Reports

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The March of Dimes Report Card indicates the maternal and infant health crisis is worsening. You can make a difference. Share your state's grade on your social channels, by email or by text and encourage others to take action by advocating for change.

Technical Notes

1. Preterm Birth

   Preterm Birth Rate

   Preterm birth is a birth occurring before 37 completed weeks of gestation, based on the obstetric estimate of gestational age. The data used in this report card are derived from the National Center for Health Statistics (NCHS) natality files, which compile information from 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.¹ This national data source ensures consistency and comparability across state and jurisdiction-specific report cards. Data provided on the report card may differ from data obtained directly from state or local health departments and vital statistics agencies due to the timing of data submission and handling of missing data. The preterm birth rates shown at the top of the report card were calculated using NCHS 2024 final natality data for all US states and District of Columbia (DC). The trend graph includes preterm birth rates from NCHS final natality data for the years 2014-2024. County and city preterm birth rates are based on NCHS 2024 final natality data for US states and DC. Preterm birth rates for bridged racial and ethnic categories and insurance payer were calculated from NCHS 2022-2024 final natality data. All provided measures for Puerto Rico are obtained from the Puerto Rico Department of Health for 2024 or the US territorial natality file, 2014-2024. Preterm birth rates were calculated by dividing the number of preterm births by the total number of live births with known gestational age, then multiplying the result by 100. Statistical significance was evaluated using pooled two proportion z-tests, with significance determined at the 95% confidence level.

   Preterm Birth Grading Methodology

   Preterm birth grades range from an F to an A. Expanded grade ranges were introduced in 2019. 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. The grade ranges remain based on how far each state’s or jurisdiction’s preterm birth rate deviates from the March of Dimes goal of 8.1 percent. This deviation is measured using the standard deviation of the final 2014 preterm birth rates for all US states and DC. The formula used to score grades is as follows: (current preterm birth rate of each jurisdiction – 8.1 percent) / standard deviation of final 2014 state and DC preterm birth rates.

   Grade	Preterm Birth Rate Range Scoring Criteria
   A	Preterm birth rate less than or equal to 7.7%.
   A-	Preterm birth rate of 7.8 to 8.1%.
   B+	Preterm birth rate of 8.2 to 8.5%.
   B	Preterm birth rate of 8.6 to 8.9%.
   B-	Preterm birth rate of 9.0 to 9.2%.
   C+	Preterm birth rate of 9.3 to 9.6%.
   C	Preterm birth rate of 9.7 to 10.0%.
   C-	Preterm birth rate of 10.1 to 10.3%.
   D+	Preterm birth rate of 10.4 to 10.7%.
   D	Preterm birth rate of 10.8 to 11.1%.
   D-	Preterm birth rate of 11.2 to 11.4%.
   F	Preterm birth rate greater than or equal to 11.5%.

   Preterm Birth by City

   The US report card displays cities with the greatest number of live births. Cities are shown if they ranked in the top 100 for total number of live births in 2024 among all cities in the US with populations greater than 100,000. City grading followed the methodology described above. For example, Detroit, Michigan ranked as the top city for preterm births and received a city preterm birth grade of F, calculated as: (the city preterm birth rate – 8.1 percent)/standard deviation of all final 2014 preterm birth rates.

   Preterm birth by maternal race/ethnicity

   Maternal race and Hispanic ethnicity are reported separately on the birth certificate. Rates for Hispanic women include all bridged racial categories (White, Black, American Indian/Alaska Native, Asian, and Pacific Islander). Rates for non-Hispanic women are classified according to race. The 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 birth by insurance payer

   Insurance payer is classified as the payment method used at time of birth. Insurance types presented are private, Medicaid, and other. Other includes those who self-pay or have insurance through TRICARE/CHAMPUS, Indian Health Service, other government programs, and all other types. Unknown payment types are excluded. To provide stable rates, insurance groups are shown on the report card if the group had 10 or more.

