Background: A better understanding of the context specific epidemiology, outcomes and risk factors for death of critically ill parturients in resource-poor hospitals is needed in order to tackle the still alarming in-hospital maternal mortality in African countries.Methods: One–year retrospective cohort in a referral maternity hospital in Freetown, Sierra Leone. Primary data source was the patient chart. The primary endpoint was the association between risk factors and HDU mortality. The study was registered on ClinicalTrials.gov (study identifier NCT04121234).Results: 523 patients (median age 25 years, IQR 21-30) were admitted to the HDU for a median of 2 (IQR 1-3) days. 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week. 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were: ward rather than post–operative referrals (odds ratio (OR), 3.21 [95%-confidence interval (CI) 1.48 to 7.01]; P = 0.003), admissions with a red vs. yellow/green OEWS (OR, 3.66 [95%-CI 1.15 to 16.96]; P = 0.04), responsiveness to pain or unresponsiveness on the AVPU scale (OR, 5.25 [95%-CI 2.64 to 10.94]; P =<0.0001), use of vasopressors (OR, 3.24 [95%-CI 1.32 to 7.66]; P =0.008). Higher SpO 2 was associated with improved survival (OR, 0.95 [95%-CI 0.91 to 0.98]; P =0.007).Conclusions: Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Mortality is high and mostly occurs during first day. Medical admission, a red OEWS code, a poor neurological and hemodynamic status were independently associated with mortality, while adequate oxygenation was associated with survival.Trial Registration: The study was registered on ClinicalTrials.gov (study identifier NCT04121234).Plain English summarySierra Leone is one of the countries with the highest maternal mortality rate of the world. Understanding of critical care issues and potential interventions is lagging behind approaches in the primary care and obstetric domain. This study, reporting data from 525 patients admitted to an obstetric HDU, to date represents the largest cohort of critically–ill parturients from a low–income country. At multivariable analysis, being referred from the ward rather than being post–operative (OR 3.21, 95% CI 1.48 to 7.01), red OEWS code (OR 3.66, 95% CI 1.15 to 16.96), being responsive to pain or unresponsive on AVPU scale (OR 5.25, 95% CI 2.64 to 16.96) at admission, use of vasopressors at admission (OR 3.24, 95% CI 1.32 to 7.66) were independent risk factors for mortality, while higher SpO2 (OR 0.95, 95% CI 0.91 to 0.99) was associated with increased survival.The findings of this study can be summarized as follows (1) in a low–resource referral maternity hospital one out of 14 deliveries needed critical care attention, with a crude mortality rate of 10.5%; (2) independent predictors of mortality were poor neurological status, a red OEWS code at admission to HDU and the use of vasopressors during the stay; (3) higher oxygenation was associated with survival. Clinicians and policy makers may use these findings to prioritize simple critical care interventions to address maternal mortality in a high burden scenario.