A coroner has warned that more babies could die without greater clarity and guidance over the role of home birthing assistants, after the death of a baby girl raised concerns about a doula delaying access to hospital treatment.
Matilda Pomfret-Thomas died of a brain injury in November 2023, 15 days after her mother had a difficult home labour and was not immediately transferred to hospital despite signs of foetal distress, an inquest concluded last month.
A prevention of future deaths report published on Wednesday urged the Department of Health and the National Institute of Health and Clinical Excellence 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.
The Hampshire assistant coroner Henry Charles noted that midwives from Portsmouth’s Queen Alexandra hospital felt their access “was being restricted by the doula” when the child’s mother went into labour on 29 October 2023.
A midwife who attended the home birth first offered a transfer to hospital at 7.19am when meconium – a sign of foetal stress – was discovered, the coroner said. The offer was turned down, and again at 10am despite “deteriorating” labour, because it was “not communicated [to the family] in such a way as to lead to a transfer to hospital”.
Charles said: “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.”
He added: “I found that [the doula] did not actively discourage midwife access but that she was seen as, in effect, a buffer by members of the midwifery team. 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.”
Charles noted that expectant mothers were increasingly using doulas. But he suggested doulas’ role could lead to other fatal misunderstandings.
He said: “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.”
Charles noted that many doulas were represented by Doula UK, which provides training and guidance but is not a regulatory body and does not cover all doulas.
He said: “There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present.”
A separate report by Maternity and Newborn Safety Investigations (MNSI) into Matilda’s birth, cited by the coroner, highlighted that there was no regulation of doulas, nor guidance on how they interact with hospital maternity services. It said doulas could be viewed as “interference rather than surveillance”.
A report in 2023 when MNSI was part of the Healthcare Safety Investigation Branch noted doulas were involved in 29 of the 2,827 maternity investigations it had completed.
MNSI said it “found evidence in 12 of the 29 investigations that doulas worked outside of the defined boundaries of their role. The care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the baby.”
In one of these cases the doula had encouraged the mother to stay at home “in direct conflict with the advice from the midwifery team to urgently transfer to the hospital. The significant delay in transfer to hospital contributed to the baby having a severe brain injury.”
A spokesperson for Doula UK said: “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.
“In September 2025, Doula UK and the Nursing and Midwifery Council also collaborated on a video series clarifying the distinct roles of midwives and doulas.”
