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In studies comparing the birth outcomes of rural and urban women, residency status is frequently defined dichotomously as either rural or urban. Since residency status appears to be a continuum, however, the usefulness of other categorization systems needs to be explored. The purpose of this study was to compare birth outcomes using a three-level variable for residency status (rural, rural adjacent to urban, and urban). The study population was comprised of women who delivered by cesarean section over an 18-month period (N= 263) at a tertiary care hospital. Data were collected from patient charts, interviews, and the hospital information system. Residency status was determined by county of residence. Birth outcomes examined included gestational age, birthweight, Apgar scores, maternal complications, length of hospital stay, and costs of hospital care. Rural women had worse birth outcomes overall and traveled the greatest distance for delivery. Rural-adjacent women had the best birth outcomes of the three groups, yet were the youngest, least educated, least likely to be married, and the least likely to be privately insured. By using a nondichotomous three-level variable for residency status, two distinct groups of rural women were identified whose maternal health care needs may differ from each other.