Coroner Issues Urgent Warning Over Unregulated Doulas Following Infant Death
A coroner has issued a stark warning that more babies could die without proper guidance on the role of "unregulated" birthing assistants, following the tragic death of a 15-day-old infant. The case has raised serious concerns about delayed access to hospital treatment during home births when doulas are involved.
Tragic Case Reveals Systemic Gaps
Matilda Pomfret-Thomas died in November 2023 from a brain injury caused by a lack of oxygen to the brain either before or during birth, medically known as neonatal hypoxic-ischemic encephalopathy. An inquest concluded last month that her mother experienced a difficult home labour and was not immediately transferred to hospital despite clear signs of foetal distress.
Henry Charles, an assistant coroner for Hampshire, Portsmouth and Southampton, issued a prevention of future deaths report last Wednesday. He has urgently called upon the Department of Health and Social Care (DHSC) and the National Institute of Health and Clinical Excellence (NICE) to take immediate action to prevent similar tragedies involving doulas.
How Doulas Impacted Medical Care
Doulas are non-medical professionals who provide emotional and practical support during pregnancy and birth, often working alongside NHS midwives. In this tragic case, Mr Charles believes the doula significantly affected the work of midwives from Portsmouth's Queen Alexandra Hospital.
The coroner stated that midwives felt their access to the mother "was being restricted by the doula" during labour. Although the doula did not actively discourage medical professionals, she was perceived by midwives as creating a "buffer" that limited their ability to provide standard care and advice.
Critical Delays in Hospital Transfer
The report details how the family had experienced a traumatic first birth and were determined to have a different experience for their second child. They elected to use a doula for support during a planned home birth, despite medical preference for hospital delivery.
During the home birth, multiple signs of fetal distress developed, including the presence of meconium (the baby's first stool) and concerning decreases in heart rate. Yet the mother was not taken to hospital immediately.
The report describes a "difficult atmosphere" as the doula continued to follow the birth plan, maintaining "hope that a home birth was still possible" even as the situation deteriorated over several hours.
Coroner's Detailed Findings
Mr Charles identified specific failures in communication and decision-making:
- An initial appropriate offer of hospital transfer at 7:19am upon finding meconium was not accepted
- Clear signs of deterioration at 10am requiring hospital transfer were not communicated effectively
- The doula had a "negative impact" on midwives' ability to provide standard advice and care
The coroner concluded that the doula's presence created additional challenges for medical staff, who found themselves making clinical recommendations against personal recommendations or views from the birthing assistant.
Broader Implications for Maternity Care
The Maternity and Newborn Safety Investigations (MNSI) report into the birth acknowledged there is currently no regulation of doula care and no guidance on how doula services should interact with NHS maternity services.
MNSI identified twelve cases where evidence suggested doulas worked outside defined boundaries of their role, with their care or advice potentially influencing poor outcomes for families.
The issue of doula registration, regulation and training has emerged as a critical area of concern. Experienced midwifery professionals testified at the inquest that clear guidance would benefit everyone involved in births where doulas are present.
Industry Response and Next Steps
Doula UK, the largest representative body for doulas (though not a regulatory body), has been contacted for comment regarding these serious findings. The Department of Health and Social Care has also been approached for their response to the coroner's urgent recommendations.
This tragic case highlights the complex dynamics that can emerge when unregulated birthing assistants work alongside NHS professionals, and underscores the pressing need for clear guidelines to protect both mothers and babies during childbirth.
