UPDATES & ANALYSIS

District court did not err in denying motions for directed verdict and for a new trial in obstetrician medical malpractice suit, Iowa Supreme Court determines

by Mary Grace Henderson | July 21, 2025

In Belhak v. Smith, a jury found in favor of a woman and her husband in their negligence suit against the woman’s obstetrician and the obstetrician’s employer. The Iowa Court of Appeals reversed, finding that one of the negligence claims lacked sufficient evidence for submission to the jury. However, the Iowa Supreme Court reversed the Iowa Court of Appeals and affirmed the judgment of the Scott County District Court. All justices joined in this decision, which written by Justice McDermott; however, Justice Waterman did not participate in the decision.

Fatima Belhak’s first child was delivered by obstetrician Dr. Denice Smith at the Trinity Medical Center in 2014. Belhak experienced birth complications, leading to Smith performing an episiotomy to deliver the baby. Belhak’s episiotomy caused what Smith identified as a second-degree laceration, which Smith tried to repair using “4-0” tensile strength synthetic surgical sutures. While Belhak returned home shortly thereafter, she later ended up at the University of Iowa Hospitals and Clinics in Iowa City due to further complications. University of Iowa doctors diagnosed the laceration as a fourth-degree laceration and found Belhak had an infection. Because of Belhak’s medical complications, she needed reconstructive surgery; however, the surgery was unable to occur for five months due to the infection. Belhak noted her pre-surgery “pain made it more difficult to walk, care for her newborn child, lift heavy objections, and sit or sleep in certain positions.”

Belhak and her husband Abdellatif Elfila’s subsequent negligence suit against Dr. Smith and her employer Women’s Care Specialists, P.C. proceeded to a jury trial. Smith moved for a directed verdict, asserting Belhak did not prove Smith’s behavior caused Belhak’s injury, which was denied. Smith later moved for a mistrial, contending the attorney for Belhak “(1) accused Smith’s lawyer of ‘character assassination,’ (2) vouched for his clients by telling the jury they had to hold Smith accountable, (3) made a ‘golden rule argument,’ and (4) misstated the record” in Belhak’s closing argument. The motion was taken under advisement by the court, and the jury received a limiting instruction regarding one theory for Belhak’s injury discussed in Belhak’s closing argument. The jury reached a verdict for Belhak and awarded her $3.25 million in damages.

Subsequently, Smith filed a motion for a new trial due to “(1) improper conduct by Belhak’s lawyer during closing argument, (2) improper questioning of witnesses during trial, (3) improper communication by Smith’s expert witness . . . with a juror during recess, and (4) insufficient evidence to submit to the jury the specification of negligence” as to one medical examination and 4-0 suture utilization. Following the district court’s denial of the motion, the Iowa Court of Appeals reversed based on insufficient evidence for jury consideration of the 4-0 suture negligence issue.

On appeal, the Iowa Supreme Court focused its analysis on (1) whether Smith should have been given a new trial due to alleged trial misconduct by Belhak’s attorney and (2) whether Smith’s motion for directed verdict regarding 4-0 suture utilization should have been granted.

As to the denial of Smith’s motion for a mistrial, the Court cited its 2022 decision in State v. Tucker, noting it would analyze whether the district court abused its discretion by making “clearly untenable or unreasonable” decisions. Though Smith put forth seven reasons that a mistrial should have been granted, the Court did not find the district court abused its discretion.

First, Smith asserted that “she was prejudiced by having to make fifty-six sustained objections to improper questioning.” Because the question form, rather than its substance, was usually the reason for these objections, the Court was not persuaded that the district court abused its discretion in denying the motion for mistrial. Additionally, Smith contended the attorney for Belhak incorrectly recounted the record, misleading the jury, and that the attorney made an impermissible emotional appeal to the jury. Suggesting that the district court would have been best equipped to decide if Belhak’s attorney’s behavior prejudiced Smith, the Court did not find an abuse of discretion.

Further, Smith asserted that Belhak’s attorney gave a “golden rule” argument when addressing the jury on the matter of damages, requesting that the jury imagine a hypothetical detailed by Belhak’s attorney. However, after examining the full closing argument, the Court stated a new trial was not necessary as the Court did not believe Belhak’s attorney’s argument was sufficiently prejudicial “to have caused the jurors to decide the case based on their emotions rather than the evidence,” as would be characteristic of a “golden rule” argument.

Moreover, while the Court agreed comments made during Belhak’s closing argument about Smith’s expert witness and Smith’s attorney were in appropriate, the Court did not believe the trial court abused its discretion by not allowing a new trial on those grounds. The Court noted that as to the discussion about Smith’s attorney, the Court promptly made an admonition to the jury. Smith also contended the attorney for Belhak “misled the jurors by telling them that the University of Iowa’s medical records resolved the disputed issue of the timing of Belhak’s injury.” Noting that Smith and Belhak each had the chance to share with the jury what they believed to be the correct interpretation of Belhak’s medical records, the Court determined the district court did not abuse its discretion on this topic.

Smith also argued that if these distinct errors were not prejudicial on their own, “the cumulative effect of Belhak’s lawyer’s misconduct during closing argument pushe[d] it over the prejudice threshold.” However, the Court disagreed, finding the arguments raised by Smith did not meet this threshold.

The Court then shifted to examining Smith’s motion for directed verdict and her assertion that “there was insufficient evidence to submit to the jury that Smith was negligent by using 4-0 sutures to repair [Belhak’s] episiotomy.” On the issue of what kind of suture should have been used, expert testimony conflicted; Belhak’s expert stated a 2-0 or 3-0 suture should have been used, but Smith’s expert asserted the requisite standard of care was met by the 4-0 suture utilized by Smith. Ultimately, the Court determined the testimony given by Smith’s expert could have allowed jurors to conclude that Smith’s 4-0 sutures led to a deterioration of the wound area, causing Belhak’s infection which pushed back the date of reconstructive surgery. Consequently, the Court found the district court was permitted to deny Smith’s motions for directed verdict and new trial.

Tags: Iowa Supreme Court 2024-25