Background: Near misses are defined as pregnant women with severe-life threatening conditions who nearly die but, with good care or good luck survive. Because near miss situation occurs more frequently than maternal death, more comprehensive and statistically reliable analysis could be conducted to assess the quality of maternal care and to develop evidence-based management protocols. The objectives of this study were to evaluate the determinants of near miss maternal mortality in a tertiary referral Government medical college hospital in Trivandrum, Kerala.Methods: Case control study from a defined delivery population with three randomly selected pregnant women as controls for every case. Study was conducted at Department of Obstetrics and Gynecology, Medical College Hospital Trivandrum, Kerala, India. Study duration was one year. Study population were patients admitted in Obstetrics and Gynecology Department, fulfilling the WHO criteria of near miss.Results: Of the primary determinant factors of near miss in this study, preeclampsia contributed the main role, followed by hemorrhage and eclampsia. During the antenatal period, preeclampsia was the major determinant followed by eclampsia. Hemorrhage was the major determinant in intra op /intra natal cases and next was eclampsia. Postpartum hemorrhage, eclampsia and preeclampsia were the major determinants in post-partum /post op cases. Among the associated indicators assessed, low socioeconomic status, anaemia, high body mass index, referral status, placenta praevia and caesarean section were statistically significant.Conclusions: Detailed analysis of near miss cases helps in identifying risk factors. It helps in formulating preventive strategies, and helps us in tackling the delays in referral process.