When Advice Is Given and Women’s Choice Remains

Some incidents, including deaths, echo far beyond the families who live with them. Not because they offer clarity, but because they expose how birth is understood, how responsibility is assigned, and what becomes uneasy when outcomes are tragic.

The Prevention of Future Deaths report issued on 15 January 2026 following the death of Matilda Pomfret-Thomas is one such moment. A baby died after a difficult labour that began at home. Her parents lost their child. That loss stands at the centre of everything and does not require interpretation, justification, or framing.

What invites reflection is how the events surrounding that birth have been described, and what the coroner’s concerns reveal about women’s choice, non-medical support, and the expectations placed on those present when birth does not unfold as hoped.

The report was issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 and sent to the Department of Health and Social Care, NICE, and the Nursing and Midwifery Council. Its purpose is to identify matters of concern where future incidents might occur unless action is taken.

Within that context, the coroner states that 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 later notes that experienced midwifery professionals gave evidence suggesting guidance would be helpful where a doula is present, and that issues of registration, regulation, and training should be reviewed.

Those sentences have been widely shared. Read slowly and in full, they point to something more complex than they first appear.

What the report describes

The narrative conclusion of the inquest is careful and specific.

The parents’ first birth is described as traumatic, with that experience shaping how they approached this pregnancy and birth. A home birth, supported by a doula, was seen as a way of doing things differently.

Midwives attended promptly when labour began. Meconium was observed. An offer of transfer to hospital was made early in labour and was not accepted. Later, as decelerations were observed in the presence of meconium, further information was shared. The coroner notes that this information was not communicated in a way that led to a transfer to hospital.

The report also states that the doula did not actively restrict midwife access. She was perceived by members of the midwifery team as acting as a buffer. She was supporting the parents in line with the birth plan, which appeared to sustain hope that a home birth might still be possible.

There is no finding that the doula gave clinical advice. There is no finding that she obstructed care. There is no finding that she instructed the parents to refuse transfer.

The concern sits elsewhere.

Advice, outcome, and expectation

The wording that advice was not communicated in a way that led to transfer marks a subtle shift.

It moves attention away from whether information was shared clearly and respectfully, and towards whether it produced the desired decision. Effectiveness becomes linked to agreement.

This matters because the legal position in the UK is clear. A woman with capacity retains the right to make decisions about her body throughout pregnancy and labour. She cannot be compelled to accept care, transfer, or intervention, even where professional concern is high and risk is articulated.

Pregnancy does not suspend consent. Labour does not remove agency.

When the quality of communication is assessed primarily by whether it persuades, advice begins to edge towards expectation. This does not arise from ill intent. It often grows from fear, responsibility, and the weight of hindsight. It remains a shift worth noticing.

Women’s choice and unease

Maternity care continues to hold a complicated relationship with women’s autonomy.

When women follow recommendations, choice is affirmed. When women decide differently, choice is often reinterpreted. Attention turns towards influence, misunderstanding, or resistance. Language tightens.

This pattern appears repeatedly across inquiries and reviews into maternity services. Women describe not being listened to, not being believed, and not feeling able to voice uncertainty or fear. These accounts are consistent across settings and over time.

The report acknowledges that the parents’ earlier traumatic birth shaped their decisions. Trauma offers context. Trauma does not remove capacity. Trauma does not cancel the right to choose.

A decision that differs from professional advice is not, in itself, evidence of confusion or coercion.

Support, presence, and perception

The description of the doula as a buffer is revealing.

A buffer absorbs tension. It slows the pace. It changes how urgency is felt in the room.

For a woman in labour, that slowing can be containing. It can create space to breathe, to think, to ask questions, and to remain connected to what matters to her. For professionals working within systems oriented towards escalation and risk management, the same slowing can feel difficult.

The report itself recognises this distinction. Access was not blocked. Care was not prevented. The doula supported the parents within their stated intentions.

What appears to have been unsettling was not interference, but the continuation of hope.

Hope and hindsight

Hope sits awkwardly within maternity systems. It cannot be measured or timed. It does not disappear simply because new information appears.

Holding hope for a home birth while hearing about risk does not necessarily indicate a lack of understanding. It may reflect how women weigh information alongside values, memories, and fear. From outside, and particularly in hindsight, hope can appear misplaced. From within labour, it can feel like a way of staying steady when certainty is unavailable.

Hindsight brings clarity that did not exist in the moment. That clarity reshapes how earlier decisions are interpreted.

