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2023 March of Dimes report card for

Download the report.

Preterm Birth Grade

Grade greater than or equal
to 11.5 percent
Learn more
U.S. Rate
AL Rate

The 2023 March of Dimes Report Card highlights key indicators to describe the current state of maternal and infant health. We continue to provide updated rates and grades for preterm birth and data on infant mortality and maternal health. New this year is the inclusion of maternal mortality, leading causes of infant death, and data describing selected risk factors for preterm birth. Indicators by maternal race/ethnicity are included to call attention to the need for addressing racism in our systems and communities in order to eliminate health disparities. Detailed analyses of these measures inform the development of policies and programs that move us towards improving health for birthing people and the millions of babies born each year in the U.S., D.C. and Puerto Rico. The Report Card presents policies like Medicaid extension and programs like Maternal Mortality Review Committees, which can help to achieve equity in maternal and infant health outcomes.

Preterm Birth

The preterm birth rate in Alabama was 12.8% in 2022, lower than the rate in 2021

Preterm birth by year, 2012 to 2022

The presence of purple (darker color) indicates a significant trend (p <= 0.05)

Source: National Center for Health Statistics, 2012-2022 natality data.

Preterm Birth Rates By Counties And City

Click on the underlined counties to view more data in PeriStats.

Preterm Birth Rate
Change in rate from last year

Source: National Center for Health Statistics, 2022 natality data.

Preterm Birth Rate
Change in rate from last year
Birmingham, AL

The preterm birth rate among babies born to Black birthing people is 1.5x higher than the rate among all other babies

Preterm birth rate by race/ethnicity, 2020-2022

This chart is intended to highlight disparities in data related to race/ethnicity and should serve as a starting point for discussion about addressing systemic racism and inequalities.

Source: National Center for Health Statistics, 2020-2022 natality data.

Many factors make birthing people more likely to have a preterm birth

Preterm birth (PTB) rate among birthing people by maternal factor (blue) and overall prevalence (in parentheses), 2022

(5.4% of all births)
(5.0% of all births)
Unhealthy weight
(40.1% of all births)
(1.6% of all births)
Previous preterm
(5.4% of all births)
Carrying multiples
(3.6% of all births)

Note: More than one factor can occur at the same time. Hypertension, diabetes, smoking, and unhealthy weight occur prior to pregnancy. U.S. PTB rates are as follows: smoking: 15%; hypertension: 23%; unhealthy weight: 12%; diabetes: 29%; previous preterm: 30%; carrying multiples: 62%.

Source: National Center for Health Statistics, 2022 natality data.

Infant Mortality


U.S. Rate

The infant mortality rate decreased in the last decade; 439 babies died in Alabama in 2021

Infant mortality rate per 1,000 live births

The presence of purple (darker color) indicates a significant trend (p <= 0.05)

Note: On November 1st, 2023, the Centers for Disease Control and Prevention released a preliminary report on 2022 infant deaths showing the first statistically significant increase in the U.S. infant mortality rate in over two decades. Read our press release for more information.

Source: National Center for Health Statistics, Period Linked Birth/Infant Death data, 2011-2021.

The infant mortality rate among babies born to Black birthing people is 1.5x the state rate

Infant mortality rate per 1,000 live births

Rate per 1,000 live births, 2019-2021

Notes: API = Asian/Pacific Islander; AIAN = American Indian/Alaska Native.
Source: National Center for Health Statistics, Period Linked Birth/Infant Death data, 2019-2021.

Leading causes of infant death

Percent of total deaths by primary cause, 2019-2021

Notes: PTB/LBW = preterm birth and low birth weight; SUID = sudden unexpected infant death.
Source: National Center for Health Statistics, Period Linked Birth/Infant Death data, 2019-2021.

Maternal Health

Birthing people in Alabama have a very high vulnerability to poor outcomes and are most vulnerable due to overall physical health

MVI by county in Alabama

Factors related to maternal vulnerability

Higher scores indicate higher vulnerability

Notes: The Maternity Vulnerability Index (MVI) is a tool used to understand where birthing people in each state may be more likely to have poor outcomes, including preterm birth and maternal death, due to clinical risk factors and other social, contextual, and environmental factors. Visit

Source: Surgo Health, Maternal Vulnerability Index, 2023.

Clinical Measures

The measures below are important indicators for how Alabama is supporting the health of birthing people

Per 100,000 births

Maternal Mortality

This shows the death rate of birthing people from complications of pregnancy or childbirth that occur during the pregnancy or within 6 weeks after the pregnancy ends.


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.


Inadequate Prenatal Care

Percent of birthing people 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.

Source: National Center for Health Statistics, Mortality data, 2018-2021. National Center for Health Statistics, Natality data, 2022.

Policy Measures

Adoption of the following policies and sufficient funding in Alabama is critical to improve and sustain maternal and infant healthcare

Medicaid Extension

State has extended coverage for women to one year postpartum.

Medicaid Expansion

State has adopted this policy, which allows birthing people greater access to preventative care during pregnancy.

Paid Family Leave

State has required employers to provide a paid option while out on parental leave.

Doula Reimbursement Policy

State Medicaid agency is actively reimbursing doula care.

Maternal Mortality Review Committee (MMRC)

State has a federally funded MMRC committee, which is recognized as essential to understanding and addressing the causes of maternal death.

Fetal and Infant Mortality Review

State has a Fetal and Infant Mortality Review team or teams to identify and review causes of death.

Perinatal Quality Collaborative (PQC)

State has a federally funded PQC to identify and improve quality care issues in maternal and infant healthcare.

