OBJECTIVE: Our goal was to study changing patterns of low-birth-weight outcome over the past decade as deregionalized perinatal care has occurred. STUDY DESIGN: Live births and neonatal mortality for two 5-year periods (1982 to 1986 vs 1990 to 1994) were calculated by hospital of delivery in the state of Missouri. Self-designated level of perinatal care was contrasted with number of deliveries and nursery census to evaluate outcome. Regression models were constructed to compare outcome between levels of care. RESULTS: There has been a significant shift of deliveries into self-designated level II and III perinatal centers. However, this is largely a result of redesignation of care rather than an actual increase in acuity or census. The relative risk of neonatal mortality for very-low-birth-weight infants is 2.28 in level II centers compared with level III centers, and is unchanged (2.57) from 10 years earlier. Nearly 14% of very-low-birth-weight deliveries still occur at non–level III centers. CONCLUSION: Changing patterns of perinatal regionalization have not improved outcome for inborn infants <1500 gm except in level III centers. Attempts should be made to deliver very-low-birth-weight infants in level III centers. (Am J Obstet Gynecol 1998;178:131-5.)