Evidence on doula support

The Regulation 28 report raises concerns about doulas without acknowledging the wider research on their impact.

A substantial body of evidence shows that continuous, non-medical support during labour is associated with improved outcomes. Summaries provided by Evidence Based Birth® in their article Evidence on Doulas, drawing on systematic reviews including Cochrane data, describe lower rates of intervention, reduced likelihood of caesarean birth, shorter labours, and higher satisfaction with the birth experience.

Postnatally, doula support has been linked with improved emotional wellbeing, increased confidence, and continuity during a period when many women feel vulnerable and unsupported.

This evidence does not suggest that doulas replace clinical care. It highlights the value of relational presence alongside it.

A wider context

The report focuses, appropriately, on preventing future incidents. What it does not explore is why so many women approach birth already carrying fear, mistrust, or unresolved trauma.

Inquiry after inquiry into maternity services documents women saying the same thing. They were not listened to. Their concerns were minimised. Their voices carried less weight than protocols.

This context matters. Trauma does not arise in isolation. It develops within systems where people feel rushed, unheard, or powerless. Independent support is often sought not in opposition to care, but in response to earlier experiences of it.

Looking from a wider angle, the question quietly emerges. Why does scrutiny fall on those who offer listening and continuity, rather than on the conditions that leave women seeking that support in the first place?

Support beyond doulas

Another implication sits beneath the concern about a doula acting as a buffer.

If the person offering steady presence in that birth space had been a mother, a grandmother, a sister, a close friend, or a partner, a similar dynamic could easily have arisen. Loved ones often help women slow down, ask questions, and stay connected to their wishes. They too, can absorb anxiety and soften urgency.

In those circumstances, would the same concern arise? Would guidance or regulation be suggested for partners or family members?

Stepping back further, the question becomes less about doulas and more about support itself.

If any non-medical presence that does not actively reinforce professional advice is experienced as problematic, the implied solution becomes stark. Women would need to labour without anyone beside them except the medical team once concern arises. Relationship would give way entirely to authority.

Few people would argue for that openly. Yet this is where the logic quietly leads.

Birth does not take place in isolation. Most women do not labour well when alone, frightened, or silenced. Support brings relationship into the room. Relationship inevitably shapes how information is heard and how decisions are made.

Guidance, regulation, and expectations

Calls for guidance and regulation are often presented as neutral. They also shape roles and loyalties.

In previous discussions involving Doula UK and the Nursing and Midwifery Council, an expectation has been expressed that doulas should psychologically reinforce what midwives are saying. That wording does not appear in the Regulation 28 report itself. It provides context for how concerns are framed.

Psychological reinforcement implies alignment with professional advice. It suggests that the role of the doula includes helping that advice land and encouraging acceptance.

At that point, independent support begins to shift. Loyalty moves away from the woman’s process and towards the system’s comfort.

This expectation tends to surface most clearly when women choose differently.

What regulation can and cannot do

Regulation does not change the law on consent. It does not remove women’s right to refuse care. It does not resolve the discomfort that arises when choice and risk intersect.

Regulation can clarify boundaries. It can also narrow space. It may reassure some while constraining others.

The tension exposed in this case is not confined to doulas. It reflects a broader difficulty with uncertainty and with women holding decision-making power when outcomes cannot be guaranteed.

Sitting with what remains

The Prevention of Future Deaths report raises important questions about communication, collaboration, and differing perspectives within birth. It does not establish that doulas are unsafe. It does not show that women were misled. It does not remove women’s agency.

What it reveals is familiar.

Women’s choice is supported when it aligns with expectations and questioned when it does not. Support that centres listening can feel challenging within systems focused on managing risk. Trauma is acknowledged in individuals, while its wider roots remain harder to address.

No one in that room had the legal authority to compel a transfer. That remains true regardless of outcome.

The question that remains is not only how support is regulated, but how maternity care listens, holds uncertainty, and makes room for women’s decisions as they already exist.

That question remains open.

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Disclaimer

This article is offered as reflective commentary on language, systems, and assumptions within maternity care. It is not a clinical analysis of the events described, nor does it seek to determine causation, fault, or responsibility. All references to the Regulation 28 report reflect the coroner’s published wording. Nothing here is intended to diminish the loss experienced by the family, the complexity of clinical decision-making, or the responsibilities carried by maternity professionals. The intention is to widen understanding, not to assign blame.