When care is far away, the risks don’t wait. Complications in pregnancy, labor, postpartum, or the newborn period still happen, sometimes in homes, in birth centers, in clinics, or en route to the nearest hospital. Rural communities are strongly associated with long travel times to seek care, fewer prenatal visits, more preterm births, and higher maternal mortality, especially for Black women. These communities also experience longer travel times for emergency and non-emergency transfers, more births in non-obstetric emergency departments (EDs) or in transit, and greater reliance on emergency medical services (EMS).
Since 2005, more than 181 rural hospitals have closed, and the loss of obstetric units has been a major driver of maternity care deserts. In areas with few hospitals or birth centers offering obstetric care, the burden shifts to EMS agencies and hospital emergency departments, often becoming the only available access point when urgent pregnancy-related or newborn needs arise.
Reliable, rehearsed escalation and transfer pathways are essential!
In many rural communities, when local obstetric services are limited, or when complications arise unexpectedly, EMS and the emergency department becomes the de facto bridge to care for pregnant, postpartum, and newborn patients, adding significant pressure to already-stretched emergency care teams.
EMS/EDs are designed for broad emergency stabilization, and many emergency clinicians and nurses may not routinely encounter high-acuity obstetric or newborn emergencies, making it challenging to maintain comfort and competency with low-frequency, high-risk events, especially when fetal monitoring, neonatal warming/resuscitation workflows, and obstetric-specific protocols and supplies vary by site. This is exactly why reliable, rehearsed escalation and transfer pathways are essential.
In rural systems where teams are stretched thin, the transfer itself becomes a critical clinical “moment”: communication, routing, handoffs, transport, and respectful coordination can determine how quickly someone gets the right care.
Transforming Rural Perinatal Health
In order to transform rural health we need to strengthen the ecosystem of care: partnerships, operations, workforce, preparedness, and practical models that keep care close to home when possible and move people quickly to higher-level services when needed. And this is exactly what the Step Up Together program does well.
In rural settings where teams are smaller, relationships are everything, and transfer logistics are often the “last mile” of safety, the Step Up Together program can be a high-leverage rural health improvement strategy.
Step Up Together helps communities safely support care closer to home when appropriate, while ensuring that clear and rapid escalation pathways are in place when risk changes. By focusing on what happens when warning signs first appear, the program strengthens prenatal and perinatal safety by ensuring teams have rehearsed, cross-setting responses rather than relying on ad hoc decision-making in high-stress moments. This preparation reduces preventable harm by improving the reliability of time-sensitive escalation and transfer workflows, where even small delays can compound risk for pregnant, postpartum, and newborn patients.
Reduce friction when clarity and coordination matter most
A core strength of Step Up Together is its emphasis on respectful, coordinated transfers as a fundamental component of access to care in rural communities where choice is limited. The program helps create functional rural maternity pathways that connect community-based providers, EMS and transport teams, critical access hospitals, and referral hospitals into a shared system of care. By standardizing “who calls who,” what information moves with the patient, and what respectful handoffs look like, Step Up Together reduces friction at the exact moments when clarity and coordination matter most. Just as importantly, this shared work builds relationships that help rural sites maintain services safely, even when patient volume is low and opportunities to practice together are infrequent.
Step Up Together also supports rural workforce development through structured, interdisciplinary training and coaching that brings clinicians, nurses, midwives, EMS professionals, and hospital teams together. These shared experiences build confidence and competence across disciplines, strengthening teams that often work in isolation. Learning is designed to be efficient and sustainable: drill kits, observation tools, and debrief guides enable repeatable training without requiring communities to design new curricula from scratch.
Step Up Together strengthens integration across the full primary maternity care ecosystem, including community-based models, outpatient settings, community and critical access hospitals, EMS and transport services, and community service agencies. Live drills are not an end in themselves – they are intentionally paired with structured debriefing and improvement planning that turns experience into actionable quality-improvement work. In this way, communities move beyond “practice” to measurable system change that can be sustained over time.
Health Plans Should Be at the Table
Step Up Together has already partnered with a health plan to support rural maternal care and strengthen coordinated transfer pathways across settings, demonstrating how payers can help accelerate implementation at scale.
When obstetric services are fragmented or limited in rural settings, health plans often become the link between prenatal care, ED/EMS utilization, transport, and postpartum follow-up. Health plans can strengthen moments where preventable harm tends to occur – escalation, handoffs, routing, and transfers.
By partnering with a structured, implementation-ready program, health plans can support their contracted providers, hospitals, and EMS partners in building consistent, rehearsed pathways for obstetric and newborn emergencies without asking rural teams to invent a quality strategy from scratch. The result is not just education; it is system reliability.
Health plans can help convene cross-setting teams, sponsor participation for network hospitals and EMS agencies, and align quality-improvement expectations so that escalation and transfer workflows are built, tested, and refined over time. Plans can also reinforce respectful, coordinated transfers as a standard of care, ensuring that the patient experience and the clinical handoff both improve.
Interested in a maternal/newborn component of your rural health transformation efforts that is implementation-ready?
Step Up Together is a ready-to-go program that helps rural communities do the hard, practical work that transformation requires:
- build cross-setting relationships,
- rehearse the transfer pathways that matter most,
- standardize workflows that reduce delays and prevent harm,
- and translate lessons learned into durable quality improvement.
We can make every pregnancy safe, no matter the setting.
If your state, rural health office, hospital association, EMS consortium, health plan, or regional partnership is building rural health initiatives, Step Up Together can help.
Explore our Action Collaboratives and Drill Kits, or reach out to discuss a regional or statewide approach.
