The impact of population size across twenty-three west Michigan counties was examined to determine access to prenatal care, low birth weight, and infant mortality. Surveys were completed by forty-five managers of hospitals and county health departments. Service availability, sociodemographic, system-related and lifestyle factors were examined as contributors to perinatal support utilization. Low birth weight and infant mortality were highest in the small- and large-sized counties. Positive birth outcomes in medium-sized counties may have been due to greater availability of infant and child health services through health departments, and the targeting of resources to specific problem areas, such as smoking cessation. The need for a comprehensive maternity system, which views health care as a basic right, is discussed.