnerable.  They are unable to advocate for themselves.  In protecting the rights of the unborn or barely-born (not that I oppose that ultimately, I might add), care providers knowingly and unknowingly subvert the rights of the mother.  The mother is here right now.  She is hopefully a positive contributor to her community.  She may already care for other children.  She may have a life partner.  When her health and happiness is compromised for the well-being of her innocent child, is our society really any better for it?  Which is more important – kinetic energy, a life in process, a current contribution . . . or potential energy, a life about to begin, a possible contribution.

I hope readers will take to heart the broadest implications of this post.  First, medical doctors and insurance companies are not the only ones adding to the increasing cesarean rate.  We find well-meaning contributors in some of the most unlikely places.  Second, questions beyond “how easy is it to fix” must be asked when the life and well-being of the mother-baby dyad is at risk.

For more information on cesarean delivery, please visit the International Cesarean Awareness Network (ICAN) and Childbirth Connection.

Sources Consulted:
CDC information on HPV –
Condyloma in Pregnancy Is Strongly Predictive of Juvenile-Onset RRP –
Course notes
eMedicine –
Genital HPV Infection Learning Module –
RRP Foundation –
Women’s Health, HPV and Genital Warts –

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One thought on “Contributing to the Modern Cesarean Epidemic: an example of insufficient evidence in my field

  1. Wow….how long have I been reading your blog and I’m just now reading this? You’ll never believe how I got here either….I did a google image search for vocal fold papilloma to do some studying for my voice disorders class.

    So, the answer give in my class last week was “cesarean is best” in the case of confirmed HPV infection. Again, I find myself dancing on the line of sanity, surrounded by minds being molded by the second, gulping down every word our teachers say. Did I mention that our program and field is about 95% female?

    It makes me sick to my stomach. Sick to think that if I had never had a c/s I would readily agree with the pat answer of “have the c/s”. Sick to know that there is no such thing as the right or easy answer. And even sicker to know that I’ll likely have to counsel women about this as a future professional.

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