Little is known about long-term national trends in birth outcomes and use of prenatal care in the rural population of the United States, or about intrarural differences in adverse outcome and inadequate prenatal care. In this two-year study, we examined: (1) How have rates of adverse birth outcome and prenatal care among U.S. rural residents changed in the years between 1985-1987 and 1995-1997? and (2) How have adverse birth outcomes and prenatal care changed during these periods among rural residents from racial and ethnic minority groups? We examined data from the Linked Birth Death Data Set (LBDDS), a national compilation of birth certificate data from all 50 states and the District of Columbia. We assessed inter-decade changes in rural/urban and intrarural differences in the rate of low birthweight outcome, neonatal death, postneonatal mortality, and inadequate prenatal care. We also assessed the degree to which observed changes were concentrated in particular types of rural settings or regions. Funded by HRSA’s ORHP.