OBJECTIVE: To examine the quality of the maternal health system in Eritrea to understand system deficiencies and its relevance to maternal mortality within the context of Millennium Development Goal (MDG) 5. METHODS: A sample of 118 health facilities was surveyed. Data were collected on 5 dimensions of health system quality: availability
accessibility
management
infrastructure
and process indicators. Data on the causes of hospital admissions for obstetric patients and maternal deaths were extracted from medical records. RESULTS: Eritrea has only 11 comprehensive emergency obstetric care (CEmOC) facilities, all of which are grossly understaffed. There is considerable pressure on the infrastructure and health providers at hospitals. Compliance with clinical care standards and availability of supplies were optimal. As a result, the case fatality rate of 0.65% was low. In total, 45.6% of obstetric admissions and 19.5% of maternal deaths were attributed to abortion complications. CONCLUSION: In Eritrea, critical gaps in the health system-especially those related to human resources-will impede progress toward MDG 5, and it will not be possible to reduce maternal mortality without addressing the high burden of abortion.