Introduction Birthplace in England found that transfer rates for first time mothers planning to give birth at home, or in a midwife led unit ranged between 36 and 45%. Delays in escalation, transfer and response are a quality and safety issue.

Aim Our overall aim was to describe and explore features of maternity care systems that may have affected the provision of high quality and safe care in different birth settings. This paper presents the experiences of women and families of their journey through the maternity system.

Methods Organisational case studies in 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).

Results The 3 delays model (1) escalation (2) transfer (3) treatment was drawn upon to analyse how women’s journeys through different birth settings were 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, although careful explanation by professionals was a common theme in positive narratives by women and partners.

Implications The study found wide variation in the organisation and delivery of home birth services compared to other settings. Successful management of escalation and transfer requires an understanding variation and gaps in systems, addressing boundaries that delay effective transfer and escalation of care.