Objectives <p>Reproductive complications vary across rural and urban areas in the Southeastern U.S., yet maternal mental health–an important precursor to such complications–remains understudied. This study is the first to examine how mental disorders may contribute to disparities in hypertensive disorders of pregnancy (HDP) between urban and rural settings.</p> Methods <p>We used South Carolina (SC) data on delivery hospitalizations for more than 270,000 mothers presenting with HDP who have given birth only once between 1999 and 2017. A Fairlie decomposition method was performed to examine the contribution of diagnosed maternal mental health conditions, and social inequalities account for the urban-rural differences in HDP prevalence.</p> Results <p>The prevalence of HDP was 5.75% among urban mothers and 6.16% among rural mothers. Fairlie decomposition results indicated that maternal factors such as education attainment, chronic hypertension, and gestation age explained 90% of the geographic disparities in the HDP prevalence. Interestingly, differences in maternal mental health conditions, such as mental disorders of pregnancy and perinatal mood and anxiety disorders, reduced the urban-rural gap in the HDP prevalence.</p> Conclusions for Practice <p>Our results highlight the importance of individual and community drivers required to improve maternal mental health conditions. More community support systems for the mental health along with reproductive health will greatly improve maternal health outcomes.</p>