Coroner issues warning over ‘unregulated’ doulas after death of baby

A coroner has warned more babies could die without guidance on the role of “unregulated” birthing assistants, after the death of a 15-day-old baby raised concerns about delayed access to hospital treatment.

Matilda Pomfret-Thomas died of a brain injury in November 2023, caused by a lack of oxygen to the brain either before or during birth, known as neonatal hypoxic-ischemic encephalopathy.

Her mother had a difficult home labour and was not immediately transferred to hospital despite signs of foetal distress, an inquest concluded last month.

Henry Charles, an assistant coroner for Hampshire, Portsmouth and Southampton, issued a prevention of future deaths report last Wednesday. He urged the Department of Health and Social Care (DHSC) and the National Institute of Health and Clinical Excellence (NICE) to take action to avoid similar tragedies involving doulas – non-medical professionals who provide emotional and practical support during pregnancy and birth, often alongside NHS midwives.

Mr Charles believes the doula affected the work of the midwives from Portsmouth’s Queen Alexandra Hospital and felt their access “was being restricted by the doula” when the child’s mother went into labour. He added that although the doula “did not actively discourage” the midwives, the doula was seen by them as a “buffer” for their access to the mother.

The report explains how the birth of the family’s first child had been traumatic, and they were focused on having a different experience for their second child, so they elected to use a doula to provide them with support at a home birth.

However, doctors’ preference was for a hospital delivery, and there was a discussion as to what circumstances would result in the mother being blue-lighted to hospital.

During the home birth, signs of fetal distress developed, but the mother was not taken to hospital immediately. Instead, the report describes a “difficult atmosphere” as the doula continued to follow the birth plan, providing “hope that a home birth was still possible”.

Mr Charles said the mother developed the complications over several hours at home and that the doula had a “negative impact” on midwives being able to provide advice and the usual care to the mother.

He said: “An initial and appropriate offer at 7.19am of transfer to hospital upon meconium being found was not accepted, thereafter the implications of a deteriorating situation involving decelerations against a background of the presence of meconium — including further clear signs of it at 10am, requiring hospital transfer — was not communicated in such a way as to lead to a transfer to hospital.”

The coroner concluded that there were signs the baby was in distress, including meconium, the baby’s first stool, and a decrease in her heart rate.

Maternity and Newborn Safety Investigations (MNSI) put in its report into the birth: “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other.

“MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.”

MNSI identified 12 cases in which there was evidence that doulas worked outside the defined boundaries of their role, and in which the care or advice provided by the doula was considered to have potentially influenced the poor outcome for the family.

The issue of doula registration, regulation and training was also raised as an area of concern by Mr Charles.

The report highlighted evidence given at the inquest by experienced midwifery professionals that suggested provision of guidance would be helpful for all involved with a birth at which a doula was present.

Doula UK, the largest representative body for doulas but not a regulatory body, said: “We were deeply saddened to hear of the loss of a baby, and our thoughts are with the family. Doulas support thousands of families each year by offering compassionate emotional, informational and practical care throughout pregnancy, birth and the postnatal period, working alongside midwives and doctors to help families feel informed and supported.

“Doula UK members undertake approved training, mentored practice and ongoing professional development, guided by a shared code of conduct. As an organisation, we reflect carefully on learning from reports such as this and remain committed to continually strengthening our guidance and support, so doulas can provide thoughtful, respectful care to the families they serve.”

A Department of Health and Social Care spokesperson said: “Any death of a child so young is a tragedy, and our deepest sympathies are with the family of baby Matilda.

“We are committed to responding to and learning from all prevention of future deaths report and will consider this report in full before formally responding.”