Self-Reported Versus County-Based Rurality of People Who Gave Birth in 6 US States, 2020

Objectives. To measure concordance between postpartum people's self-reported residence in rural, urban, or suburban areas and county-based measurement of rurality. Methods. We used survey data (collected January 2021-March 2022) from a representative sample of postpartum people with a live birth in 2020 in 6 US states (n = 3225), comparing respondents' self-report to county designations based on Rural‒Urban Continuum Codes (RUCCs). Results. Nearly 80% of postpartum people had concordant self-reported and RUCC-based residency. That is, 70% lived in counties that matched their self-report as urban (19%) or suburban (51%), and 9% lived in counties that matched their self-report as rural. However, almost 20% were rural discordant (lived in urban RUCC counties and self-reported as rural); these residents were more likely to lack a high-school degree and to have Medicaid-paid births compared with concordant respondents living in the same RUCC counties. Conclusions. County-based measures of rurality may incorrectly categorize substantial portions of rural residents, and those potentially misclassified are of lower socioeconomic status. Public Health Implications. Maternal health programs and policies using county-based definitions of rurality should account for rural residents living in areas designated as urban. (Am J Public Health. 2025;115(7):1095-1105. https://doi.org/10.2105/AJPH.2025.308058).