Top
2021 MARCH OF DIMES REPORT CARD

Report card for

Preterm Birth Rate
12.9%
Preterm Birth Grade
F
Preterm Birth Grade
F
Preterm birth grade greater than or equal to 11.5 percent
LEARN MORE arrow

The 2021 Report Card highlights the latest key indicators to describe and improve maternal and infant health in the U.S. It features grades for preterm birth and measures on infant mortality in addition to social drivers of health, low-risk Cesarean births and inadequate prenatal care. Our Supplemental Report Card highlights the stark disparities across race and ethnicity within these factors. 

With the onset of the COVID-19 pandemic, pre-existing health disparities have been magnified. Comprehensive data collection and analysis of these measures, and the resulting disparities, inform the development of policies and programs that move us closer to health equity. The Report Card looks at policies like Medicaid expansion and programs like Maternal Mortality Review Committees, that can help improve equitable maternal and infant health for families across the country.

Percentage of live births born preterm

Purple (darker) color shows a significant trend (p <= .05)

INFANT MORTALITY

Infant mortality rates are an indication of overall health. Leading causes of infant death include birth defects, prematurity, low birth weight, maternal complications and sudden infant death syndrome.

INFANT
MORTALITY
RATE

7.9

U.S. INFANT
MORTALITY
RATE

5.6

 

Rate per 1,000 live births

Purple (darker) color shows a significant trend (p <= .05)

PRETERM BIRTH RATE BY RACE AND ETHNICITY

The March of Dimes disparity ratio measures and tracks progress towards the elimination of racial/ethnic disparities in preterm birth. It's based on Healthy People 2020 methodology and compares the group with the lowest preterm birth rate to the average for all other groups. Progress is evaluated by comparing the current disparity ratio to a baseline disparity ratio. A lower disparity ratio is better, with a disparity ratio of 1 indicating no disparity.

No Improvement

Change from baseline

In Alabama, the preterm birth rate among Black women is 52% higher than the rate among all other women.

GO TO PERISTATS TO VIEW ADDITIONAL ALABAMA DATA.  View additional data

PRETERM BIRTH RATES BY COUNTIES AND CITY

CountyGRADEPRETERM BIRTH RATECHANGE IN RATE FROM LAST YEAR
BaldwinC 10.0%Improved
JeffersonF 11.6%Improved
MadisonF 13.4%Improved
MobileF 16.0%Worsened
MontgomeryF 15.0%Improved
TuscaloosaF 12.7%Worsened

CITYGRADEPRETERM BIRTH RATECHANGE IN RATE FROM LAST YEAR
BirminghamF 13.0%Improved

There is a critical connection between infant health, maternal health and the health of a family. All are dependent on their lived social context, the quality and accessibility of healthcare and the policies within a state. Each factor can provide insight into how a state serves its population.

SOCIAL VULNERABILITY INDEX

Where you live matters.

March of Dimes is offering the opportunity to examine social determinants of health at the county level using the Social Vulnerability Index (SVI). Socially vulnerable populations are at greater risk of experiencing poor health outcomes during a public health emergency. The same factors used in the index also contribute to poor maternal and infant health outcomes, including poor access to maternity care. The differences in counties are measured using 15 social factors, grouped into four areas including: socioeconomic status; household composition and disability; minority status and language; housing type and transportation. Each aspect of the index uses physical or social factors that help to estimate where poor health outcomes may be more prevalent.

The overall SVI for each county represents the amount of vulnerability relative to other counties in the state.  The SVI measure is always a number between 0 and 1. A lower SVI indicates lesser vulnerability and a higher SVI indicates greater vulnerability.

CLINICAL MEASURES

Your healthcare matters.

Access to and quality of healthcare before, during and after pregnancy can affect health outcomes in the future. An unnecessary Cesarean birth can lead to medical complications and inadequate prenatal care can miss important milestones in pregnancy.

