state, regional, and national organizations focused on the improvement of perinatal care. BACKGROUND The availability of neonatal intensive care has improved the outcomes of high-risk infants born either preterm or with serious medical or surgical conditions.2–4 Many of these improvements can be attributed to the concept and implementation of regionalized systems of perinatal care, broadly articulated in the 1976 March of Dimes report “Toward Improving the Outcome of Pregnancy” (TIOP I).5 The TIOP I report included criteria that stratified maternal and neonatal care into 3 levels of complexity and recommended referral of high-risk patients to higher-level centers with the appropriate resources and personnel to address the required increased complexity of care. However, since the initial TIOP I report was published more than 3 decades ago, there have been signs of deregionalization, including (1) COMMITTEE ON FETUS AND NEWBORN KEY WORDS neonatal intensive care, high-risk infant, regionalization, maternal and child health, health policy, very low birth weight infant, hospital newborn care services, nurseries ABBREVIATIONS AAP—American Academy of Pediatrics aOR—adjusted odds ratio CI—confidence interval CON—certificate of need ELBW—extremely low birth weight TIOP—“Toward Improving the Outcome of Pregnancy” VLBW—very low birth weight This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Authors with federal affiliations do not necessarily represent the official position of their agencies. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. www.pediatrics.org/cgi/doi/10.1542/peds.2012-1999 doi:10.1542/peds.2012-1999 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2012 by the American Academy of Pediatrics PEDIATRICS Volume 130, Number 3, September 2012 587 FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children Downloaded from pediatrics.aappublications.org by guest on January 13, 2015 an increase in the number of NICUs and neonatologists, without a consistent relationship to the percentage of high-risk infants, (2) a proliferation of small NICUs in the same regions as large NICUs,6–11 and (3) failure of states to reach the Healthy People 2010 goal that 90% of deliveries of very low birth weight (VLBW; 70%) is attributable to late preterm births.21 Infants born late preterm can experience significant morbidity that may result in the need for specialized care and advanced neonatal services.22,23 An increase in the supply of specialty staff24,25 and availability of new neonatal therapies (eg, bubble continuous positive airway pressure), have expanded the scope of care in level II facilities.26 Some have expressed concern that level II hospitals have expanded their scope of care without sufficient evidence of favorable outcome. Because most infant deaths in the United States occur among the most immature infants in the first few days after birth,27,28 improvements in regionalized systems may reduce mortality among the most preterm newborn infants. REVIEW OF THE LITERATURE ON NEONATAL LEVELS OF CARE SINCE THE 2004 AAP POLICY STATEMENT In 2004, the AAP defined neonatal levels of care, including 3 distinct levels with subdivisions in 2 of the levels.1 Level I centers provided basic care; level II centers provided specialty care, with further subdivisions of IIA and IIB centers; and level III centers provided subspecialty care for critically ill newborn infants with subdivisions of level IIIA, IIIB, and IIIC facilities. Data published since the 2004 statement have informed the development of the levels of care in this new policy statement. A meta-analysis of the published literature from 1978 to 2010 clearly demonstrates improved outcomes for VLBW infants and infants 113 000 VLBW infants and found that VLBW infants born at non–level III hospitals had a 62% increase in odds of neonatal or predischarge mortality compared with those born at level III hospitals (adjusted odds ratio [aOR], 1.62; 95% confidence interval [CI], 1.44–1.83). Subset comparisons of studies identifying infants 100 annual admissions would have prevented 21% of VLBW deaths in 2000.30 In a secondary data analysis, Chung et al found that deregionalization of California perinatal services resulted in 20% of VLBW deliveries occurring in level I and level II hospitals, with lower-volume hospitals having the highest odds of mortality.31 A population-based study of 4379 VLBW infants who were born between 1991 and 1999 in Lower Saxony, Germany, evaluated neonatal mortality in relation to both the annual volume of births and NICU volume.32 There was an increased odds of mortality in centers with annual NICU admissions of fewer