Maternal mortality, defined as a death during pregnancy or within 42 days of its termination,¹ remains a critical indicator of healthcare system effectiveness and social equity. Despite global initiatives such as Millennium Development Goals (MDG),² and the subsequent Sustainable Development Goals (SDG), which aim to reduce the global maternal mortality ratio (MMR) to under 70 per 100 000 live births by 2030,³ progress has stagnated, particularly in developing nations.⁴ South Africa (SA), despite maintaining a world-class surveillance system, the National Confidential Enquiry into Maternal Deaths (NCEMD), continues to face high MMRs,⁵ exacerbated by socioeconomic inequalities.

Established in 1999 in response to alarmingly high death rates driven initially by human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS),^6,7,8 the NCEMD has offered crucial insights into the causes, trends and preventable factors associated with maternal mortality, serving as an exemplary model for other low- and middle-income nations. Its strength lies in its near-complete capture and rigorous investigation of maternal deaths in healthcare institutions (iMMR), making its data robust for national analysis. Its primary mission is quality improvement through identifying preventable factors and disseminating evidence-based recommendations. However, COVID-19 pandemic presented an unprecedented shock that threatened to reverse prior gains⁹ and to worsen existing disparities.¹⁰ This study, therefore, analyses recent NCEMD data to evaluate the pandemic’s impact and to assess South Africa’s trajectory towards its SDG commitments.

Our analysis identified three distinct phases in South Africa’s maternal mortality trends. The iMMR during the pre-pandemic period showed a clear improvement, suggesting that targeted interventions and programming, such as ESMOE and BANC, were indeed having a positive and measurable impact,^11,12 though the role of enhanced data reporting cannot be discounted. While these advancements are promising, some argue that the improvements might not be sustainable, especially given the ongoing challenges within the healthcare system.¹³

The COVID-19 pandemic significantly reversed previous progress, resulting in a 49.9% rise in the national iMMR. This setback is consistent with global trends observed in countries such as Uganda,¹⁴ Kazakhstan,¹⁵ and Kenya.¹⁶ The alarming surge, however, might be a temporary deviation attributable to the extraordinary pressure on healthcare systems during the early stages of the pandemic, rather than an indicator of a fundamental and enduring decline in maternal healthcare. In the post-pandemic period (2022), the iMMR decreased but remained above the pre-pandemic baseline of 98.8 in 2019. Similarly, a study conducted in Kenya indicated a decrease in the national iMMR to 99 per 100 000 live births during the same year.¹⁶ Our findings suggest an incomplete recovery and indicate the pandemic may have exacerbated underlying weaknesses in the healthcare system.

Finally, the analysis revealed profound and alarming provincial disparities, findings that are consistent with a previous study conducted in Kenya.^16,17 Our study indicated that two provinces demonstrated a clear downward trend or maintained lower-than-average rates. While factors such as improved quality of emergency obstetric care, better staffing, and more reliable supplies of essential medicines are potential drivers for the decline in these two provinces, the observed trend may also reflect advancements in data collection and reporting mechanisms.^13,18 In contrast, three provinces exhibited consistently high and volatile iMMRs, pointing to critical public health challenges potentially influenced by socioeconomic factors and systemic instability, while the majority showed no clear progress.

This study concludes that the COVID-19 pandemic significantly reversed South Africa’s maternal health progress and exposed critical systemic weaknesses. With an incomplete recovery and stark provincial inequalities, the country is off-track to meet its maternal mortality reduction goal (SDG 3.1). Recovery depends on a dual approach: strengthening the health system’s overall resilience and implementing targeted, equitable interventions in struggling provinces. Building a robust system requires learning from both pre-pandemic successes and the hard lessons of the pandemic.