28.4

PERCENT

25.6

U.S. PERCENT

LOW-RISK CESAREAN BIRTH

This shows Cesarean births for first-time moms, carrying a single baby, positioned head first and at least 37 weeks pregnant. Even in low-risk women, there are multiple reasons that a Cesarean birth would be the safest choice for delivery 4 however, increasingly high rates of Cesarean births in low-risk delivery situations reveal that in some cases, the procedure happens electively.

18.8

PERCENT

14.9

U.S. PERCENT

INADEQUATE PRENATAL CARE

Percent of women who received care beginning in the fifth month or later or less than 50% of the appropriate number of visits for the infant's gestational age. Adequacy of prenatal care is measured using the Adequacy of Prenatal Care Utilization Index, which classifies prenatal care received into 1 of 4 categories (inadequate, intermediate, adequate and adequate plus) by combining information about the timing of prenatal care, the number of visits and the infant's gestational age.5 Inadequate prenatal care will be calculated using the NCHS 2019 final natality data.1

POLICY MEASURES

The policies in your state matter.

Adoption of the following policies and organizations can help improve maternal and infant health care.

MEDICAID EXPANSION

MEDICAID EXPANSION

Medicaid expansion to cover individuals up to 138% of the federal poverty level can play an essential role in improving maternal and infant health. Medicaid expansion has reduced the rates of uninsured women of childbearing age. Increased access and utilization of health care are significantly associated with Medicaid expansion. 7

MEDICAID EXTENSION

MEDICAID EXTENSION

The adoption of this policy allows women to qualify for pregnancy-related Medicaid coverage for more than the standard 60 days after pregnancy for up to one year.8 Extending this coverage typically requires both state legislation and an appropriation in addition to a Section 1115 waiver in order to receive federal match.9 Three states have extended the full benefits of Medicaid extension at this time.

MIDWIFERY POLICY

MIDWIFERY POLICY

Midwives are health care professionals that may be part of the birth care team or stand alone in providing prenatal, delivery and postpartum care. States that have policies to allow direct entry midwives and certified nurse midwives to practice may increase access to care, especially in under-resourced areas. Midwifery care can further reduce medical interventions that contribute to the risk of maternal mortality and morbidity in initial and subsequent pregnancies, lower costs, and potentially improve the health of mothers and babies.

MATERNAL MORTALITY REVIEW COMMITTEE

MATERNAL MORTALITY REVIEW COMMITTEE

These committees investigate deaths related to pregnancy to determine underlying causes of death and respond to improve conditions and practices. The committees can be made up of representatives from public health, nursing, maternal-fetal medicine, obstetrics and gynecology, midwifery, patient advocacy groups and community-based organizations. 10 States that have an MMRC are better equipped to prevent pregnancy-related deaths. States who review pregnancy-related deaths up to one year after pregnancy will best help us understand all the causes of pregnancy-related mortality.

PERINATAL QUALITY COLLABORATIVE

PERINATAL QUALITY COLLABORATIVE

The PQC involves partnerships with families, key state agencies and organizations in order to identify and initiate programs or procedures that increase the quality of care in clinical settings. The work done by PQC's across the nation focus on a collaborative learning method between healthcare providers and the members of the PQC.12

DOULA LEGISLATION

DOULA LEGISLATION

Doulas are non-clinical professionals that emotionally and physically support women during the perinatal period, including birth and postpartum.14 Increased access to doula care can help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States. Doula support is not routinely covered by health insurance. Insurance coverage for doula support through Medicaid, the Children's Health Insurance Program, private insurance, and other programs may be a way to improve birth outcomes.

