In a heartbreaking case, a coroner has issued a warning about the potential dangers of “unregulated” doulas after the death of a 15-day-old baby. Matilda Pomfret-Thomas passed away in November 2023 due to a brain injury caused by a lack of oxygen, either before or during her birth.
The inquest into Matilda’s death revealed that her mother had a difficult home labour, but was not immediately transferred to the hospital despite signs of fetal distress. Assistant Coroner Henry Charles believes the doula involved in the birth had a “negative impact” on the midwives’ ability to provide the necessary care.
Charles stated that the doula “affected the work of the midwives” from Portsmouth’s Queen Alexandra Hospital, with the midwives seeing the doula as a “buffer” restricting their access to the mother. The coroner added that although the doula did not actively discourage the midwives, the “difficult atmosphere” led to a delay in the mother being transferred to the hospital.
The Maternity and Newborn Safety Investigations (MNSI) report acknowledged that there is currently no regulation of doula care or guidance on how doulas and midwives should interact. The report identified 12 cases where doulas were found to have worked outside the boundaries of their role, potentially influencing poor outcomes for families.
Doula UK, the largest representative body for doulas in the UK, expressed their deep sadness over the tragic loss of baby Matilda. The organisation stated that its members undergo approved training, mentored practice, and ongoing professional development, guided by a shared code of conduct. However, the coroner’s report has highlighted the need for clearer guidance and regulation to ensure the safety of mothers and babies.
The Department of Health and Social Care has said it will consider the coroner’s report in full before formally responding, acknowledging that the death of a child is a tragedy and that the department is committed to learning from such cases.
This case underscores the importance of establishing clear guidelines and regulations for the role of doulas within the maternity care system. As the use of doulas continues to grow, it is crucial that their practices are properly monitored and integrated with the work of qualified medical professionals to prevent similar tragedies from occurring in the future.
