Abstract :We performed an institutional review of maternal mortality to identify risk factors, improve obstetric safety, and develop a template for institutional maternal death review citywide. There were fourteen cases of maternal mortality between 2008 and 2015. Autopsy reports and electronic medical records were reviewed. Causes of death varied widely, but three main themes arose in our cohort: pulmonary embolus following stillbirth, hemolysis elevated liver enzyme low platelet syndrome with eclampsia, and complications of human immunodeficiency virus. Barriers to institutional review included lack of standardized method of tracking medical records and differences in city, state, and institutional reporting of maternal death. Despite these barriers, with a standardized approach to maternal death review, we were able to identify a potential association between stillbirth, maternal death, and pulmonary embolism. Large, national epidemiological studies are urgently needed, as physicians have an opportunity to intervene with thrombosis prophylaxis after stillbirth if such prevention is indicated.