Technical Notes

Preterm Birth: Definition and Source

Preterm birth is a birth with less than 37 weeks gestation based on the obstetric estimate of gestational age. Data used in this report card came from the National Center for Health Statistics (NCHS) natality files, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.1 This national data source was used so that data are comparable for each state and jurisdiction-specific report card. Data provided on the report card may differ from data obtained directly from state or local health departments and vital statistics agencies due to timing of data submission and handling of missing data. The preterm birth rates shown at the top of report card was calculated from the NCHS 2020 final natality data. Preterm birth rates in the trend graph are from the NCHS 2010-2020 final natality data. County preterm birth rates are from the NCHS 2019 final natality data. Preterm birth rates for bridged racial and ethnic categories were calculated from NCHS 2017-2019 final natality data. Preterm birth rates were calculated as the number of premature births divided by the number of live births with known gestational age multiplied by 100.

Grading Methodology

Expanded grade ranges were introduced in 2019. Grade ranges remain based on standard deviations of final 2014 state and District of Columbia preterm birth rates away from the March of Dimes goal of 8.1 percent by 2020. Grades were determined using the following scoring formula: (preterm birth rate of each jurisdiction - 8.1 percent) / standard deviation of final 2014 state and District of Columbia preterm birth rates. Each score within a grade was divided into thirds to create +/- intervals. The resulting scores were rounded to one decimal place and assigned a grade. See the table for details.

Grade

Preterm Birth Rate RangeScoring Criteria

A

Preterm birth rate less than or equal to 7.7 percent

A-

Preterm birth rate of 7.8 percent to 8.1 percent

B+

Preterm birth rate of 8.2 percent to 8.5 percent

B

Preterm birth rate of 8.6 percent to 8.9 percent

B-

Preterm birth rate of 9.0 percent to 9.2 percent

C+

Preterm birth rate of 9.3 percent to 9.6 percent

C

Preterm birth rate of 9.7 percent to 10.0 percent

C-

Preterm birth rate of 10.1 percent to 10.3 percent

D+

Preterm birth rate of 10.4 percent to 10.7 percent

D

Preterm birth rate of 10.8 percent to 11.1 percent

D-

Preterm birth rate of 11.2 percent to 11.4 percent

F

Preterm birth rate greater than or equal to 11.5 percent

Infant Mortality Rate

Infant mortality rates were calculated using the NCHS 2019 period linked infant birth and infant death data. Infant mortality rates were calculated as the number of infant deaths divided by the number of live births multiplied by 1,000. Infant mortality rate in the trend graph are from the NCHS 2009-2019 period linked infant birth and infant death files.

Preterm Birth by Race/Ethnicity of the Mother

Mother's race and Hispanic ethnicity are reported separately on birth certificates. Rates for Hispanic women include all bridged racial categories (white, black, American Indian/Alaska Native and Asian/Pacific Islander). Rates for non-Hispanic women are classified according to race. The Asian/Pacific Islander category includes Native Hawaiian. To provide stable rates, racial and ethnic groups are shown on the report card if the group had 10 or more preterm births in each year from 2017-2019. To calculate preterm birth rates on the report card, three years of data were aggregated (2017-2019). Preterm birth rates for not stated/unknown race are not shown on the report card.

Preterm Birth by County and City

Report cards for states and jurisdictions, except District of Columbia, display the city with the greatest number of live births. Cities are not displayed for Delaware, Maine, Vermont, West Virginia and Wyoming due to limited availability of data. Grades were assigned based on the grading criteria described above. Change from previous year was calculated by comparing the 2019 city preterm birth rate to the 2018 rate.

Preterm Birth Disparity Measures

The March of Dimes disparity ratio is based on Healthy People 2020 methodology and provides a measure of the differences, or disparities, in preterm birth rates across racial/ethnic groups within a geographic area.2 The disparity ratio compares the racial/ethnic group with the lowest preterm birth rate (comparison group) to the average of the preterm birth rate for all other groups. 

