The care-seeking behavior of mothers of 125 children who died at age 1-30 months in the Bandim 1 and Bandim 2 suburbs of Bissau was investigated by verbal autopsy. 93% of the children were seen at a health center or hospital during the 2 weeks before death. Comparison of the elapsed time from disease onset to first consultation between children who died and matched surviving controls found that the interval was shorter for children who died than for those who survived. 56 of the 125 terminally ill children were hospitalized, while 20 children died on the way to the hospital or while waiting in the outpatient clinic. A lack of hospital beds resulted in 15 mothers being refused hospitalization for their child. 42% of hospitalized children were discharged as improved or recovered during the 30 days preceding death. These findings point to the need to improve hospital admission criteria, the recognition of the symptoms of serious illness, and discharge criteria, as well as the implementation of quality assurance systems for health services.