HORRY COUNTY, S.C. (WBTW) –- When Caitlin Tarleton’s second baby was “sunny side up” and labor wasn’t progressing, she was knocked out and wheeled into the operating room.

No one spoke to her. When she woke up, she discovered that her son had been born via cesarean section.

“My son was with my husband, and that experience was so traumatic that I don’t remember his first year of life,” she said. “I look at pictures, and I don’t remember being there.”

Four years later, she’s still facing complications.

Now, she leads the International Cesarean Awareness Network’s Central Savannah River Area chapter – also known as ICAN of the CRSA – and hopes to empower women by educating them about their options, providing them a space to talk about their experiences in an effort to lower C-section rates.

“A lot of women don’t realize you have as many rights as you do,” Tarleton said. “In any birth setting, you’re the customer, and it is required that they have permission to do things, and that is not the vibe you get when you go in.”

Depending on what dataset is used, statistics show that between one-fourth and one-third of babies in South Carolina are delivered via C-section. That’s far from the World Health Organization’s recommendation of 10% to 15%.

The South has traditionally lagged behind the rest of the nation when it comes to lowering C-section rates, with a decrease in the numbers stalling in recent years. 

More interventions

C-sections can be a life-saving measure for many mothers and their babies. However, what was intended to be an emergency procedure has now become routine. 

There is “no justification” for a region to rise above that 15% rate, according to the WHO.

“When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity,” a WHO document reads. “However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure.”

The opposite may be true.

The procedure involves cutting through a parents’ stomach and uterus to retrieve a baby. It can be deployed for conditions such as placenta previa, infections like HIV and genital herpes that can be passed to a newborn during a vaginal birth, and for mothers who have conditions like diabetes or high blood pressure that can make a vaginal birth risky, according to the March of Dimes. It can also be used if a baby is in a breech position, if there’s a pinched umbilical cord or if a baby is in distress.

The organization discourages using the procedure for the sake of convenience. 

The procedure increases the risk for complications. There’s also a chance that a scheduled, not medically necessary C-section could lead to a baby being born too early if an estimated due date is inaccurate.

C-section rates in South Carolina rose sharply from the 1990s to the late 2000s, peaking in 2009, before decreasing again. 

In 1990, that rate was 14.1%. In 2020, it reached 19.1%, according to data from the South Carolina Department of Health in Environmental Control. It was 23.1% in 2009. 

However, a different dataset from the U.S. Centers for Disease Control and Prevention indicates that number is much higher, at 33.5% of births. Southern states claimed the top spots for the most C-sections. Mississippi is the highest at 38.2%.

South Carolina ranks 13th in the nation for the most procedures. Across the U.S., 30 states have rates above 30%. 

Within the state, rates jumped the most for Marion County, going from 15.8% of births to 26.3% in 2020, according to DHEC. Georgetown County also saw a large increase from 12.1% to 22.5% within that same timeframe. 

Florence County hit 34.4% in 2009, and has since decreased to 21.4%. C-sections made up 15.7% of births in the county in 1990. 

Numbers have largely remained the same since 2015. 

Risk of complications

Risks that go along with C-section procedures include a higher chance of infection, blood loss, injury to organs, a longer hospital stay and recovery time, the risk of needing additional surgeries and a higher chance of death, according to the American Pregnancy Association. About 1% to 2% of babies will be cut during the surgery.

Emotional reactions – such as women saying they had a negative birth experience and had trouble bonding with their baby – also occur.

The National Partnership for Women and Families points to several causes behind an increase in C-sections, which include doctors citing that they don’t want to face a negligence lawsuit, casual attitudes around the surgery and a limited awareness of the harms and financial incentives for providers, since some payment schedules offer more money for a C-section than a vaginal birth.

The procedures are also “efficient” and can be scheduled on weekdays to avoid staff working on nights, weekends and holidays. Some providers, the organization said, might even be unwilling to offer a choice between a C-section and a vaginal birth.

The group said that many C-sections could be avoided with patience, changing a mother’s position, giving her nourishment and letting her rest. Inducing labor can also lead to a C-section, as can lying in a bed instead of another position.

The role of hospitals

C-section rates can vary greatly from one hospital to the other, according to Leapfrog, a non-profit organization that advocates for transparency in health care.

