Purpose: To explore the relationship between histologic chorioamnionitis (HCA) and decidual macrophage (DM) polarization and their influence on outcomes of neonates born before the 32nd gestational week. Materials and Methods: Eighty-four neonates and their placentas were included in this retrospective case-control study and divided into two groups: with and without HCA present (HCA + and HCA-). Neonatal, maternal, and placental risk factors were explored and their influence on neonatal outcomes was examined. We used CD68 and iNOS as markers for polarized DMs type 1 (M1) and CD163, CD206 and arginase (Arg-1) for polarized DMs type 2 (M2). Results: HCA was present in 47 (56%) cases, and 37 (44%) cases were without the present HCA. There was no statistically significant difference in neonatal risk factors between the two groups (HCA + and HCA-). Higher rates of HCA (p = .042) were observed in mothers who received antepartum corticosteroid therapy. The frequency of vaginal deliveries in HCA + pregnancies was significantly higher than in HCA- pregnancies where deliveries by cesarean section were more frequently observed (p < .001). M2 DM were more abundant in the HCA + group (p = .035). Multiple regression model assessed the association between the presence of HCA, M1, and M2 DM with ROP stages. It has been observed that HCA is a risk factor for ROP stages (β coefficient = 0.34, rpartial = 0.246, p = .024). With the logistic regression model, the association between the presence of HCA, M1, and M2 DM with neonatal nCPAP respiratory support and necrotizing enterocolitis (NEC) was assessed. The presence of M2 macrophages in decidua is an independent risk factor for neonatal nCPAP respiratory support (coefficient -0.07, OR = 0.928, 95% CI 0.87-0.99, p = .024) and the presence of M1 macrophages in decidua increases the risk for NEC (coefficient 0.010, OR = 1.0108, 95% CI 1.00-1.02, p = .032). Conclusions: The significantly more abundant presence of M2 DM was detected in HCA + placentas and their association with the increased risk for neonatal nCPAP respiratory support was observed. On the contrary, the presence of M1 DM increases the risk for NEC. The presence of HCA is a risk factor for ROP stages.