When an emergency happens in a community birth setting, every minute counts. In Step Up Together, we use the 3 Delays Framework to help teams identify and address the most common barriers to safe, timely, and respectful transfers from home or birth center to hospital care.
The 3 Delays model has been used worldwide to understand and prevent avoidable maternal and newborn morbidity and mortality. In our work, we adapt it to the U.S. context, and to the unique dynamics of community-to-hospital transfers, so teams can improve their readiness before the next urgent case.
Delay 1: Recognizing a Problem and Initiating Transfer
Even the most skilled team can lose precious time if there’s hesitation or uncertainty about whether to transfer, how to get the process started, or who to notify first.
Common barriers include:
- Delayed recognition of complications
- Lack of agreement between patient and provider about the need to transfer
- Anticipation of breakdowns in communication and collaboration based on prior interactions with the hospital
Strategies to address Delay 1:
- Clear eligibility and escalation guidelines for community birth providers and facilities
- Shared mental models and opportunities for team building through regular interdisciplinary training and other collaborations
- Scripts and patient education to prepare families for the possibility of transfer
How to test in drills:
- Use Partial or Full Transfer Drills to practice the “moment of decision”
- Time how long it takes from recognition of the problem to activation of EMS or notification of the hospital
- Include role-play for communicating the need for transfer to the patient and family
Watch: Highlights from our Spring/Summer Focused Action Cycle session on Delay 1
Delay 2: Reaching the Higher Level of Care
Once the decision is made, the clock starts on transportation. This is where the logistical realities — distance, traffic, EMS availability, weather — can quickly become life-or-death factors, and where culture clash can begin to emerge.
Common barriers include:
- Slow EMS dispatch or limited availability
- Lack of familiarity and role clarity between EMS and the birth team
- Inefficient routing to the appropriate unit (e.g., routing through the emergency department)
- Missing or incomplete documentation for the receiving team
Strategies to address Delay 2:
- Relationship-building with EMS so they know your facility, your team, and your common scenarios
- Direct-admit pathways to the appropriate hospital unit
- Pre-prepared transfer packets with all essential records, labs, and notes
- Clear transport scripts for communicating with EMS dispatch and en route
How to test in drills:
- Map and practice the exact process for conducting an emergency transfer via EMS, including 911 dispatch.
- Involve EMS and the emergency department in planning the drill
- Use the drill opportunity to review key supplies, equipment, and clinical management practices with EMS personnel by including a mini inservice before the drill or as part of the debrief.
Watch: Highlights from our Spring/Summer Focused Action Cycle session on Delay 2
Delay 3: Receiving Care at the Higher Level Facility
A patient’s arrival at the hospital is not the finish line — it’s the next starting point. Poor coordination or unclear hand-offs here can cause dangerous delays in treatment.
Common barriers include:
- Waiting in triage or the emergency department despite urgent needs
- Miscommunication or incomplete transfer of clinical details
- Negative bias toward community birth patients and their providers
- Unclear interdisciplinary roles in emergencies
Strategies to address Delay 3:
- Warm hand-offs between midwife and receiving clinicians, ideally face-to-face
- Standardized hand-off tools to ensure all critical details are shared
- Joint training and debriefs between community and hospital teams
- Hospital champions who advocate for smooth reception of transfers and respectful care
How to test in drills:
- Practice the full chain of events from arrival through initiation of definitive care, including inputting the patient into the electronic medical record, entering orders, and convening the full team required for emergency care.
- Time how long it takes for the patient to reach the appropriate provider and treatment
- Debrief with hospital partners on what worked and what caused delays
Watch: Highlights from our Spring/Summer Focused Action Cycle session on Delay 3
Turning Insight Into Action
Every team has the power to reduce these delays. The key is to plan and practice before an emergency happens — and to involve every player in the process: community midwives, birth assistants, doulas, EMS, emergency department staff, labor & delivery teams, NICU, leadership, and patients and families themselves.
Our Drill Kits and Action Collaborative model are built around the 3 Delays framework because when you address all three, you not only improve safety, you build trust, strengthen relationships, and ensure that every family gets timely, respectful, and equitable care.
Ready to Put the 3 Delays Framework Into Practice?
Our next Step Up Together Action Collaborative is your chance to work side-by-side with community birth providers, hospital teams, and EMS partners to plan, conduct, and debrief your own interdisciplinary transfer drill. Over five months, you’ll get access to our Drill Kits, expert coaching, and a national network of peers who are tackling the same challenges.
Applications are open through September 12 — form your team and apply today to secure your spot.
A note of gratitude to our funders. The educational sessions highlighted in the videos above were supported through a contract with the Massachusetts Department of Public Health. Funding for the upcoming Action Collaborative is provided by the Skyline Foundation.
