IntroductionDespite global efforts to reduce maternal mortality, progress has stalled, particularly in sub-Saharan Africa, where the maternal mortality ratio remains high. This study aims to assess in-facility maternal mortality, maternal and foetal complications, and stillbirths in referral hospitals at different levels of the health system in Guinea.MethodsThis was a cross-sectional study conducted at three urban referral hospitals in Guinea at the district (Hôpital de district de Forécariah or HD), regional (Hôpital Régional de Mamou or HR) and national (Hôpital National Ignace Deen or HN) levels from May 2021 to April 2023. Key indicators assessed included in-facility maternal mortality ratio (IMMR), maternal and foetal complication rates and stillbirth rates.ResultsA total of 25 235 women were admitted to the three hospitals over the 24-month period for maternal indications. The highest IMMR was recorded at HN (1264 per 100 000 live births), followed by HD (376) and HR (245). Postpartum haemorrhage was the leading cause of maternal death, accounting for 37% of cases at HR and 58% at HN. At HN, the other frequent causes included anaemia, postpartum sepsis and pre-eclampsia/eclampsia, whereas at HR, obstructed labour, anaemia and pre-eclampsia/eclampsia were frequently reported. Maternal and foetal complications were observed in 23% of deliveries at HD, 24% at HR and 40% at HN. Caesarean section rates were 35% at HD, 29% at HR and 54% at HN. Stillbirth rates ranged from 77 to 103 per 1 000 across the hospitals, with fresh stillbirths accounting for 40-50% of cases.ConclusionsThis study highlights the pressing need to strengthen emergency obstetric care and referral systems at district, regional and national hospitals. Investing in healthcare workers' capacity, ensuring timely transport for referrals and enhancing data quality systems for evidence-based decision-making are essential steps to reduce maternal and perinatal mortality and to achieve the sustainable development goals.