A midwife has been told to apologise to a woman whose baby was still-born after not being referred to a specialist despite red flags and may face further action.
In a report released on Monday, Health and Disability Commissioner Anthony Hill says the community-based midwife breached standards by not giving the high-risk patient the care she needed.
The commission heard the 27-year-old woman was pregnant with her first baby in 2014.
But despite the fact the woman was obese, a smoker and had a family history of diabetes, she was not referred to a specialist by her midwife - who was her lead maternity carer.
Ministry of Health guidelines state women with BMIs over 40 are meant to have their care transferred to specialists.
Although the pregnancy went full term, there were complications and the child ended up being still-born.
Mr Hill has referred her to the Director of Proceedings to see if any other action should be taken and has recommended the midwife write a written apology.
He said the woman was not still practising, but if she returned the Midwifery Council of New Zealand would decline a practising certificate unless she passed a competence test.
A five-year, 240,000-birth Otago University study released last month found babies born to mothers with medical-led care had substantially lower adverse health outcomes than those with midwife-led care.
New Zealand adopted an autonomous midwife-led model of maternity care in 1990.