摘要:During a period of five years (1971-75) 29 maternal deaths occurred in 15794 deliveries at the Amin Maternity Hospital in Isfahan (18.36 per 10.000). Death was considered to be due to direct obstetrical cause in 18 cases (62.0%), indirect obstetrical cause, in 8 cases (27.5%), add no related cause in 3 cases (10.3%). In 14 cases of 29 the maternal death was considered avoidable. Especially amongst those deaths with direct obstetrical cause the proportion of avoidable deaths was higher (12 out of 18 deaths). Responsibility for short comings in action amongst avoidable deaths is examined. Lack of regular prenatal care, delay of referral, referral from far distances, unavailability of compatible blood, and cultural inhibitions are found to be the most important factors.