: The challenges of providing health services in rural settings are quite unique and few professionals are educated to function in the generalist role required in rural areas. This challenge is compounded by disparities in health status of rural Americans, one of which is the continued elevated neonatal mortality rate. Little is known about factors that influence outcomes for neonates requiring resuscitation who are born in rural hospitals. Much of the variability in the rural neonatal mortality remains unexplained and it is possible that differences in care practices may account for some of that variation. The purpose of this project is to explain variability in newborn morbidity and mortality as a function of provider care quality and hospital maternity unity characteristics. Twenty rural hospitals from two Midwestern states will be selected at random without replacement for study participation. At each hospital, nurse managers will provide information about obstetrical unit characteristics (structure). Physicians and nurses (approximately 30 per hospital) who provide care to neonates at birth will provide demographic data, describe past experiences and comfort when performing skills required during resuscitation, and participate in a knowledge survey. Birth logs from each unit will be used to gather data for newborns (approximately 120) and identify the healthcare providers present at delivery. A hierarchical linear model will be used to estimate parameters of a statistical model that links birthing unit preparedness (structure) and provider readiness (process) to very early neonatal health status (outcome). ? ?