BACKGROUND:Assessment of severe maternal morbidity is increasingly being undertaken to understand the aetiology and factors which lead to adverse maternal outcomes. Their use in conjunction with maternal deaths may allow a comprehensive assessment of care provided, highlight areas for improvement within the health system and allow benchmarking of care against other institutions. Timor-Leste has one of the highest rates of maternal mortality in the Asia-Pacific region; however, there has been limited research into the level of severe obstetric morbidity in the country. AIM:To determine the aetiology and rates of severe obstetric morbidity and mortality at Hospital Nacional Guido Valadares, Timor-Leste. METHODS AND MATERIALS:Cases of maternal 'near misses' and deaths were prospectively identified over a period of 12 months using the World Health Organization maternal near-miss criteria. Cases of maternal death and near miss were combined (severe maternal outcomes) for descriptive analysis. RESULTS:During the audit period, 69 severe maternal outcomes were identified: 30 maternal deaths and 39 'near misses'. The maternal mortality ratio and the maternal near-miss ratio were 662/100 000 live births and 8/1000 live births, respectively. The main identified obstetric aetiologies were haemorrhage and pre-eclampsia, while 22% of severe maternal outcomes did not have a clearly identified cause. CONCLUSION:The high institutional maternal mortality ratio requires urgent attention and identification of areas for improvement. Auditing and benchmarking using the WHO near-miss criteria provide a mechanism for standardised comparison of obstetric care but require further refinement to the local context.