Nebraska and Iowa both received a grade of “D” in a report card by the March of Dimes when it comes to preventing pre-term birth.

Not a single state earned an "A." Vermont was the only one to earn a "B." Eight states earned a grade of “C.” Including Nebraska and Iowa, 23 states earned a “D” grade. The rest failed.

Researchers point to several problems leading to pre-term births, including smoking and uninsured women of child-bearing age.

Another area of concern is a combination of unnecessary inductions and C-sections. In Nebraska, the C-section rate is 28.6. Iowa fairs slightly better at 26.7.

The March of Dimes is urging physicians to more closely scrutinize whether the procedures are medically necessary, particularly before 39 weeks gestation.

Toshanna Avenetti of Council Bluffs is 39 weeks pregnant with her fifth child. She’s among the women who’ve requested to be induced early without a medical reason. “(I’m) tired. I've got some aches and pains and cramps that I haven't experienced before."

Her other children arrived early without medical intervention. Her doctor advised her that this one will come in his own time as well. “He's not ready to induce. He's not ready to break my water. He won't do anything. He says it all just needs to happen on its own this time."

The decision is likely a wise one, according to physicians who sit on the local March of Dimes board.

"If you happen to be a month off on dating the pregnancy, what you think is 38 weeks might actually be 34 weeks and those are the areas that we're focusing on," says Chairman Dr. Carl Smith.

By focusing on, Dr. Smith says, he means trying to limit potential health hazards for the unborn infant. He says babies born several weeks too soon can have long-term health problems from brain development to chronic health conditions.

"There's a whole list of reasons why induction of labor at or after 39 weeks is reasonable." Dr. Smith adds induction is deemed reasonable when the baby’s a week or more overdue or when the health of the baby or mother is at stake.

He cautions, women should be made aware that induction carries an increased risk of C-section, particularly in a first pregnancy. "Those babies have a higher rate of breathing difficulties in the nursery intensive care unit." Their lungs aren’t able to release fluid as easily as babies who travel through the birth canal.

Mothers also face increased risks of blood loss during C-sections, Dr. Smith says. With each additional C-section, he says, the risks increase and can result in the need for a hysterectomy to control the bleeding.

Avenetti says she understands her doctor's stance. "It's for the best, right? I want a healthy baby and I want everything to go good with my delivery." She says it's the baby's needs that matter.

Whether caused by preventable or non-preventable factors, the rate of pre-term birth has climbed more than 20 percent in the U.S. since 1990. The March of Dimes hopes more federal funding will be allocated to studying the issue further.