Clinical overview
Maternity care in South Africa is delivered within a national, public-sector framework best understood not as a list of facts but as a working system — who is seen where, by whom, with what package of care, and when a woman must be moved up the chain. The single most important document is the National Integrated Maternal and Perinatal Care Guidelines for South Africa (NDoH, 2024) (the "Maternity Guideline"), released on the NDoH Knowledge Hub on 23 October 2024, which supersedes all earlier editions of the Guidelines for Maternity Care. This is the SA source of truth: where it diverges from an international guideline, the SA guideline governs SA practice.
Working with this objective means more than reciting the guideline: it means applying the right pathway to a clinical scenario, justifying a referral, recognising where SA practice deliberately diverges from NICE or RCOG, and understanding why the system is shaped the way it is. That shape is driven by epidemiology. South Africa's maternal mortality is dominated by a small number of causes catalogued in the triennial Saving Mothers (NCCEMD) reports — non-pregnancy-related infections (chiefly HIV/AIDS and TB), obstetric haemorrhage, and hypertensive disorders of pregnancy — many of them avoidable. The guideline is, in large part, an engineering response to those audited deaths. It is the framework onto which every other obstetric chapter hangs: Antenatal booking, HIV in pregnancy, Hypertension in pregnancy, Postpartum haemorrhage and Normal labour all live inside this system.
Core knowledge
The structure of the system: levels of care
South African maternity care is tiered. Knowing which level does what is the backbone of safe referral.
- Community / primary level — clinics and community health centres (CHCs), midwife-led, providing antenatal care for low-risk women and basic antenatal care, and Midwife Obstetric Units (MOUs) for low-risk delivery. No on-site doctor or theatre.
- District hospital — generalist doctors, basic emergency obstetric and neonatal care (BEmONC), caesarean section capability, basic resuscitation. The workhorse for most deliveries.
- Regional hospital — specialist obstetricians and paediatricians, comprehensive emergency obstetric and neonatal care (CEmONC), higher-care/HDU, blood bank.
- Tertiary hospital — subspecialist services, maternal-fetal medicine, neonatal ICU, the destination for the sickest mothers and fetuses.
The guideline ties this to a risk-stratified antenatal pathway: low-risk women are managed at primary level on a basic antenatal care schedule; risk factors detected at booking or during pregnancy trigger referral up a level. Detail of who is high-risk sits in High-risk pregnancy factors; detail of the booking visit in Antenatal booking.
Figure I1.1 — SA maternity-care levels and referral triggers: low-risk care starts at primary/MOU level, with escalation to district, regional or tertiary care when risk or capability needs change.
Antenatal care: the SA schedule and package
The SA guideline follows a Basic Antenatal Care Plus (BANC Plus) approach, structured around an increased number of contacts compared with the older goal-oriented BANC model, broadly aligning with the WHO 2016 recommendation of a minimum of eight antenatal contacts. (Standard SA teaching — confirm the exact contact schedule against the 2024 NDoH guideline; flagged in notes.)
Booking should be as early as possible, ideally in the first trimester. The booking package, classically, includes:
- History and risk assessment, calculation of gestational age (see Gestational age assessment).
- Routine bloods: blood group and Rh (see Rh isoimmunisation), haemoglobin/full blood count, syphilis serology (RPR), and HIV testing.
- HIV — universal opt-out HIV testing at booking, with repeat testing through pregnancy and the breastfeeding period; HIV-positive women started on lifelong ART, first-line TLD (tenofovir + lamivudine + dolutegravir) per the National Consolidated Guidelines (NDoH, published January 2026). This is the cornerstone of the Prevention of Vertical Transmission (PVT) programme (formerly "PMTCT") and is expanded in HIV in pregnancy.
- Screening for proteinuria and blood pressure at every visit (hypertension surveillance), and gestational diabetes screening per the guideline's risk-based approach.