A coroner has issued a stark warning regarding childbirth safety following the tragic death of a newborn baby girl at just fifteen days old. The case has raised significant questions about the role of doulas during home births and their interaction with medical professionals.
Heartbreaking Loss of Baby Matilda
Baby Matilda Pomfret-Thomas passed away on November 13, 2023, from neonatal hypoxic-ischemic encephalopathy (HIE), a form of brain damage caused by oxygen deprivation before or during birth. An inquest into her death has prompted Assistant Coroner Henry Charles for Hampshire, Portsmouth and Southampton to issue a prevention of future deaths report.
Traumatic Background Influencing Decisions
The coroner's report reveals that Matilda's parents had experienced a traumatic hospital birth with their first child, leading them to plan a home birth for their second pregnancy. They hired a doula to provide emotional and practical support during labour, seeking a different birth experience.
Mr Charles noted in his findings: "The background is of a traumatic first birth that impacted upon decision making for this second pregnancy and birth. Matilda’s parents had seen a home birth as the best way forward."
Critical Moments During Labour
Labour commenced in the early hours of October 29, 2023, with prompt midwife attendance at the family home. However, several concerning signs emerged during the process:
- Meconium was observed, which can indicate fetal distress
- Decelerations in fetal heart rate were detected by midwives
- An initial hospital transfer offer at 7:19am was declined
- The mother was not transferred to hospital until 12:13pm
Matilda was eventually delivered at Queen Alexandra Hospital, but had already developed HIE over several hours during the home labour.
Doula's Impact on Medical Care
The coroner found that the presence of the doula "negatively impacted" the midwives' ability to provide advice and usual care. He described how a difficult atmosphere developed, with midwives feeling their access was being restricted by the doula, who was perceived as acting as a buffer between them and the parents.
"The doula was following the birth plan. The doula was supporting the parents per the birth plan, and this appears to have been perceived as grounds for hope that a home birth was still possible," Mr Charles noted in his report.
Regulatory Concerns and Investigation Findings
The coroner highlighted significant concerns about the lack of regulation surrounding doula services. He pointed out that Doula UK, while being the largest representative body for doulas, is not a regulatory organisation and many doulas operate outside its membership.
The Maternity and Newborn Safety Investigations (MNSI) report into the birth identified issues with how doulas and midwives work together. MNSI acknowledged there is no regulation of doula care or guidance on how the two services should interact.
Mr Charles revealed that MNSI identified twelve cases where "doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family."
Calls for Review and Response
The coroner's report, which is being sent to the Department of Health, the Nursing and Midwifery Council, and Doula UK among others, recommends urgent review of:
- Doula registration processes
- Regulation of doula services
- Training standards for doulas
- Guidance on doula-midwife interaction
A spokesperson for Doula UK responded to the Guardian, stating: "We take the implications of the coroner’s report extremely seriously. We have policies and practices in place to protect members and the families they support to ensure doulas remain within the scope of their practice."
The organisation confirmed they would be reviewing and strengthening their policies, guidance and continuing professional development provision in light of the report. They also noted collaboration with the Nursing and Midwifery Council on a video series clarifying the distinct roles of midwives and doulas.
Broader Implications for Maternity Care
This tragic case highlights the complex dynamics that can emerge when unregulated support workers interact with medical professionals during critical healthcare situations. The coroner's warning emphasises the need for clearer boundaries, better communication protocols, and proper regulation to ensure the safety of both mothers and babies during childbirth.
As doula services become increasingly popular and are often offered on a paid basis, the case of baby Matilda serves as a sobering reminder of the importance of maintaining clear professional boundaries and ensuring that medical advice takes precedence during emergency situations in childbirth.
