The birth of a high-risk infant is still a relatively rare, not totally predictable event; and the management of high-risk newborns requires highly skilled personnel and sophisticated technology. In the early days of neonatal intensive care, scarce resources led to regionalized systems of neonatal and, later, perinatal services, generally based on voluntary agreements but sometimes reinforced by planning legislation. At present, a vastly increased pool of skilled professionals and technical resources is available in the context of a rapidly changing medical care system characterized by intense competition, coalescence of services under large managed care plans, and substantial cost pressures. The evidence suggests that, in many areas, these forces have led to the dismantling of regional networks; however, the full potential for these changes to hinder or facilitate access to neonatal intensive care remains to be assessed.