Inquest into baby girl’s death sees coroner warn of the danger of doulas affecting midwives’ work

A warning was issued about doulas influencing the work of midwives after the death of a girl 15 days after her birth.

Henry Charles, coroner for Hampshire, Portsmouth and Southampton, issued the warning following an inquest into the death of little Matilda Pomfret-Thomas last month.

Matilda’s parents hired a doula as part of their plan for a home birth after experiencing a traumatic hospital birth for their first child.

A doula is an unregulated, non-medical professional whom parents may employ to provide ongoing emotional, physical and practical support throughout pregnancy and birth.

There is controversy surrounding the use of doulas, with some – including doctors – arguing that they put women and babies at risk.

Matilda died of neonatal hypoxic-ischemic encephalopathy (HIE) on November 13, 2023, 15 days after birth; This was a type of brain damage caused by a lack of oxygen to the brain before or after birth.

Mr Charles concluded that Matilda had developed HIE for hours during the home birth and that the presence of a doula at the scene had a ‘adverse impact’ on the ability of midwives present to advise the mother and provide usual care.

Decelerations (decreases in the fetal heart rate) were also observed by midwives caring for the mother at home; However, the mother was not taken to the hospital as complications became apparent until 12.13 p.m.

Matilda was eventually delivered at Queen Alexandra Hospital in Portsmouth.

Mr Charles said in his report: ‘The background is a traumatic first birth which influenced decision making for the second pregnancy and birth.

‘Matilda’s parents saw a home birth as the best way forward.

‘The birth began in the early hours of October 29, 2023, with immediate midwife involvement.

‘The initial and appropriate offer to transfer him to hospital at 7.19am upon the discovery of meconium was not accepted; Subsequently, the consequences of a worsening condition with background decelerations regarding the presence of meconium – including more obvious symptoms requiring transfer to hospital at 10am – were not communicated to require transfer to hospital.

‘One element of what happened is that the presence and work of a doula in this case adversely affected the effective provision of midwifery services in terms of creating a rapport that would assist in the delivery of effective advice and care.’

Detailing the events surrounding Matilda’s birth, Mr Charles said the parents had experienced a traumatic birth with their first baby and were “focused on achieving a different birth experience” for their Matilda, using a doula to provide support.

‘The hospital’s choice was to give birth in the hospital, and it was discussed what the conditions might be that would cause the mother to give the blue light to the hospital.

‘Signs of fetal distress appeared but the mother was not immediately transported to hospital.

‘It was a difficult atmosphere, midwives felt access was restricted by the doula.

‘I discovered that it did not actively discourage midwife access but was actually seen as a buffer by midwifery team members.

‘The doula was following the birth plan. ‘The doula was supporting the parents according to the birth plan and this appears to have been perceived as the basis for hope that a home birth might still be possible.’

Matilda’s parents believed a home birth with doula support was best after previously experiencing a traumatic birth in hospital (stock photo Queen Alexandra Hospital)

Mr Charles stated that the organization Doula UK ‘is the largest representative body for doulas, but it is not a regulatory body, it does not represent all doulas, in fact many doulas are not members’.

She said: ‘Doula UK has introduced membership requirements, training offerings and a lot of guidance, but the role of a doula is clearly dispersed in practical terms and can have multiple understandings, not only by doulas but also by their clients and midwives.’

Mr Charles also highlighted that Maternity and Newborn Safety Investigations (MSNI), which investigates patient safety incidents in NHS maternity care, recognizes problems with how doulas and midwives work together.

‘MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other,’ Mr Charles said.

‘MNSI takes into account the dynamics of a situation where a third party is involved which may create additional challenges for staff, such as making clinical recommendations as opposed to personal recommendations or opinions and providing usual care which may be viewed as intervention rather than supervision.’

He said MNSI had identified 12 cases where ‘doulas were working outside the defined boundaries of their role and care or advice provided by the doula was considered to have a potential impact on poor outcomes for the family.

‘Doula registration, regulation and training issues are therefore points of concern that I recommend to be reviewed.’

Mr Charles’ report will now be sent to the Department of Health, Nursing and Midwifery Council, Doula England and others.