   Preterm birth ranks

   All US states, DC, and Puerto Rico were ranked by preterm birth rate (rounded to tenths place as presented on the report card), with a rank of 1 being assigned to the state or territory with the lowest rate and ranks increasing as preterm birth rates increase. States that tied were given the same rank and the next rank would be skipped. For example, if two states had the same preterm birth rate and were tied for 15th place, they both would receive the rank of 15, and the next state to be ranked would be in 17^th place.

   Chronic health conditions

   Selected chronic health conditions are presented in the Report Card to show additional circumstances that may increase the risk of preterm birth and other poor birth outcomes. These include smoking (pre-pregnancy), hypertension (pre-pregnancy), hypertension (during pregnancy), unhealthy weight (pre-pregnancy), and diabetes (pre-pregnancy) (see definitions below). All risk conditions presented are not mutually exclusive, meaning more than one can occur at the same time. For instance, a pregnant person could have both diabetes prior to pregnancy and have an unhealthy weight prior to pregnancy. Rates provided reflect the percentage of live births exposed to the given condition, i.e., the percentage of births where the mom was diagnosed with pre-pregnancy hypertension.
   
   Smoking before pregnancy
   Smoking status was ascertained when the mom reported having any cigarettes in the 3 months prior to pregnancy regardless of the number of cigarettes consumed. Smoking before pregnancy is a self-reported measure and data did not include those that smoked during their pregnancy. Smoking status does not capture individuals who use electronic cigarettes or vape.
   
   
   
   
   
   
   
   Pre-pregnancy hypertension
   Pre-pregnancy hypertension was defined as the elevation of blood pressure above normal for the moms age and physiological condition prior to onset of the current pregnancy. Data presented for pre-pregnancy hypertension does not include gestational hypertension and pregnancy induced hypertension (or preeclampsia).
   
   Hypertension during pregnancy
   Hypertension during pregnancy was defined as the elevation of blood pressure above normal for the moms age and physiological condition where the onset of the condition occurred during the current pregnancy. Data presented for hypertension during pregnancy includes gestational hypertension and pregnancy induced hypertension (or preeclampsia).
   
   Unhealthy weight before pregnancy
   Body mass index (BMI) is a measure of body fat based on height and weight. The percent of moms with an unhealthy weight before pregnancy was calculated as the number of moms with a BMI that is categorized as either underweight (BMI less than 18.5) or obese (BMI 30 or higher) divided by the number of moms who had a live birth multiplied by 100.
   
   Diabetes
   Diabetes was defined as pre-pregnancy diabetes (type 1 or type 2) and does not include gestational diabetes (diabetes during pregnancy).

2. Infant Mortality

   Infant mortality rate

   Infant mortality rates were calculated using the NCHS 2023 period-linked infant birth and death data.² The rates were determined by dividing the number of infant deaths by the number of live births in a given year and then multiplying by 1,000. The trend graph reflects infant mortality rates from the NCHS 2013-2023 period-linked infant birth and infant death files. Weights were applied to account for deaths in which linking was not possible. Statistical significance was evaluated using pooled two proportion z-tests, with significance determined at the 95% confidence level.

   Infant mortality rank

   All US states, DC, and Puerto Rico were ranked by infant mortality rate (rounded to tenths place as presented on the report card), with a rank of 1 being assigned to the state or territory with the lowest rate and ranks increasing as infant mortality rates increase. See preterm birth ranks (page 1) for additional details.

   Infant mortality by maternal race/ethnicity

   Mother’s race and Hispanic ethnicity are reported separately on the birth certificate. Rates for Hispanic women include all bridged racial categories (White, Black, American Indian/Alaska Native, Asian, and Pacific Islander). Rates for non-Hispanic women are classified according to race. The 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 infant deaths. To calculate infant mortality rates by maternal race/ethnicity on the report card, three years of data were aggregated (2021-2023). Infant mortality rates for not stated/unknown race are not shown on the report card. Weights were applied to account for deaths in which linking was not possible.

   Leading causes of infant death

   NCHS period linked birth/infant death files (2021-2023) were used for cause of death analyses. See Appendix A for a detailed list of ICD10 codes and their groupings.³ SUID deaths were further classified using Centers for Disease Control and Prevention methodology.⁴ The top four cause of death categories by percent of total deaths per state were selected for chart inclusion. The percent of deaths attributed to causes outside of the categories selected were combined in an “other” category. Weights were applied to account for deaths in which linking was not possible.

