A midwife has been criticised for leaving a mother in labour during a "tragic" birth at a rural home with no electricity, phone or internet coverage.
The mother was 43 weeks when she gave birth in 2020. Her baby was not breathing and could not be revived. The umbilical cord had severed.
A report by Health and Disability Commissioner Rose Wall said the woman should have given birth in a hospital after her waters broke two weeks earlier, with meconium present.
But once she was in labour at home, the midwife breached care by leaving her unattended, he said.
She had been with the woman in the initial stages, but had thought the labour was not well established and went to town, and told her back-up midwife to leave.
She told the women's husband to call her if he needed to, but when the labour ramped up he felt he could not leave his wife to run to the road for cell phone reception.
Wall said the case had been extremely difficult to investigate because of the different accounts of the mother and her midwife.
At times, they were completely opposite.
The midwife said after the meconium was found she recommended the mother, known as Mrs A, go to the closest birthing unit and have the baby's heart rate measured - but that the mother declined.
However, Mrs A said the midwife told her that was the "hospital's" recommendation to do that, and if she went they would induce labour, give her antibiotics and "would not let her out."
Mrs A told the commission she thought antibiotics were harmful to the baby but that the midwife did not explain otherwise or tell her that the baby was at high risk without them.
But the midwife said she explained to the mother the recommendation for antibiotics and it was the mother who disagreed with using them.
Mrs A also said her midwife gave her a tincture known as black cohosh and advised her to drink it even though the woman had read it should not be taken in pregnancy.
But the midwife said it was the woman who asked her to pick up the remedy from a herbalist, which she only agreed to do because the woman lived so remotely.
Either way, the commissioner said the midwife breached standards by simply giving the woman the cohosh because she did not have the correct qualification to deal in herbal medicine.
The two women also disagreed about whether the mother had been recommended to have an ultrasound, about how much information was given on the risk to the baby and about examinations during labour.
Wall said the midwife should have ordered the woman an ultrasound and done more to address her concerns about medical intervention.
"Several concerning risk factors meant that it was unsafe for Mrs A to give birth at home in a remote locality with no communication channels and no ready access to specialist input," Wall's report said.
Since the incident, the midwife had made changes such as consulting with medical teams if a woman declines to see them, had been under supervision and had taken some education
Wall further recommended the midwife apologise to the parents, that she undertake more education.
