The opioid epidemic has reached crisis levels, and its effects are especially apparent in rural communities. One consequence of the opioid epidemic is opioid-affected births. Non-medical opioid use during pregnancy has potential health consequences for pregnant women and their infants, yet little information is available about its prevalence and associated factors in rural communities. This brief presents data on rural-urban differences in non-medical opioid use among pregnant women to inform policy, programmatic, and clinical efforts to address this crisis.