Introduction Birthplace in England found that although there were no differences in perinatal outcome for multiparous women, nulliparous women planning birth at home had poorer perinatal outcomes compared to those who planned birth in an obstetric unit, including a transfer rate of 36 to 45%. Poor management of escalation, handover and transfer are a concern in maternity reviews, and are known to be a patient safety issue in wider healthcare.

Methods Case studies of 4 NHS Trusts in 4 health regions in England. Data collected from March 2010 to December 2010 included: observation of meetings and ward life (>150 hours); semi-structured interviews with staff, managers and external stakeholders (n=86); postnatal women and birth partners (n=72). Data was analysed by team triangulation using NVivo8 software.

Results The 3 delays model (1) escalation (2) transfer (3) treatment was drawn upon to analyse how women's journeys through different birth settings was managed and experienced. Most women felt prepared for the unpredictability of events, and some experienced transfer and handover with feelings of worry, disempowerment or disappointment. Some felt unable to ask about options with professionals, and reported frustration, self-blame or anger. However, careful explanation by professionals was a common theme in positive narratives by women and partners.

Conclusion There appeared to be wider variation in the organisation and delivery of home birth services compared to FMUs. Successful management of escalation and transfer depends on understanding variation and gaps in systems, and addressing boundaries that delay effective transfer and escalation of care.