   Age at infant death

   For Puerto Rico, age of infant death data is presented as percentages of total deaths. Infant deaths are classified as either neonatal (0 to 28 days old) or postneonatal (>28 days to 1 year).⁵

3. Maternal Mortality

   Maternal Mortality

   Maternal mortality refers to death from complications of pregnancy or childbirth that occur during the pregnancy or within 6 weeks after the pregnancy ends.⁶ Maternal deaths are ascertained using the NCHS 2019-2023 mortality data.⁷ Puerto Rico data were provided by the Puerto Rico Department of Health. The number of maternal deaths does not include all deaths occurring to pregnant or recently pregnant women, but only deaths with the underlying cause of death assigned to International Statistical Classification of Diseases, 10th Revision code numbers A34, O00–O95, and O98–O99. Rates are calculated by dividing the number of maternal deaths by the number of births in the same geographic region during the same data year(s) and multiplying by 100,000.
   
   Maternal mortality rates fluctuate from year to year because of the relatively small number of these events and possibly due to issues with the reporting of maternal deaths on death certificates.⁸ Five-year aggregate rates are presented for all racial and ethnic groups and by state, still, some states do not have enough deaths to provide reliable estimates and are therefore suppressed. Individual year rates at the US level were provided for 2019-2023. Statistical significance was evaluated using pooled two proportion z-tests, with significance determined at the 95% confidence level.
   
   
   
   

4. Additional Factors

   Additional Maternal Health Indicators

   Prenatal care adequacy
   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.⁹ Inadequate prenatal care is defined as an infant whose mom received less than 50% of their expected visits or started care in or after the fifth month. Adequate prenatal care is defined as an infant whose mom received 80-109% of their expected visits and started their care before the fifth month of pregnancy. Adequate plus prenatal care (presented in combination with adequate care) is defined as an infant whose mom received over 110% of their expected visits and started their care before the fifth month of pregnancy. Prenatal care adequacy is calculated using the NCHS 2024 final natality data for all records with complete data on the timing of prenatal care initiation and number of visits. Statistical significance was evaluated using pooled parameter significance tests.
   
   Prenatal care initiation
   Prenatal care initiation is measured from the month of pregnancy a mom began prenatal care. First trimester (early) prenatal care initiation is when a mom began prenatal care in the first to third month of pregnancy. Initiation rates are calculated as a percentage of live births. Prenatal care initiation is calculated using the NCHS 2024 final natality data.
   
   Inadequate prenatal care by maternal race/ethnicity
   Inadequate prenatal care rates by race/ethnicity use 3-year aggregate data from NCHS 2022-2024. Maternal race and Hispanic ethnicity are reported separately on the birth certificate. Rates for Hispanic women include all bridged racial categories (White, Black, American Indian/Alaska Native, Asian, and Pacific Islander). Rates for non-Hispanic women are classified according to race. The 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.
   
   Low-risk Cesarean birth rate
   A low-risk Cesarean birth occurs when a woman undergoes the surgical procedure if the baby is a single infant, is positioned head-first (vertex position), the mother is full-term (at least 37 weeks) and has not given birth prior.¹⁰ This is also referred to as a NTSV Cesarean birth. NTSV abbreviated to mean Nulliparous (or first-time mother), Term, Singleton, Vertex.
   
   Low-risk Cesarean birth rates were calculated using the NCHS 2024 final natality data for the US, DC, and Puerto Rico. 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 100. Statistical significance was evaluated using pooled parameter significance tests.
   
   Severe maternal morbidity
   Severe maternal morbidity is the rate of unexpected outcomes of labor and delivery that result in significant short- or long-term health consequences per 10,000 in-hospital deliveries. Blood transfusions are not included. The rate is calculated and published by the Healthcare Cost and Utilization Project (HCUP)¹¹ and the Puerto Rico Health Insurer Commissioner.
   
