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There is a paucity of longitudinal research comparing early-life mental health in rural and metropolitan communities. Living in rural areas is associated with limited access to specialist care, as well as additional stresses such as natural disasters. To address health disparities for rural communities it is critical to understand variance in predictors and outcomes for child mental health. Data was obtained on 595 women and their children, recruited before 20 weeks of pregnancy and followed up until their child was 3-4 years of age. Rurality was assessed using the Modified Monash Model (MM Model) with 432 children in metropolitan cities MM1, and 163 in rural communities MM2-7. Child mental health was measured using the Preschool Age Psychiatric Assessment and the Child Behavior Checklist at 3-4 years of age. This study found no differences in rates of child mental health disorders at 3-4 years. Rural mothers with untreated depression were more likely to report internalising and externalising symptoms in their children. Compared to rural families, metropolitan families were twice as likely to access childcare and kindergarten across the first 4 years. Parenting stress showed no differences, although rural children spent more time with their mother and had less screen time. While there were no significant differences in child mental health, there were differences in childcare and kindergarten attendance. Whether this occurred due to preference or access is unclear. Furthermore, children of mothers with untreated depression in rural communities had elevated symptoms suggesting vulnerability to poorer mental health.