These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of <2000 g to a regional NICU. For infants with BW of <2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of <2000 g at hospitals with regional NICUs.

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LPIs are at increased risk of poor health-related outcomes during their birth hospitalization and of increased health care utilization during their first year.

We use data from 1983 and 1988 on hospital use in Alabama to examine the decisions of rural pregnant women to bypass the nearest rural hospital providing obstetric services and seek care elsewhere. The proportion of women who made the decision to bypass the nearest rural hospital increased from 40 percent to 45 percent between 1983 and 1988, while the proportion who traveled to metropolitan areas increased from 41 percent to 68 percent. Women with resources appear to choose longer travel distances in order to use hospitals with high birth volumes and high-risk infant services, but women from counties with large Medicaid populations also more frequently bypassed nearby hospitals.

Physicians underestimate survival and freedom from handicap in preterm infants. Underestimation of outcome is associated with restriction in the use of appropriate interventions.