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Objective: To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community. Data Sources and Study Settings: Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021. Study Design: Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size. Data Collection/Extraction Methods: Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance. Principal Findings: On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]). Conclusions: Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community. KEYWORDS child and adolescent health, health care organizations and systems, integrated delivery systems, maternal and perinatal care and outcomes, rural health, social determinants of health, substance use: alcohol/chemical dependency/tobacco What is known on this topic * Pregnant and parenting women in recovery and their family members often face barriers to care and need services and supports from multiple sectors. * Local substance use treatment programs may collaborate with other organizations to ensure comprehensive services and facilitate successful recovery during and after residential treatment. * The Framework for Aligning Sectors conceptualizes that when the healthcare, public health, and social services sectors align, community capacity to promote health and well-being is improved. What this study adds * There are differences in network structure and cross-sector alignment in rural and urban networks, suggesting different needs to build system capacity at a local level. * The position of and roles played by organizations in each sector may vary across urban and rural communities and network disruptions could impact care delivery., 1 | INTRODUCTION Substance use and the opioid epidemic have had considerable impacts on individuals, families, and communities, more so during the COVID-19 pandemic. In 2020, there was a 30% [...]