Dramatic increases in survival of VLBW neonates have occurred over the last 2 decades. The pattern of this change and its impact on resource utilization remain to be clarified. Using a verified computerized database, we determined changes in birth weight (BW)-, race-, and gender-specific rates for survival until hospital discharge for 3,903 neonates 501-1500 g delivered at a large county hospital from 1977 through 1995. We delineated the survival curve for non-survivors and assessed the impact of increased survival on resource utilization. The study was divided into 4 epochs: Epoch 1, 1977-81 (n=981); Epoch 2, 1982-85 (n=637); Epoch 3, 1986-90 (n=1207); and Epoch 4, 1991-95(n=1078). While BW distribution was unchanged during the study period, overall survival rose from 50% in Epoch 1 to 65% in Epoch 2, 73% in Epoch 3, and 81% in Epoch 4. The BW above which 50% of VLBW neonates survived fell by 100 g per epoch, decreasing from 1000 g in Epoch 1 to 700 g in Epoch 4. Between Epochs 1 and 4, race-specific survival increased from 55% to 83% for Blacks, 46% to 82% for Whites, and 37% to 77% for Latins. BW-specific survival (using 250 g increments) also increased for cach race during the study period. While Blacks always had the lowest BW-specific mortality, survival differences between Blacks and non-Blacks fell 50% during the study period; thus differences were minor in Epoch 4. Sex-specific survival rose from 54% to 83% for females and 46% to 79% for males between Epochs 1 and 4. The survival advantage for females over males followed a similar pattern to BW, declining by 50%, during the study period; thus differences were minor in Epoch 4. The cumulative percent of deaths as a function of day of life (DOL) was similar in each epoch: 60% occurring on DOL 1, 75% by DOL 3, and 5-7% after 3 wks of age. Hospital days committed to non-survivors fell from 6-7% during Epochs 1-3 to 3% in Epoch 4. Although survival for neonates 501-750g rose from 4% to 36% between Epochs 3 and 4, resource utilization (hospital days for all neonates/number of survivors) rose from 115d in Epoch 1 to 179 in Epoch 2 and then fell to 140d and 111d in Epochs 3 and 4, respectively. In conclusion, BW-specific survival for inborn VLBW neonates at Parkland Memorial Hospital has significantly increased between 1977 and 1995. The substantial survival advantage identified in Epoch 1 for Blacks and females diminished progressively during this time and was insignificant in Epoch 4. Despite an increase in survival for the highest-risk group of VLBW neonates, resource utilization per survivor decreased over the 19 year study and was lowest during the last five years.