The perinatal mortality rate (PMR) at the Hopital Evangelique in the Borgon region of Benin was 224/1000 in 1984 compared to 164/1000 in 1994. Despite the decrease, the rate was still high. Perinatal deaths for 1994 were reviewed retrospectively from case notes and data routinely recorded (presentation, distance traveled, and prenatal care). The probable causes of death were determined. A total of 511 babies were delivered by 484 women in 1994 at the hospital. There were 62 stillbirths (26 cases of birth asphyxia, 14 cases of antepartum hemorrhage, 7 cases of ruptured uterus, and 6 cases of intrauterine death before labor) and 22 neonatal deaths (7 cases of birth asphyxia and 11 cases of prematurity). Maternal errors accounted for 14 stillbirths and 4 neonatal deaths; logistical difficulties accounted for 8 stillbirths and 4 neonatal deaths; and the errors of management/referring maternity accounted for 4 stillbirths and 1 neonatal death. Some examples of maternal errors included a patient (gravida 6, para 5) who had not received prenatal care and presented with antepartum hemorrhage after being in labor for 72 hours. She had a ruptured uterus and required hysterectomy. Another patient (gravida 6, para 5) who had not received prenatal care presented to a maternity unit in labor with a shoulder presentation. On arrival, and after referral, intrauterine death was diagnosed and the fetus was delivered. Examples of logistical problems included a primigravida referred from a maternity unit more than 50 km away for delay in the second stage of labor. She delivered normally after arrival; however, the baby was asphyxiated and died. A patient who was gravida 2, para 1 was referred from a maternity unit with a cord prolapse. The fetal heart beat was present on leaving the maternity unit but was absent on arrival at the hospital. Bad management cases related to prolonged labor or attempts at a traumatic vaginal delivery. Maternal errors were the main source of deaths; thus, prenatal and intrapartum care should be more accessible to reduce the PMR.