initial birth admission, but the cost differences persisted through the subsequent 4 years of life. Gestational age at birth was the strongest predictor of total costs during the first 5 years of life. The authors concluded that prematurity was a major predictor of the cost of medical services during the first 5 years of life (82).

Petrou et al. performed a meta-analysis of studies of the long-term costs of preterm birth and LBW. In their analysis, the authors used evidence from 20 studies to conclude that (a) “preterm or low birth weight infants are significantly more likely to be rehospitalized” than term or normal-birth-weight infants; (b) “the increased use and cost of health care services consumed by preterm or low birth weight infants persists into childhood,” with major neurologic abnormalities increasing the families’ use of hospital and outpatient services in the longer term; (c) survivors have high rates of school failure and learning problems, requiring special education services; and (d) families have increased out-of-pocket expenses related to the consequences of prematurity and often have substantial reductions in family income (83).

In population-based surveys assessing medical expenditures and family health, it was noted that children born with LBWs were 50 percent more likely than normal-birth-weight children to require special education services and were slightly more likely to repeat a grade of school (75).

In the 1980s and 1990s, perinatal care was regionalized in an attempt to improve maternal and neonatal outcomes. Women with complicated pregnancies were referred to higher-level perinatal centers for specialized care and neonatal therapies. It now appears that deregionalization is occurring, as the need for neonatal intensive care continues to grow (84). Community hospitals have begun offering intensive therapies, such as high-frequency ventilation and nitric oxide, raising concerns about quality of care. The ethical concerns that have arisen as a result of this deregionalization include the following: (a) parents who are less savvy or less informed may not be aware that their premature infant is not being treated at a perinatal center of the correct level, and (b) clinicians may be inadequately trained to use intensive therapies. As shown by the data that follow, premature infants delivered at hospitals without the proper level of neonatal care may have worse prognoses. One retrospective study looking at the outcomes for infants with necrotizing enterocolitis and mortality showed no difference in outcomes whether or not there was immediate access to surgical care. The study’s conclusions are limited by its methodology.