Which maternity unit? Who makes the choice?

To investigate the factors determining the choice of maternity unit in an outer London district where half of all births occur outside the district, a self-administered questionnaire was distributed by community midwives at postnatal home visits. The main outcome measures were: (1) proportion of mothers able to deliver in unit of first choice; (2) proportion of mothers making a personal choice rather than taking advice from their GP; (3) reasons for not choosing district unit, by parity. It was found that 28/166 (17 per cent) of mothers were unable to deliver in their first choice of unit, and 3/166 (2 per cent) were unable to obtain their second choice. Of the women who did obtain their first choice, 84/136 (62 per cent) had made a personal decision rather than being advised or told by their GP; 58 of these 84 personal deciders went outside the district, but for 36/58 (62 per cent) this was either because the other unit was nearer their home or because they had delivered there before. It is concluded that, although GPs are theoretically free to refer to any maternity unit, a sizeable minority of women are unable to realize their own choices. GPs seem to regulate flows by advising women without strong personal views to attend the local unit. Differences in the quality of care as perceived either by women or their GPs do not seem particularly important in determining choices. The introduction of an internal market in maternity care seems unlikely to result in improved quality of care.