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ABSTRACT: Context/Purpose: To examine a low-income sample of women in the rural Midwest (N = 1,086) who were screened for perinatal depression through the outreach and education activities within a Healthy Start Initiative project. Specifically, we describe the frequency and severity of depressive symptoms, explore social and demographic correlates of depression, and examine help-seeking through patterns of self-referral to a Healthy Start perinatal depression project in a rural, medically underserved community. Methods: Depression screening data using the Primary Care Evaluation of Mental Disorders (PRIME-MD) as well as intake records from the project were analyzed in a retrospective analysis to identify important demographic and psychosocial characteristics associated with elevated levels of depressive symptoms and help-seeking patterns. Findings: Thirty-six percent of screened women met criteria for major, minor, or subthreshold depression, with 13% meeting diagnostic criteria for major depression alone. Less than 8% were currently receiving any type of mental health services or treatment at screening. The most significant correlate of self-referral to the Healthy Start project was meeting symptom criteria for major depression, although minor depression, subthreshold depression, and status as low-income/Temporary Aid to Needy Families (TANF)-eligible were all significantly associated with self-referral. Conclusions: The findings from this study highlight the potential significance of identifying and addressing the unmet mental health needs of low-income rural women during and around pregnancy. In addition, the study illustrates that low income, in addition to depressive symptoms, impacts mental health service delivery in this rural community with a fragmented mental health service infrastructure.