To calculate the disparity ratio, the 2017-2019 preterm birth rates for all groups (excluding the comparison group) were averaged and divided by the 2017-2019 comparison group preterm birth rate. The comparison group is the racial/ethnic group with the lowest six-year aggregate preterm birth rate (2010-2015) among groups that had 20 or more preterm births in each year from 2010-2015. A disparity ratio was calculated for U.S. states, the District of Columbia, and the total U.S. A disparity ratio was not calculated for Maine, Vermont, and West Virginia. A lower disparity ratio is better, with a disparity ratio of 1 indicating no disparity.

Progress toward eliminating racial and ethnic disparities was evaluated by comparing the 2017-2019 disparity ratio to a baseline (2010-2012) disparity ratio. Change between time periods was assessed for statistical significance at the 0.05 level using the approach recommended by Healthy People 2020.2 If the disparity ratio significantly improved because the average preterm birth rate for all other groups got better, we displayed "Improved" on the report card. If the disparity ratio significantly worsened because the lowest group got better or the average of all other groups got worse, we displayed "Worsened" on the report card. If the disparity ratio did not significantly change, we displayed "No Improvement" on the report card.

The report card also provides the percent difference between the racial/ethnic group with the 2017-2019 highest preterm birth rate compared to the combined 2017-2019 preterm birth rate among women in all other racial/ethnic groups. This percent difference was calculated using only the racial/ethnic groups displayed on the state or jurisdiction-specific report card. This difference was calculated for each U.S. state with adequate numbers and the District of Columbia.

Social Vulnerability Index

March of Dimes recognizes the importance of certain risk factors that are associated with maternal and infant health outcomes. The social vulnerability index is calculated by the Center for Disease Control.3 This index is comprised of fifteen variables from the American Community Survey (ACS), 2014-2018 and is represented at the county level. These variables are grouped into the following themes: socioeconomic, household composition/disability, minority status/language and housing type/ transportation. Socioeconomic includes poverty, unemployment, income and  level of high school completion. Household composition and disability includes aged 65 or older, aged 17 or younger, disability and single-parent household. Minority status includes minority and speaks English "Less than well".  Housing type and transportation includes multi-unit structures, mobile homes, crowding, no vehicle and group quarters. 

Low-Risk Cesarean Birth Rates

A low-risk Cesarean birth occurs when a woman undergoes the surgical procedure if the baby is a single infant, is positioned head-first, the mother is full-term (at least 37 weeks), and has not given birth prior.4 This is also referred to as a NTSV Caesarean birth. NTSV abbreviated to mean Nulliparous (or first-time mother), Term, Singleton, Vertex (head-first position).

Low-risk Cesarean birth rates were calculated using the NCHS 2019 final natality data.1 Low-risk Cesarean birth rates were calculated as the number of Cesarean births that occurred to first-time mothers of a single infant, positioned headfirst with a gestational age of at least 37 weeks (NTSV) divided by the number of first-time mothers of a single infant, positioned headfirst with a gestational age of at least 37 weeks (NTSV) multiplied by 1,000. 

Inadequate Prenatal Care

Adequacy of prenatal care is measured using the Adequacy of Prenatal Care Utilization Index, which classifies prenatal care received into 1 of 4 categories (inadequate, intermediate, adequate and adequate plus) by combining information about the timing of prenatal care, the number of visits and the infant's gestational age.5 Inadequate prenatal care is defined as a woman who received less than 50% of her expected visits. Inadequate prenatal care will be calculated using the NCHS 2019 final natality data.1

Medicaid Expansion

Medicaid expansion allows more people to be eligible for Medicaid coverage-it expands the cut-off for eligibility. Medicaid expansion status is provided from the Kaiser Family Foundation as adopted or not adopted.6 Medicaid expansion has reduced the rates of uninsured. Increased access and utilization of health care are significantly associated with Medicaid expansion.7

Medicaid Extension

The adoption of this policy allows women to qualify for pregnancy-related Medicaid coverage for more than the standard 60 days after pregnancy for up one year.8 Extending this coverage typically requires both state legislation and an appropriation in addition to a Section 1115 waiver in order to receive federal match.9 Medicaid extension status is provided by Kaiser Family Foundation as adopted (having an approved 1115 waiver), waiver pending or planning or planning is occurring, or the state does not have the indicated organization/policy.8

