目的:通过孕产妇死亡评审了解主要死因,提出降低孕产妇死亡率的干预措施。方法:对芜湖市2003～2008年孕产妇死亡个案表、调查报告和评审结果进行回顾性分析。结果:6年中芜湖市孕产妇死亡27例,前3位死因分别为产科出血、羊水栓塞和心脏病。评审结果为可以避免死亡18例,占66.67%;创造条件可以避免死亡4例,占14.81%;不可避免死亡5例,占18.52%。结论:孕产妇死亡是由医学和社会诸多因素相互影响的结果。政府重视,全社会多方面、多部门共同努力才能降低孕产妇死亡率。 OBJECTIVE: To assess the main causes of death through maternal death review and propose interventions to reduce maternal mortality. Methods: A retrospective analysis was made on the maternal death cases, investigation reports and review results from 2003 to 2008 in Wuhu city. Results: In the past 6 years, 27 maternal deaths occurred in Wuhu City. The first three causes of death were obstetric bleeding, amniotic fluid embolism and heart disease. The results of the assessment were as follows: 18 cases were avoidable, accounting for 66.67%; 4 cases were avoidable under the conditions of creation, accounting for 14.81%; 5 cases were inevitable death, accounting for 18.52%. Conclusion: Maternal death is a result of the interplay between medical and social factors. The government attaches importance to various aspects of society and departments to work together to reduce maternal mortality.