  • Legend
  • State has the indicated funding/policy
  • State reimburses up to $1,500
  • State is progressing legislation but not yet active
  • State does not have the indicated funding/policy



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 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 2022 final natality data for all U.S. States and Washington D.C. Preterm birth rates in the trend graph are from the NCHS 2012-2022 final natality data. County and city preterm birth rates are from the NCHS 2022 final natality data for U.S. states and Washington D.C. Preterm birth rates for bridged racial and ethnic categories were calculated from NCHS 2020-2022 final natality data. All provided measures for Puerto Rico are obtained from the Puerto Rico Department of Health for 2022 or the U.S. territorial natality file, 2012-2021. 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. Joinpoint Trend Analysis Software2 was utilized to assess significant trends in preterm birth.

    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. 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. 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.

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

    Preterm Birth by City

    The U.S. 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 2022 among all cities in the U.S., District of Columbia and Puerto Rico with populations greater than 100,000. City grading followed the methodology described above. For example, Birmingham Alabama ranked as the top city for live 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 Race/Ethnicity of Mother

    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 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 Birth By Factors

    Multiple new factors were introduced in the 2023 report card to show additional circumstances that may impact preterm birth. This year's report card includes smoking, hypertension, unhealthy weight, diabetes, previous preterm birth, and carry multiples. All risk factors 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 by factors are calculated as: the total number of preterm births among the selected factor divided by the total number of all live births for the selected factor, multiplied by 100 to get the rate of preterm birth among each factor. To make comparisons we include the percentage of each factor for all live births in parenthesis below each rate. A few ways to interpret the new preterm birth factors are:
    In the U.S., the preterm birth rate among those who had pre pregnancy hypertension was 23.4 percent whereas pre pregnancy hypertension accounts for 2.9 percent of all live births.
    The preterm birth rate in Mississippi is 14.8 percent however the preterm birth rate among smokers is 17.4 percent.

    All factors were assessed using data from NCHS 2022 natality data and Puerto Rico Department of Health and were selected based on their association with preterm birth and availability within natality data.

    Smoking status was ascertained when the birthing person 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.

    Pre- pregnancy hypertension was defined as the elevation of blood pressure above normal for the birthing persons age, sex, and physiological condition prior to onset of the current pregnancy. Data presented for preterm birth by hypertension does not include gestational hypertension and pregnancy induced hypertension (or preeclampsia).

    Diabetes was defined as pre-pregnancy diabetes (type 1 or type 2) and does not include gestational diabetes (diabetes during pregnancy).

    Unhealthy Weight Before Pregnancy
    Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women. The percent of women with an unhealthy weight before pregnancy was calculated as the number of women with a BMI that is categorized as either underweight (BMI <18.5), overweight (BMI 25 to 29.9), or obese (30 or higher) divided by the number of women who had a live birth multiplied by 100.

    Previous Preterm Birth
    A previous preterm birth was defined as having a prior birth where the baby was born before 37 weeks' gestation.

    Carrying Multiples
    Carrying multiples was defined as any pregnancy with more than one baby. Multiples can include twins, triples, quadruplets or more.

  2. Infant Mortality
  3. Additional Factors
  4. State Level Policies
  5. Appendix A: Cause Of Death Categories And Corresponding Codes


  1. National Center for Health Statistics, final natality data 2010-2022.
  2. Joinpoint Trend [computer software]. Version 5.0.2. Retrieved from
  3. Centers for Disease Control and Prevention. Tenth Revision 130 Selected Causes of Infant Death Adapted for Use by DVS. Accessed October 5, 2023.
  4. National Institue of Child Health and Human Development (NICHD). Maternal Morbidity and Mortality. Accessed October 5th, 2023.
  5. Hoyert DL. Maternal Mortality Rates in the United States, 2021. NCHS Health E-Stats. 2023. DOI:
  6. 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.
  7. Surgo. Maternal Vulnerability Index. Accessed October 5, 2023.
  8. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: Final Data for 2018. Natl Vital Stat Rep 2019;68(13):1- Retrieved from:
  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. Kaiser Family Foundation. Medicaid Postpartum Coverage Extension Tracker. Published September 28, 2023.
  11. Kaiser Family Foundation. Status of State Medicaid Expansion Decisions: Interactive Map. Accessed September 22, 2023.
  12. Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. Accessed September 29, 2023.
  13. U.S. Department of Labor- Women’s Bureau. Paid family and medical leave fact sheet. Accessed October 4, 2023.
  14. Paid Family Leave Laws: A State-by-State Guide. OnPay. Updated: September 7, 2023. Accessed September 22, 2023.
  15. DONA International. What is a Doula? Accessed October 4, 2023.
  16. National Health Law Program. Doula Medicaid Project. Accessed September 22, 2022.
  17. Guttmacher Institute. Maternal Mortality Review Committees. Accessed September 29, 2023.
  18. Centers for Disease Control and Prevention. Maternal mortality. Accessed September 22, 2023.
  19. The National Center for Fatality Review and Prevention. Fetal & Infant Mortality Review. Accessed October 4, 2023.
  20. The National Center for Fatality Review and Prevention. FIMR map. Accessed September 22, 2023.
  21. Centers for Disease Control and Prevention. State Perinatal Quality Collaboratives. Published August 22, 2023. Accessed September 22, 2023.
  22. Health Resources and Services Administration, FY 2023 Alliance for Innovation (AIM) on Maternal Health Awards, Published September 2023.