A coroner has warned more women could die unless action is taken to bring about national guidance on home births after the death of a mother and her newborn daughter.
Jennifer Cahill, 34, died at North Manchester General Hospital on 3 June 2024 shortly after giving birth to her second child Agnes Lily at home in Prestwich. Her daughter died a few days later at the same hospital.
An inquest found their deaths were contributed to by neglect after “gross failings” in antenatal care and the actions of midwives.
Joanne Kearsley, senior coroner for Manchester North, said there was no national guidance on home births or on staffing, training and experience for midwives providing this type of care.
The inquest found Mrs Cahill died as a result of complications from the delivery and her daughter died due to birth complications.
Mrs Cahill had opted for a home birth after suffering complications during her first delivery, including a post-partum haemorrhage for which she received an iron and blood transfusion.
In her original conclusion the coroner found Mrs Cahill “had not made an informed decision to have a home birth” and if the relevant information had been given to her “it is more likely than not she would have given birth in an alternative setting”, and both mother and baby would have survived.
Ms Kearsley issued a prevention of future deaths report after the inquest, where she warned there is an increase in the number of women with ‘high-risk pregnancies’ requesting home births.
In these situations, “required interventions cannot take place or would be significantly delayed, and there is no robust framework for midwives supporting home birth care”, she added.
“There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.”
This lack of guidance has led to “differing models of care”, Ms Kearsley said.
The risk of death, although small, is also not discussed with women, the report warned.
There is also a lack of national data showing the number of women who are transferred to hospital from home during labour or after birth.