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Racial differences in the use of high-quality hospital care contribute to racial disparities in mortality for very low birth weight (VLBW) neonates.We explored the role that geographic distribution of hospitals plays in the racial disparity in the use of top-tier hospitals by mothers of VLBW neonates in New York City.Retrospective analysis of Vital Statistics and administrative databases.VLBW deliveries in New York City from 1996 to 2001 to non-Hispanic Black (n = 4947) and non-Hispanic White (n = 1615) mothers.Black mothers were less likely to deliver in a top-tier hospitals (White = 44%, Black = 28%; P < 0.001) and top-tier hospitals were less likely to be located in Black mothers' neighborhoods (White = 40%, Black = 33%; P < 0.001). Distance, however, did not contribute to the disparity in use of top-tier hospitals. Non-Hispanic Black mothers lived marginally closer to a top-tier hospital than non-Hispanic White mothers (0.65 miles closer; P < 0.001), and mothers of both the races often bypassed their neighborhood hospital (Black = 62% bypassed, White = 71%; P < 0.001). Inattention to recommended prenatal behaviors was associated with using a closer hospital, suggesting that geographic proximity was most important to mothers of vulnerable neonates. Purported measures of hospital quality such as Neonatal Intensive Care Unit level and volume were more strongly associated with use of hospital for White mothers than for Black mothers.The influence of geography on the use of top-tier hospitals for mothers of VLBW neonates is complex. Other personal and hospital characteristics, not just distance or geography, also influenced hospital use in New York City.