I too practice rurally, most of the time, in Southern OH, which is the northern edge of the area called "Appalachia" A very depressed part of the country. I do get occasional calls from more urban areas, 2 hrs away. I realized that when I do get calls from the cities, it is usually because I am cheaper than the city midwives, so I have started charging more to go into the cities (Columbus, Dayton & Cincinnati) However, most of the ppl near me are on welfare, so go to the hospital for a "free" birth. Many say they would love to have a homebirth, but cannot afford one, even w/o asking my fee, so how do they know they can't afford my services? Very frustrating!
In general though, I do see more transfers from my urban clients than the rural ones. I think ppl are more likely to live a healthier lifestyle in the country than the city, but not always.