Of area hospitals that self-reported data to the organization, the highest C-section rate in the 2021 report was at Grand Strand Medical Center in Horry County. At a 42.9% rate, the hospital is considered to have “limited achievement,” which is the lowest classification. McLeod Health Loris, at 40%, and Carolina Pines Regional Medical Center in Hartsville, at 32.9%, are also in the category. 

“Grand Strand Medical Center is dedicated to making sure that C-sections are performed only when they are medically necessary,” a statement from the hospital reads. “Our nurses are frequently moving, turning and repositioning soon-to-be moms who are in labor and any scheduled C-section is reviewed and approved by our Chief Medical Officer. We appreciate our physicians and other colleagues for their commitment to provide the best possible care to babies born at our hospital.”

A hospital spokesperson noted that new scores are expected to be released soon. 

The lowest rate within News13’s South Carolina coverage area was at McLeod Regional Medical Center in Florence. The hospital is the only one in the region to have reached the “achieved the standard” rating, at 22.7% of births.

Conway Medical Center, at 27.9%, MUSC-Florence, at 26%, and Tidelands Waccamaw Community Hospital in Murrells Inlet, at 29.3%, are rated as having “some achievement.”

Three hospitals did not self-report data. 

Empowerment through education

The number of women who have given birth at home increased during the pandemic, and it hasn’t decreased. Wanting to stay out of hospitals due to COVID-19 concerns and visitor restrictions has contributed, but so has the desire to want to avoid medical interventions, according to Audrey Trepiccione, a certified professional midwife and owner of Oceanside Midwives in North Myrtle Beach. 

“I think that [women] are very medically oriented from birth,” Trepiccione said. “I’ve met women who were born by cesarean and thought that might be a way to do it in our modern world.”

Using a midwife or a doula – a birth coach – reduces the odds that a women will need a C-section. Part of that might be because at-home midwives won’t accept patients who have high-risk pregnancies.

Trepiccione said the expecting parents she works with tend to be more health conscious. She explains to clients how C-sections can be harmful if it’s not necessary. 

Midwives delivered most babies in the state until about the midcentury, when births shifted to hospitals. Trepiccione said that midwives were nearly driven out of the business by medical lobbies, and different pay structures provided economic incentives to get rid of the profession.

That’s starting to shift back, although South Carolina’s lack of a midwifery school has limited the number of midwives in the state. 

Trepiccione said midwives also have lower C-section rates because they won’t induce patients unless it’s for a medical reason. They try to keep the births unmedicated and use effective positions and strategies.

“Most people who get induced at around 39 weeks, so that leads to a cascade of interventions,” she said.

Women now, she said, are learning that that doesn’t have to be the case with their own births.

“Kind of like how they have to relearn to breastfeed, they are learning how to give birth again,” Trepiccione said. 

Tarleton said women need to choose how they give birth, whether that’s in a hospital or at home. But she said a lot of parents don’t know their options and how to advocate for them. 

“Here in the South, I see that women, there is very much the assumption that you’ll do what your doctor says, and I think a lot of that has to deal with the culture here, and the misogyny and the internalized misogyny that you will do what you’re told,” she said. 

Pregnant women are expected to be childlike, she said, and aren’t expected to deny an intervention that’s being proposed to them. 

ICAN helps educate about those options by providing support, advocacy and education. ICAN of the CRSA’s Facebook page gives mothers the opportunity to talk without being screenshotted, she said. 

The organization lets women know that just because they’ve had a C-section once, that doesn’t mean they have to have another with their next baby.

“These repeat cesareans are driving a lot of the cesarean rates, because it’s assumed you’ll have a cesarean again, if you have one,” Tarleton said. 

She discovered the organization following her own C-section. After her surgery, she said that she wasn’t given physical therapy and still experiences issues due to the procedure. 

“The amount of pain, the risk of infection, all of the many risks that go along with the surgery are so downplayed and it is seen as the safest way, and I don’t understand that, especially when it is repeated over and over again,” she said. 

People need to demand fewer unnecessary interventions in order to help drive down the rate, she said. 

Her experience led her to choose a homebirth with her most recent child. For a previous baby, when she’d given birth at a hospital and vocalized that she didn’t want continuous fetal monitoring because it led to a high C-section rate, she said staff responded by saying they had to call risk management. 

Women are becoming traumatized by birth, and she said a lot of that has to due to losing control of what’s happening during it.

“It’s a horrible way to enter parenthood,” Tarleton said.