Julia Clardy was sharing a spaghetti dinner with her husband Jason one evening in late April 2019 when she began to feel some pain.

At 23 weeks pregnant, she was just over half way to her due date. But the signs were unmistakable. She was in labor.  

At the hospital, doctors said her baby boy had only a 12 to 15 percent chance of survival.

“We were told … to expect the worst. That discussion was very hard,” Julia Clardy said. “But I knew that he still had a fighting chance.”

So the Williamston, S.C., couple began praying.

When baby Lawson arrived three days later by emergency C-section, he weighed just 1 pound, 7 ounces, earning him the nickname Pencil Baby, Clardy told Integrated Media, publishers of Greenville Business Magazine, Columbia Business Monthly and Charleston Business Magazine. 

The tiny infant had jaundice as well as a hole in his intestines that required surgery and an ostomy. He also had a hole in his heart and pneumonia, leaving him with chronic lung disease that puts him at high risk for infections. 

Lawson is one of the more than 6,000 babies born preterm, or before 37 weeks, in South Carolina each year, according to the state Department of Health and Environmental Control.

South Carolina’s preterm birth rate is 11.8 percent of all live births, up from 10.8 percent in 2014, according to the March of Dimes. And at 15 percent, the rate among African Americans is 55 percent higher than whites, the group reports.

These statistics, along with the state’s infant mortality rate – which is 7 per 1,000 births, higher than the national average of 5.6 – earned the Palmetto State an F in the group’s latest report card, said Laura Goodwin, executive director for the South Carolina market of the March of Dimes.

“Unfortunately, this is not new,” she said. “Our rate of preterm births actually worsened last year. We had an uptick of 0.3 percent … (which) continues to place us in an unacceptable range and higher than the national average.”

The causes of prematurity are multifaceted and often unknown, but include chronic diseases like diabetes and hypertension, and risk factors such as smoking and substance use, said Kimberly Seals, director of DHEC’s Bureau of Maternal and Child Health.

South Carolina fared so poorly on the report card for many reasons, said Dr. Scott Sullivan, vice chair of the Department of Obstetrics and Gynecology and professor of maternal-fetal medicine at the Medical University of South Carolina.

“Historically, there’s been a lack of access to care,” he said. “There are several counties without an OB-GYN or a midwife.”

Between 2010 and 2020, the number of OB-GYNs grew from 552 to 604 – an increase of 9.4 percent, according to the South Carolina Office of Healthcare Workforce. 

But at the same time, the population grew more than 11 percent, from 4.6 million to 5.1 million, according to the U.S. Census Bureau.

Meanwhile, 14 counties have no OB-GYNs, another 10 have fewer than three per 10,000 women, and only 12 have five or more per 10,000 women and they are in the more populous counties, like Greenville, Lexington and Charleston counties, the Office of Healthcare Workforce reports. 

And the number of certified nurse midwives declined from 84 to 77, a drop of 8.3 percent, according to that office. Some 28 counties have no nurse midwives at all, while only one has three or four per 10,000 women, and none have five or more.

That means patients often must travel distances for care, Sullivan said, which can make regular prenatal visits difficult, especially for those without transportation. 

In addition, three of 44 hospitals closed their labor and delivery units for financial reasons in the past three years, forcing residents in those areas to travel even farther for care, he said.

South Carolina is also plagued by high rates of poverty, poor nutrition, and a lack of health insurance. 

While uninsured women can get Medicaid while they’re pregnant, it doesn’t last long once the baby is born, so they may not get treatment for health conditions that put them at risk for preterm births, he said. 

“A person who may get Medicaid while pregnant, after six weeks is cut off,” he said. “So until they’re pregnant again, they don’t have prescription coverage and they can’t get insulin or blood pressure medication or contraceptives. 

“They come back to us sicker and sicker with each pregnancy.”

Poverty also impacts nutrition, which is critical before and during pregnancy, he said. Many women live in food deserts, he added, and if they have access to a grocery store, they often can’t afford the healthy foods. That sets them up for preterm births as well, he said.

South Carolina also has high rates of infections, smoking, and domestic violence, which are also risk factors, he said.