Maternal Mortality Review Committee

These committees investigate deaths related to pregnancy to determine underlying causes of death and respond to improve conditions and practices. The committees can be made up of representatives from public health, nursing, maternal-fetal medicine, obstetrics and gynecology, midwifery, patient advocacy groups and community-based organizations.10 The measure is provided by the Guttmacher Institute and is categorized as: state has the indicated organization/policy, state has an MMRC but does not review deaths up to a year after pregnancy ends or state does not have the indicated organization/policy.11

Perinatal Quality Collaborative

The PQC involves partnerships with families, key state agencies and organizations in order to identify and initiate programs or procedures that increase the quality of care in clinical settings. PQC's work focus on collaborative learning among healthcare providers and the PQC.12 Data is provided by the Society of Maternal Fetal Medicine (SMFM) and the measure is reported as: state has the indicated organization/policy or the state does not have the indicated organization/policy.13

Doula Policy on Medicaid Coverage

Doulas are non-clinical professionals that emotionally and physically support women during the perinatal period, including birth and postpartum.14 Doula policy status show states that have enacted bills relating to Medicaid coverage of doula care, or not. The measure is reported as: state has the indicated organization/policy or the state does not have the indicated organization/policy. Data is provided by the National Health Law Program under the Doula Medicaid Project.15

Midwifery State Laws

Midwives are health care professionals that may be part of the birth care team or stand alone in providing prenatal, delivery and postpartum care. Certified Nurse-Midwives (CNM) hold national certification and state licensure to practice in all 50 states. Measures depict states where both direct entry and nurse midwifery may practice and be licensed or where no licensure/practice is available/allowed. The measure is reported as: state has the indicated organization/policy or the state does not have the indicated organization/policy. Data is retrieved from the Midwife Alliance of North America.16

Calculations

All natality calculations were conducted by March of Dimes Perinatal Data Center.

References

1 National Center for Health Statistics, final natality data 2017-2020.

2 Talih M, Huang DT. Measuring progress toward target attainment and the elimination of health disparities in Healthy People 2020. Healthy People Statistical Notes, No 27. Hyattsville, MD: National Center for Health Statistics. 2016

3 CDC/ATSDR Social Vulnerability Index. Available at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html

4 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: Final Data for 2018. Natl Vital Stat Rep 2019;68(13):1- Retrieved from: https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf

5 Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a Proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994;84(9):1414-1420.

6 Kaiser Family Foundation. Status of State Medicaid Expansion Decisions: Interactive Map. Available at: https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

7 Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision. Available at: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

8 Kaiser Family Foundation. Medicaid Postpartum Coverage Extension Tracker. Available at: https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/

9 Equitable Maternal Health Coalition. Available at: https://static1.squarespace.com/static/5ed4f5c9127dab51d7a53f8e/t/5ee12b312ecd4864f647fe67/1591814991589/State+White+Paper+061020-V6.pdf

10 Center for Disease Control (CDC), Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008- 2017. Available at:  https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html

11 Guttmacher Institute. Maternal Mortality Review Committees. Available at: https://www.guttmacher.org/state-policy/explore/maternal-mortality-review-committees

12 Center for Disease Control (CDC), Perinatal Quality Collaboratives. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pqc.htm

13 Society for Maternal-Fetal Medicine. SMFM Scorecard: 2020-2021. Available at: https://www.smfm.org/scorecard/2020

14 DONA International. What is a doula? Available at: https://www.dona.org/what-is-a-doula/

15 National Health Law Program. Doula Medicaid Project. Available at: https://healthlaw.org/doulamedicaidproject/

16 Midwife Alliance of North America. Midwives & the Law, State by State. Available at: https://mana.org/about-midwives/state-by-state