A total of 29 babies died every single day in South African public hospitals in 2024 before they were one-month-old, according to figures from the latest District Health Barometer, meaning that altogether, 10 560 newborns died that year, write Linda Pretorius and Karen Harkema for the Bhekisisa Centre for Health Journalism.
The statistic is one of 11 others being tracked as a measure of how well the public health system is doing when it comes to caring for pregnant women and young children, and with the number of women dying during pregnancy or birth.
And although the rate of newborns dying in government hospitals is at 13 per 1 000 births – which is close to the United Nations sustainable development target of not having more than 12 deaths per 1 000 births by 2030 – the broader picture is not promising.
That’s because the maternal mortality in-facility rate, which is the number of mothers per 100 000 births who died at a health centre because of complications during pregnancy or delivery, stood at just more than 105 per 100 000 births in 2024 (in absolute numbers the count is 902 women).
The rate is 1.5x higher than the United Nations 2030 target of no more than 70 deaths per 100 000 births – and it’s been hovering around this level since 2016 (apart for some ups and downs between 2019 and 2021).
Compare this with rates in some South American countries like Brazil (67), Colombia (59) and Peru (51) in 2023, who’ve all been at or below the 70 mark for at least a decade.
Even some southern African countries such as Zambia (85) and Mozambique (99) come in lower than South Africa, despite having at least seven times less to spend on healthcare.
Experts say the numbers are a sign of serious cracks along the system that’s meant to keep mothers and their babies safe.
Tracking health service delivery at the district level over many years – as the District Health Barometer has been doing for the past two decades – is therefore a valuable tool in decision-makers’ kit, especially as close to half of a province’s health budget goes to the district health system.
But with the purse strings tightening specifically for primary healthcare, which includes services like pregnancy check-ups, helping women deliver healthy babies and keeping newborns safe, knowing where the system is not working well can help to direct spending choices so that everyone can get fair care.
We dug into the latest District Health Barometer to see what the data show about maternal and newborn deaths. Here are our questions, and what the numbers say the answers are.
Will the public health system keep mothers and babies safe?
It depends on where you live, the data show. Nationally, 13 out of every 1 000 newborns under a month old died in public health facilities in 2024. But although it’s close to the sustainable development target of 12 or fewer, the performance is uneven: only every second district managed to hit the mark.
And there’s more to consider.
Only 29%, or 15 out of 52 districts, have a maternal mortality rate below the sustainable development target of 70 per 100 000 live births, and only about half even come in under the national rate of 105.4 per 100 000, our counts show.
For instance, if you live in Zululand (28.1) in KwaZulu-Natal or the Cape Winelands (33.9) in the Western Cape, your chances of dying during pregnancy or giving birth are much lower than that of someone giving birth in the Capricorn district (182.3) in Limpopo, Lejweleputswa (216.5) in the Free State or OR Tambo (205.4) in the Eastern Cape.
Getting maternal deaths down to under 70 per 100 000 live births is a big goal but not an impossible one, says Peter Barron, who helped start the District Health Barometer 20 years ago and now chairs the Health Systems Trust, which publishes the Barometer.
Barron said the number of maternal deaths recorded in a country is almost like a report card on how well its health system is working. Some things have a direct impact on whether a mother survives, he says – like health workers’ skill during a complicated birth or their access to working equipment or supplies.
But there are also other things that feed into the process of ensuring that a woman has a healthy pregnancy and delivery, like whether she has enough nutritious food to eat and her level of education before she becomes pregnant and after the delivery.
Understanding where the gaps are and fixing them “is like peeling back the layers of an onion”, he says.
What does the past predict about the future?
Over the past nine years, South Africa’s maternal mortality has been hovering in a fairly narrow band around 100 and 110 per 100 000 births, barring the low of just under 90 in 2019 and the highs at around 120 the next two years.
So, despite a big drop in the number of mothers dying because of a complicated pregnancy or delivery after 2014, our calculations suggest that, nationally, South Africa will still be about 20% off target by 2030 if things keep going as they are.
Newborn deaths show a worrying trend, too.
Rates have idled between 12 and 13 per 1 000 live births since 2010, going up or down by a few tenths every year. The lowest value – 11.4 – was in 2013, with the highest – 13.4 – a decade later.
A change of a few tenths year on year, in other words, less than one unit count, could seem negligible if we think of the numbers just in terms of maths. But when the scale is taken into account, the significance of a decimal change becomes clear: these are not just numbers, they’re lives.
Newborn deaths are reported per 1 000 live births. This means that for every 1m babies born, a 0.1 change in the mortality rate translates to 100 babies either dying or surviving.
Close to 813 000 babies were born in South Africa’s public health facilities in 2024. If the same number of births were to be recorded in 2030, a jump of 0.4 units in the neonatal mortality rate – from 13.0 as measured in 2024 to 13.4 predicted by the trend line on our graph – would translate to 325 more newborns dying.
Where are the hotspots and the top spots?
When looking at maternal mortality rates, we saw that three Eastern Cape municipalities – the Nelson Mandela Bay metro, Buffalo City metro and OR Tambo district – were among the 15 worst-performing areas when considering the average over six years, and also when looking just at the 2024 snapshot.
What also stood out for us was that five of the 15 worst-performing areas in 2024 were metro municipalities. But Barron said this is not necessarily a reflection of the quality of care in these spots.
Rather, he says, because these municipalities have “the big tertiary and academic hospitals, all the complicated cases get referred to them, and if a woman or baby dies while in their care, the death will be counted in that municipality, not the home address of the patient”.
Barron also cautions that it’s important to keep the population size of a district, the denominator of the indicator – whether it’s reported per 100 000 or per 1 000 – and the local conditions in an area in mind when judging the numbers.
For example, a district with a very small population is unlikely to see many births in a year, and if a statistic is measured out of 100 000, it’s possible that a low mortality rate could be the result simply of small numbers, rather than great quality of care.
Yet the distribution of mapped data points shows that the care people receive depends on where they live, and that’s worth investigating if South Africa wants to find solutions to keep mothers and their babies safe.
Barron said that to improve impact, we need to get both coverage and quality of care right. If either is not up to scratch, impact will be compromised. “On the coverage level we’re not doing badly, but on the quality side we’re not doing well.”
How can it be fixed, though?
Barron said leadership is the most important factor.
“A clinician can only be as good as the ecosystem allows. If there are no drugs, no supplies, no nurses to support, it doesn’t matter if you’re a brilliant doctor; you won’t achieve success. It’s a team sport.”
See more from MedicalBrief archives:
Respectful maternity care can save South African lives – Lancet
Africa’s deadly legacy – one stillbirth every 30 seconds
Bara stillbirth rate 17 times the national average – Wits study