The regionalization of rural perinatal care during the 1980s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study determined whether there was evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization had adversely affected neonatal mortality among infants born to rural residents. We analyzed national Linked Birth Death Data Set data over a 10-year period. The study population included all low-birthweight infants born to rural residents. This study demonstrated the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA’s FORHP.