A senior UK coroner has issued a chilling warning that more babies will die unless the government urgently regulates the "diffuse and dangerous" role of doulas, following the tragic, preventable death of baby Matilda Pomfret-Thomas.

The Prevention of Future Deaths report, released this Wednesday, serves as a grim indictment of a home birth system where lines of authority have become lethally blurred. Matilda died of a catastrophic brain injury in November 2023, just 15 days after a home birth in Hampshire turned into a nightmare. The inquest found that her transfer to the hospital was critically delayed because a doula—a non-medical birth companion—acted as a "buffer," effectively blocking the life-saving advice of NHS midwives.

The "Buffer" Effect

Hampshire assistant coroner Henry Charles did not mince words. His investigation revealed a harrowing timeline of missed opportunities. At 7:19 AM on the day of the birth, midwives identified meconium—a clear sign of fetal distress—and recommended an immediate transfer to Portsmouth’s Queen Alexandra Hospital. The offer was declined.

By 10:00 AM, with the labor deteriorating, the advice was given again. Again, it was not acted upon. The coroner found that the doula, while following the parents' birth plan, had created an atmosphere where the midwives felt their access to the mother was "restricted."

• A Fatal Misunderstanding: "The doula was seen as, in effect, a buffer by members of the midwifery team," Charles wrote. He noted that while the doula did not actively bar the midwives, her presence emboldened the parents to persist with a home birth long after it had become dangerous. "The birth plan became a suicide pact for the delivery," one medical expert testified.
• Regulatory Vacuum: Unlike midwives or doctors, doulas are unregulated. They require no medical training and are not held to clinical standards. The coroner has now ordered the Department of Health and the National Institute for Health and Care Excellence (NICE) to define exactly where a doula’s role ends and medical necessity begins.

Global echoes, Local Lessons

While this tragedy occurred in the UK, it resonates deeply in Kenya, where the "doula" movement is gaining traction among the urban middle class in Nairobi and Mombasa. In a country where maternal mortality remains a stubborn challenge (355 deaths per 100,000 live births), the introduction of unregulated birth companions into an already strained healthcare system poses new risks.

Kenyan obstetrics experts have long warned against the "romanticization" of natural birth when it ignores clinical red flags. The tragedy of Matilda Pomfret-Thomas is a universal cautionary tale: emotional support is vital, but it cannot replace clinical judgment when a child’s brain is starved of oxygen.

"We are risking lives on the altar of 'experience'," the coroner concluded. Without immediate guidelines, the murky interplay between paid companions and medical professionals will almost certainly claim another life. For Matilda’s parents, the clarity comes too late; for the rest of the world, it is a desperate wake-up call.