A panel that reviewed high foetal and newborn mortality rates in Counties Manukau says pregnant women are not being told how to look after themselves.
The district health board commissioned an independent report after it was revealed the region has the highest perinatal mortality rates in the country.
The review says high rates of diabetes, smoking and obesity are the reasons for that.
Chair Ron Paterson says no one is screening the women for health risks when they first go to a doctor to get their pregnancy confirmed.
He says for many, that's their only visit to a medical professional until they give birth.
Dr Paterson says they are not being told how to access maternity care.
Counties Manukau DHB chair Gregor Coster says the board hopes to have all recommendations from the review in place within a year.