Coroner Warns of Potential Infant Deaths Amid Concerns Over Doula Roles in Home Births
Table of Contents
A new report following the tragic death of a newborn has raised critical questions about the oversight and guidance surrounding doulas – non-medical birth assistants – and their potential impact on safe delivery practices. The coroner’s findings highlight the urgent need for clearer boundaries and communication protocols to prevent future tragedies.
Fatal Delay in Hospital Transfer Linked to Home Birth Complications
The case centers around Matilda Pomfret-Thomas, who died in November 2023, fifteen days after a difficult home labor. An inquest concluded last month revealed that despite signs of foetal distress, the mother was not immediately transferred to a hospital. A prevention of future deaths report, published on Wednesday, directly addresses the role of the doula present during the birth, urging the Department of Health and the National Institute of Health and Clinical Excellence to take decisive action.
Doula’s Presence Perceived as a Barrier to Medical Intervention
Hampshire assistant coroner Henry Charles noted that midwives from Portsmouth’s Queen Alexandra Hospital felt their access was “restricted by the doula” during the October 29, 2023, labor. The first recommendation for a hospital transfer came at 7:19 am after the discovery of meconium – a substance indicating fetal stress. This offer, and a subsequent one at 10:00 am despite a “deteriorating” labor, were not acted upon because, according to the coroner, they “were not communicated [to the family] in such a way as to lead to a transfer to hospital.”
“The presence and work of a doula did on this occasion negatively impact upon the effective provision of midwifery services in terms of building a rapport conducive to effective advice and care being given,” Charles stated. He clarified that the doula did not actively discourage hospital access, but was perceived by the midwifery team as a “buffer,” prioritizing adherence to the pre-arranged birth plan and maintaining a belief in the possibility of a successful home birth.
Increasing Use of Doulas Raises Concerns About Lack of Regulation
The coroner emphasized the growing trend of expectant mothers utilizing doulas, but cautioned that the ambiguity surrounding their role could lead to further misunderstandings with potentially fatal consequences. “The role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives,” he explained.
Currently, many doulas are affiliated with Doula UK, which provides training and guidance, but operates as a non-regulatory body. This lack of formal oversight was further underscored by a separate report from Maternity and Newborn Safety Investigations (MNSI), which highlighted the absence of regulation and clear guidance on how doulas should interact with hospital maternity services. The MNSI report suggested doulas could be perceived as “interference rather than surveillance.”
Investigations Reveal Doulas Operating Outside Defined Roles
Data from 2023 revealed that doulas were involved in 29 of the 2,827 maternity investigations completed by the Healthcare Safety Investigation Branch. Alarmingly, MNSI found evidence in 12 of those 29 cases that doulas were operating outside the defined boundaries of their role, with the care or advice provided potentially contributing to adverse outcomes for the baby.
In one particularly concerning instance, a doula actively encouraged a mother to remain at home “in direct conflict with the advice from the midwifery team to urgently transfer to the hospital,” resulting in a significant delay and ultimately contributing to the baby suffering a severe brain injury.
Doula UK Responds, Pledges Policy Review
Responding to the coroner’s report, a spokesperson for Doula UK stated, “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, and in light of the report we will be taking steps to review and strengthen our policies, guidance and ongoing CPD [continuing professional development] provision in consultation with our members and approved course providers.”
The organization also highlighted a collaborative effort with the Nursing and Midwifery Council, resulting in a video series clarifying the distinct roles of midwives and doulas, scheduled for release in September 2025. This initiative aims to improve understanding and communication between all parties involved in the birthing process.