   Calculations
   All calculations were conducted by March of Dimes Perinatal Data Center. Contact: PerinatalDataCenter@MarchofDimes.org
   
   Summary table
   Preterm birth, infant mortality, low-risk Cesarean birth, adequate prenatal care, maternal mortality, and severe maternal morbidity are summarized on page 3 of state Report Cards. For each measure, the table includes the state’s rate; rank among other states, districts, and territories with available and comparable data (includes all states, DC, and Puerto Rico); direction of change compared to the prior year, including whether the change was statistically significant; how the measure is calculated e.g., as a percentage or rate and of which denominator group; and the corresponding Healthy People 2030 target. For maternal mortality, 2019-2023 data is compared to 2018-2022 data. For severe maternal morbidity, statistical significance was not assessed.

5. State Level Policies and Programs

   Medicaid extension and expansion The adoption of this Medicaid extension allows women to qualify for pregnancy-related Medicaid coverage for more than the standard 60 days after pregnancy for up to one year. Extending this coverage option can be done through a State Plan Amendment (SPA) or Section 1115 Waiver. Medicaid extension status is provided by Kaiser Family Foundation as adopted, progressing or not adopted.¹²
   
   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 by the Kaiser Family Foundation as adopted, progressing, or not adopted.¹³ Medicaid expansion has reduced the rates of uninsured. Increased access and utilization of health care are significantly associated with Medicaid expansion.
   
   Paid family and medical leave
   Paid family and medical leave refers to policies that enable workers to receive compensation when they take extended time off work for qualifying reasons, such as bonding with a new child, recovering from one’s own serious illness or caring for a seriously ill loved one.¹⁴ The measure is reported as: state has an active policy that provides an option for pay while out on extended leave or it does not have an active policy in place. Data is provided by A Better Balance.¹⁵
   
   Doula policy on Medicaid coverage
   Doulas are non-clinical professionals that emotionally and physically support moms during the perinatal period, including birth and postpartum.¹⁶ Doula policy status show states that have enacted bills relating to Medicaid coverage of doula care, or not. The measure is reported as: state Medicaid agency is actively reimbursing doula care or state Medicaid agency does not reimburse doula care. An additional measure includes identifying states that reimburse up to $1,500 for doula services. Data is provided by the National Health Law Program under the Doula Medicaid Project.¹⁷ Data for Connecticut is provided by Connecticut Social Services and data for Delaware is provided by Delaware First Health.^18,19
   
   Maternal mortality review committees (MMRC)
   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.²⁰ The MMRC measure is provided by the Centers for Disease Control (CDC) and is categorized as; state has a MMRC or the state does not have an MMRC.²¹ Data for Texas is provided by Texas Department of State Health Services.²² Data for Washington, DC is provided by The Office of Chief Medical Examiner (OCME).²³
   
   Postpartum maternal mental health screening
   The adoption of this policy requires postpartum depression screening and reimbursement during well-child visits for mothers and/or caregivers of children enrolled in Medicaid (except Washington that basis eligibility on the mother’s Medicaid status). These efforts reflect 2016 federal policy guidance from the Centers for Medicare & Medicaid Services (CMS) allowing states to provide Medicaid coverage under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Data was provided by the National Academy for State Health Policy.²⁴ The measure is reported as: state requires and reimburses for postpartum depression screening during well-child visits or state does not require and reimburse for postpartum depression screening during well-child visits.
   
   All policies were assessed as of September 26, 2025.

6. Appendix A: Cause Of Death Categories And Corresponding Codes

   Cause of death category	ICD10 codes included
   Birth defects	Q00–Q99
   Preterm birth/low birth weight	P07
   SUID	R95, W75, R99
   Maternal complications	P01
   Respiratory distress of newborn	P22
   Complications of the placenta, cord, or membranes	P02
   Accidents (unintentional injury)	V01–X59, Y85–Y86
   Bacterial sepsis of newborn	P36
   Diseases of the circulatory system	I00–I99
   Neonatal hemorrhage	P50–P52, P54

