A new study has found only one-third of severe illnesses in pregnancy are being managed appropriately, and many of those illnesses are potentially preventable.
Severe maternal morbidity, or SMM, is a near-death experience in pregnancy, childbirth or the termination of a pregnancy.
"When we go through pregnancy we have different things that happen to us, we can have haemorrhages, high blood pressure, infections and all of these are life threatening," says Beverley Lawton, a Professor of Women's Health Research.
They also significantly increase the odds of harm or death for babies.
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A new study reviewed nearly 350 cases.
Professor Lawton says these didn't need to happen.
"A third of them were potentially avoidable. That means they didn't need to get as sick as they did and almost die."
The reason? Poor care.
"Ninety percent of avoidable ones, there was clinical sub-standard of care," says Prof. Lawton.
That includes across general practitioners, emergency departments, obstetricians and midwives.
Pacific women were most likely to be admitted to ICU or high dependency units, with double the rate of New Zealand Europeans, at 10 per 1000 deliveries. Maori women was 5.6 per one thousand, Asian women 8.2 and New Zealand Europeans just 4.6.
Prof. Lawton says training, education and protocols need to be improved to help prevent life-threatening illness from occurring in the first place.
The Health Quality and Safety Commission told Newshub a Maternity Early Warning System is now being implemented across DHBs over the next year to identify and respond to deterioration among women admitted to hospital during pregnancy.