Background: To determine the prevalence and factors associated with severe ('near miss') maternal morbidity and mortality in the University Teaching Hospital of Kigali - Rwanda. Methods: We performed a cross sectional study of all women admitted to the tertiary care University Hospital in Kigali with severe "near miss" maternal morbidity and mortality during a one year period using the WHO criteria for 'near miss' maternal mortality. We assessed maternal demographic characteristics and disease processes associated with severe obstetric morbidity and mortality. Results: The prevalence of severe maternal outcomes was 11 per 1000 live births. The maternal near miss ratio was 8 per 1000 live births. The majority of severe obstetric morbidity and mortalities resulted from: sepsis/peritonitis (30.2 %)--primarily following caesarean deliveries, hypertensive disease (28.6 %), and hemorrhage (19.3 %). Majority of our patients were found to be of lower socioeconomic status, refered from district hospitals to the tertiary care center, and resided in the eastern part of the country. Conclusion: The main causes associated with MNH were peritonitis, hypertensive disorders and bleeding. The high prevalence of peritonitis may reflect suboptimal intraoperative and intrapartum management of high-risk patients at district hospitals. Direct causes of severe maternal outcome are still the most prevalent. The study identified opportunities for improvement in clinical care to reduce potentially these adverse outcomes.