7. References
   1. National Center for Health Statistics, final natality data 2014-2024, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
   2. National Center for Health Statistics, final period-linked infant birth and death data 2013-2024, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
   3. Research Data Assistance Center. 130 ICD-10 Cause of Infant Death Recodes. Accessed October 6, 2025. https://resdac.org/cms-data/variables/130-icd-10-cause-death-recodes.
   4. Centers for Disease Control and Prevention. SUID by Cause of Death, 2022. Accessed October 6, 2025. https://www.cdc.gov/sudden-infant-death/data-research/data/suids-deaths-by-cause.html.
   5. National Center for Health Statistics. Sources and Definitions, 2024. Accessed October 6, 2025. https://www.cdc.gov/nchs/hus/sources-definitions/rate.htm.
   6. National Institute of Child Health and Human Development (NICHD). Maternal Morbidity and Mortality. Accessed October 6, 2025. https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality.
   7. National Center for Health Statistics, final mortality data 2018-2023, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.
   8. Hoyert DL, Miniño AM. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, 2018. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020. Accessed October 6, 2025. https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69-02-508.pdf.
   9. 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.
   10. Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: Final data for 2023. National Vital Statistics Reports; vol 74, no 1. Hyattsville, MD: National Center for Health Statistics. 2025. DOI: https://stacks.cdc.gov/view/cdc/175204.
   11. HCUP Fast Stats. Severe Maternal Morbidity Among In-Hospital Deliveries, Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. https://datatools.ahrq.gov/hcup-fast-stats/?tab=special-emphasis&dash=92.
   12. Kaiser Family Foundation. Medicaid Postpartum Coverage Extension Tracker. Published January 17, 2025. Accessed September 26, 2025. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/.
   13. Kaiser Family Foundation. Status of State Medicaid Expansion Decisions: Interactive Map. Published September 29, 2025. Accessed September 26, 2025. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.
   14. US Department of Labor, Women’s Bureau. Paid Family and Medical Leave Fact Sheet. Accessed September 26, 2025. https://www.dol.gov/sites/dolgov/files/WB/paid-leave/PaidLeavefactsheet.pdf.
   15. A Better Balance. Overview of Paid Family and Medical Leave Laws in the United States. Updated March 15, 2024. Accessed September 26, 2025. https://www.abetterbalance.org/resources/paid-family-medical-leave-laws/.
   16. DONA International. What is a Doula? Accessed September 26, 2025. https://www.dona.org/what-is-a-doula/.
   17. National Health Law Program. Doula Medicaid Project. Updated September 2025. Accessed September 26, 2025. https://healthlaw.org/doulamedicaidproject/.
   18. Connecticut Social Services. HUSKY Maternity Bundle, Doula Integration. Accessed September 26, 2025. https://portal.ct.gov/dss/health-and-home-care/husky-maternity-bundle/doula-integration?language=en_US.
   19. Delaware First Health. Doula Services. Accessed September 26, 2025. https://www.delawarefirsthealth.com/members/medicaid/benefits-services/Pregnancy/doula-services.html
   20. Building US Capacity to Review and Prevent Maternal Deaths Project. Report From Maternal Mortality Review Committees: A View Into Their Critical Role. Accessed September 26, 2025. https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf.
   21. Centers for Disease Control and Prevention. Enhancing Reviews and Surveillance to Eliminate Maternal Mortality. Accessed September 26, 2025. https://www.cdc.gov/maternal-mortality/php/erase-mm/index.html#cdc_generic_section_2-erase-mm-participants-across-the-nation.
   22. Texas Department of State Health Services, Maternal Mortality and Morbidity Review Committee. Accessed September 26, 2025. https://www.dshs.texas.gov/maternal-child-health/maternal-mortality-morbidity-review-committee.
   23. Government of the District of Columbia, Office of the Chief Medical Examiner (OCME). Accessed September 26, 2025. https://ocme.dc.gov/.
   24. National Academy for State Health Policy. Medicaid Policies for Caregiver and Maternal Depression Screening during Well-Child Visits, by State. Updated 2023. Accessed September 26, 2025. https://nashp.org/state-tracker/maternal-depression-screening/.