The babies of Maori women experience nearly twice the burden of potentially avoidable death, than the babies of New Zealand European mothers. Severe acute maternal morbidity is strongly associated with maternal mortality, stillbirth and neonatal death and harm, particularly for Maori. Our research into maternal morbidity has shown a high stillbirth rate and 22% of live babies had oxygen deprivation– potentially leading to brain damage. For Maori the overall goal of this proposal is to study the causes, consequences and preventability of poor fetal and infant outcomes for women who have had a SAMM event using expert case review and whanau interviews in order to reduce the impact of this harm for the Maori infant and their whanau. The results from this project will lead to clinical and educational interventions to reduce preventable Maori fetal/infant harm and mortality and reduce the immediate and on-going impact on their whanau.