Women & Children First

A young mother arrives at a small town delivery room in preterm labor, 12 weeks before her due date. Doctors and nurses are on standby with all the specialized equipment to keep the 2-pound baby girl stable until she can be transported to a larger hospital in Columbia. Among that equipment is something unexpected. As soon as the baby is born, she is placed in a plastic bag up to her neck.

Today, placing a premature baby in a warming bag is a common delivery room practice, a move that prevents a preemie’s body temperature from dropping and lowers the baby’s chances of complications and death. Twenty years ago, things might have ended differently.

Ask Robin Dail. Two decades ago, Dail was a NICU nurse when she conducted a groundbreaking study to prove bags could effectively reduce hypothermia in preterm infants. Now the Health Sciences Endowed Professor in USC’s College of Nursing, she is broadening her efforts as director of the university’s Perinatal, Pediatrics and Family Research Center.

Launched last fall, the PPFRC brings together interdisciplinary researchers, clinical faculty members and doctoral students to study health issues related to pregnancy and childhood. 

According to the Centers for Disease Control and Prevention, the nation’s maternal death rate has increased from about 17 deaths per every 100,000 live births in 2018 to nearly 24 per 100,000 in 2020. Black women are three times more likely to die than white women. And while overall infant mortality rates continue to trend downward, the U.S. still saw nearly 20,000 infant deaths in 2023, with Black infants more than twice as likely to die as white ones.

Where you live matters, too. Mothers and children are especially vulnerable in South Carolina, where inadequate prenatal care and high rates of morbidities — conditions such as hypertension, diabetes and renal failure — can cause pregnancy complications. And the state’s high preterm birth rate sets children up for lifelong health challenges, particularly when socioeconomic barriers limit early intervention.

“Much of our research is aimed at preventing neurologic developmental delays and other health challenges in children born premature,” Dail says. “We know families experience socioeconomic stress due to complications from prematurity. We aim to decrease that burden on families and, ultimately, society.”

Expanding Access

Access to women’s reproductive health care isn’t the same nationwide — and disparities can be even greater in rural areas. Birth control access is just one example.

In South Carolina’s most rural counties, seeing a doctor to discuss birth control options can be a frustrating process. Appointments often need to be scheduled months out. Patients may need to take time off work, find transportation and line up childcare. The longer all that takes, the higher the risk of unplanned pregnancy. 

A new law is changing that. In 2022, Gov. Henry McMaster signed off on the Pharmacy Access Act, which allows South Carolina pharmacists to prescribe contraceptives without a doctor’s prescription. Passed with broad bipartisan support, the bill aims to improve birth control access statewide, particularly in rural areas where health care providers are scarce.

But putting legislation into practice involves a lot of legwork. Patti Fabel, an associate professor and executive director of the Kennedy Pharmacy Innovation Center in the USC College of Pharmacy, is part of the team designing the training for pharmacists and pharmacy students who want to become birth control prescribers. USC’s pharmacy curriculum already includes extensive education on contraceptives, covering everything from medicinal chemistry to contra­indications. The new certification training will supplement that by explaining the legal requirements specific to South Carolina.

“We have to talk to patients about Medicaid and enrollment in Medicaid. We have to assess for interpersonal violence and human trafficking,” Fabel says. “So we’re going to incorporate some of these things that pharmacists aren’t really trained to do on a regular basis.”

And pharmacists are open to participating. A residency research project led by 2022 Pharm.D. alumna Tate Cook Owens surveyed pharmacists across the state to gauge their attitudes about the new legislation and identify potential barriers. While hesitancy was an issue 17 years ago when the FDA approved over-the-counter sales of Plan B, concerns now focus mainly on implementation logistics.

“The biggest hurdles were mainly about their staffing concerns, the time that they had to devote to this service and making sure that they were given the resources needed to do it appropriately. That’s fixable,” Fabel says.

Patients still need to see their doctors for routine preventive care, such as cancer screenings. But those screenings are no longer a prerequisite to accessing birth control. That could translate into lower maternal morbidity and mortality rates.

“An adult female can decide she needs hormonal contraceptives without a physician,” Fabel says. “At that point, they just need someone to tell them if it is safe and appropriate for them to have this version or should they have that version? And who’s more well-versed in medication and appropriateness of medication than a pharmacist?”

About half of all states have similar laws on the books. Based on responses in those states, Fabel anticipates the most uptake in areas where access is needed most.

“If a patient doesn’t really have a problem with accessing birth control, they’re probably not going to change the way they’re getting their prescription,” she says. “But in those areas of the state where it’s really tough for them, where it’s going to take them six months just to get an appointment with their OB, and their physician is the type that says I’m not going to send in refills until you come see me — yeah, those patients are probably going to go to the pharmacist.”

Addressing Birth Inequities

Across the U.S., more than 2 million women of childbearing age live in maternity care deserts — counties without obstetric care facilities and providers. In South Carolina, nearly one in five pregnant women receives inadequate prenatal care, according to the March of Dimes.

“People don’t realize sometimes how rural a state we are, particularly if they live in one of the urban areas, and they don’t really understand how difficult it can be to get the kinds of services that are necessary,” says Kathryn Luchok, a senior instructor in the Department of Women’s and Gender Studies and affiliate faculty member in the Department of Anthropology.

Since joining the South Carolina Birth Outcomes Initiative’s Birth Equity work group 12 years ago, Luchok has helped the organization improve maternal care disparities by supervising student projects aimed at better understanding the issue. Racial disparities in the state’s rural areas have been an area of focus.

“When you look at birth equity, rural areas are more predominantly African American and Hispanic,” Luchok says. “So if you don’t address the needs there, you’re also not addressing the needs for people of color who have less than stellar outcomes in the state to begin with.”

One project that’s garnered attention, a comprehensive map of perinatal services in South Carolina, was created in 2022 by exercise science major and medical humanities minor Taylor Olson for her Honors College senior thesis. Women’s and gender studies major Teddi Meier did follow-up work on the map for her capstone project.

Built with data from a variety of sources, including provider data from USC’s Institute for Families in Society, the map allows users to search for everything from hospitals to licensed midwives, making it easier for women in rural areas to identify the nearest maternity care provider. 

“We’d like to do quarterly updates and also have a way for providers to be able to tell us their updates, changes or things that they add or delete,” Luchok says. “But in the meantime, we’re using the map to help us figure out where the gaps in services really are.”