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The objective of this study was to determine causes and contributing factors to maternal deaths in a poor rural setting. We included all maternal deaths (N =42), identified from January to September 2002, in a remote area of The Gambia. To gain a comprehensive picture of medical causes and contributing factors a combination of audit procedure and verbal autopsy was applied. The results showed that anaemia (n =12) was the leading cause of death followed by haemorrhage (n =10), eclampsia (n =8) and obstructed labour (n =8). Placental abruption accounted for 9 of the 10 haemorrhage cases. Substandard obstetric care was identified for the majority of deaths. Substantial inadequacies were revealed at the hospital, characterized by operational difficulties and an uncoordinated emergency preparedness, including malfunction of the blood transfusion service, failure to obtain operative delivery, poor birth monitoring and lack of trained personnel, electricity, medical equipment and drugs. Substandard primary care and logistic difficulties within the referral process further complicated the situation. Delay in seeking care by the cases themselves played a less important role. It was concluded that interventions, addressing the profound deficiencies within the health care system and increasing access to emergency obstetric care, are warranted to reduce maternal deaths in a poor setting such as rural Gambia. [ABSTRACT FROM AUTHOR]