Abstract: A substantial number of premature deliveries occur in hospitals lacking neonatal intensive care facilities. Advances in perinatal and neonatal care over the last 30 years have contributed to improved survival among extremely low birth weight (ELBW) infants. Little is known about how birth outcomes vary in rural referral hospitals, by degree of rural isolation. We conducted a retrospective cohort study, from Feb 2012- Jan 2013, about etiologies and the mortality of preterm birth in MVJ medical college, Hoskote, which is a rural hospital, Much higher neonatal death rates were observed for preterm or low-birth weight babies in rural areas with no metropolitan influence, suggesting inadequate access to optimal neonatal care. We conclude that birth outcomes in rural areas differ according to the degree of rural isolation. Fetuses and infants of mothers from rural areas with weak or no metropolitan influence are particularly vulnerable to the risks of death during the perinatal and postnatal periods.