A setback for Sustainable Development Goal 3.1: Documenting the coronavirus disease 2019 pandemic's impact on maternal mortality through a National Confidential Enquiry in South Africa

Background: Maternal mortality highlights health system effectiveness and social fairness. South Africa's Confidential Enquiry into Maternal Deaths (CEMD) monitors and improves maternal healthcare. While initial decreases in maternal mortality were positive, the COVID-19 pandemic and ongoing provincial inequalities jeopardise reaching the Sustainable Development Goal (SDG) target. Aim: This analysis evaluated South Africa's maternal mortality reduction path by examining CEMD data trends, the pandemic's effect and provincial disparities to gauge progress towards its SDG commitments. Methods: A longitudinal trend analysis was conducted using secondary data from CEMD reports (2017-2022). The analysis focused on national and provincial institutional Maternal Mortality Ratio (iMMR) trends. Comparative analysis quantified changes and identified patterns of disparity. Results: Pre-pandemic improvement was abruptly reversed by a significant 42 surge in the national iMMR during the pandemic, underscoring the fragility of previous gains. Although a decrease was observed in 2022, the rate remained above the 2019 baseline, indicating an incomplete recovery. Furthermore, profound inter-provincial disparities were evident, with only two provinces sustaining a downward trend, the majority showing no clear improvement and three provinces consistently exhibiting exceptionally high and volatile iMMRs. Lessons learnt: South Africa is not yet on track to meet its SDG target for maternal mortality. The pandemic exposed and exacerbated systemic weaknesses, while deep-rooted provincial inequities persist. Achieving sustainable progress requires a dual strategy: building a more resilient health system capable of withstanding future shocks and implementing targeted, equity-focused interventions in underperforming regions to ensure that maternal healthcare is accessible and effective for all.