Identification of the main operational factors in cases of maternal de
ath within and outside the health care system is necessary for safe mo
therhood programmes. In this study, a follow-up was done of all 117 ca
ses of maternal deaths in Ilala district, Dar es Salaam, 1991-1993, at
all levels of care. ln all, 79% received some medical care whereas 11
% arrived too late for treatment. For each case the major operational
factors and all health care interventions were defined through intervi
ews with family members and health care staff and from hospital record
s, and the avoidability of each case was determined. In the health ins
titutions where the women had consulted, the available resources were
assessed. It was found that in most cases the husband (29%) or the mot
her (31%) of the woman decided on her care in cases of complications,
and together with the lack of transport, this often caused delay at ho
me. Also, delay in transfer from the district hospital was common. Cas
es of abortion complications were often not managed on time because of
the delay in reporting to hospital or misleading information. Subopti
mal care was identified in 77% of the cases reaching health care. Inad
equate treatment was identified by the district health staff in 61% an
d by the referral centres in 12% of their cases. Wrong decision at the
district level and lack of equipment at the referral centre were the
main reasons for inadequate care. It is concluded that although commun
ity education on danger signs in pregnancy and labour is important, pr
ovision of the core resources and supplies for emergency obstetric int
erventions, as well as clear protocols for management and referral, ar
e absolutely necessary for improvement of maternal survival.