Background: Maternal deaths are often unrecognized and improperly documented in the health system. Objective: To identify causes of maternal death occurring in hospitals and determine avoidability of maternal death. Methods: The study assessed each death for the cause and surrounding circumstances as well as avoidable factors, by reviewing two years patient and facility records and interviewing individuals who were involved in caring for the deceased. Data were collected between December 2005 and May 2006. Result: A total of 34 maternal deaths were identified in five public hospitals in Tigray over a period of two years, of which 12 (35.2%) were reported to have been avoidable. The leading causes of death were infection, haemorrhage and hypertensive disorders. Avoidable factors were mainly related to hospital service or medical factors such as lack of blood for transfusion, delay in transfusion, and inappropriate treatment. Lack of transportation and delayed careseeking also contributed to avoidable maternal deaths. The quality of medical records was very poor. Nearly 73.5% of maternal deaths were of rural residents and 20.5% of those who died were under the age of 18, which shows that young girls and rural residents carry significant maternal death risk. Conclusions: Maternal deaths are not properly documented in health facilities. Improper care led to avoidable maternal death. Improving care and information systems is crucial to making pregnancy safer and reducing maternal death.