Background: Reduction of maternal mortality remains a challenge for developing countries like India as per the sustainable development goals put forward by UN. Near-miss audit is emerging as a new tool for setting new protocols in reduction of MMR. This study aimed, to analyze the near miss events and mortality events which occurred in the study setting from January 2011 to December 2012, and to compare the causes that led to the events.Methods: A descriptive comparative study was conducted at SAT Hospital, Government Medical College, Thiruvananthapuram, a tertiary care center in Kerala, India on the data accounted for a period of 2 years, 2011 and 2012. Maternal near-miss during the period is studied according to WHO 2009 criteria and compared with the maternal deaths during the same time period. The data was recorded using structured proforma; the same proforma was used to record maternal mortality cases of the same period.Results: Total live births during the time period were 18,663. Eighty-eight near miss cases and 26 maternal deaths occurred during the study period. Incidence proportion of maternal near-miss was 4.71/1000 live births. Severe maternal outcome was 6 per1000. For every maternal death, there were 3.38 near-misses. Mortality index of our institute was 22.8% and maternal mortality ratio (MMR) of the study setting was 139/1 Lakh live births. Post-partum hemorrhage was the leading cause for near-miss and systemic diseases were the major contributors to mortality.Conclusions: It is evident from the present study that PPH, once the leading cause of maternal mortality is now the leading cause of maternal near miss and by improving the resources of FRUs it can be further reduced. Systemic diseases are emerging as a new threat to the obstetric population leading to mortality.