“(It’s) like an onion. You peel it back and it’s one problem after another,” he said. “It’s a large systemic chronic problem.”

Can anything be done? Sullivan said that depends on the issue.

The nation is struggling with a doctor shortage exacerbated by a cap on federal funding for medical residency slots, which is not likely to change any time soon, he said.

Meanwhile, doctors are graduating with as much as $500,000 in debt, he said, which leads them to work in higher paying urban areas. Tuition forgiveness programs designed to increase rural doctors cover only a small portion of the debt, making it not worthwhile, he said. 

In addition, he said, there is no traction to expand Medicaid in South Carolina, even though preemies cost the system a lot more than full-term births.

“One premature baby can easily run into the millions, and that’s just a NICU stay,” he said, adding that preterm babies are three times as likely to develop autism. 

“If they have long-term disabilities like blindness or deafness or cerebral palsy,” he added, “we’re talking about tens of millions.”

Yet on average, every dollar Medicaid spends on preventive care saves $8 to $10 in more advanced care for these babies, he said, so investing money on the front end would save a lot on the back end.

“The NICUs … save kids who would die otherwise,” he said. “But they’re always full of premature babies that don’t need to be there.”

The higher rate of preterm births among African Americans is linked to systemic racism, he said.

“Infant death, the risk of dying in childbirth, preterm births are all increased in African Americans no matter what the social situation, and it’s doubled or tripled if there are other disadvantages,” he said. “Our system is just rampant with systemic racism. And that’s going to be another heavy lift.”

Some reforms are doable – help with transportation, for instance – providing the will exists to do it, he said, while research into the causes of preterm birth and treatments holds out some long-term hope. 

Goodwin said the March of Dimes has partners across the state, including DHEC and hospital systems, that have come together to deal with preterm birth.  

The state’s Birth Outcome Initiative, for example, spreads awareness about the importance of prenatal care, managing chronic diseases and eliminating risk factors, Seals said.

Meanwhile, the March of Dimes is working on a common agenda to address access to care, prenatal education and the health equity gap that exists beyond socioeconomic factors, investing in implicit bias training for providers, for example, Goodwin said. 

It’s also funding research to identify women who are more likely to deliver preterm or have complications, and to provide solutions like medical devices that could help regulate contractions, she said. 

The group took a hit to donations in 2020 because of the pandemic, she said, but was on track to raise $1 million more in 2021.

But Sullivan said that for those on the front lines, it can be hard to be optimistic. 

“We try to keep each individual pregnancy as healthy as we can,” he said.  “But we really need some drastic changes. So I don’t see that F changing any time soon.”

“The … report card continues to highlight why we as a state must be diligent in our efforts to improve maternal and infant health care,” added Seals, “and continue to make investments in programs and policies that give every baby in our state a fighting chance at life.”

Clardy, a third-grade teacher at Palmetto Elementary, said her pregnancy had been normal until that April day. 

Pregnant during the winter months, she remembers being sick. But she didn’t know she had a common viral infection known as cytomegalovirus – which she says was blamed for Lawson’s early birth.

Doctors told her and Jason, 36, a project manager for an industrial flooring company, to prepare themselves that Lawson probably wouldn’t survive. So when he let out a faint cry and opened an eye after he was delivered, the medical team was stunned, she said. 

After 133 days in the NICU, he was released weighing 7 pounds, 5 ounces. The bill for the NICU stay alone was over $1 million, not including surgeries, she said. 

For the first year and a half of his life, Lawson had a feeding tube. He still suffers from a weakened immune system and was hospitalized four times this year alone, once for a week with RSV, or respiratory syncytial virus. 

He also survived Covid. 

“It was definitely a roller coaster,” said Clardy, 32.

Lawson has graduated from occupational and physical therapy and a program for medically complex children, though he still gets speech therapy, she said. 

And the Clardys, who are the March of Dimes 2021 Ambassador Family for South Carolina, have every hope that as he grows, he’ll be fine. 

“In the beginning, we feared a lot of things. He is tiny. And he just called me ‘Mommy’ for the first time this past summer,” Julia Clardy said. 

“But he’s a fighter,” she added. “And when you see how far he has come, you know he’s going to be OK.”

To learn more, go to marchofdimes.org.