Anaesthesia plays a critical role in maternal care. In approximately 30% of maternal death cases in South Africa, an anaesthetic is given. As the country enters a new triennium of the Confidential Enquiry into Maternal Deaths (CEMD), strengthening anaesthesia representation and reporting is essential to support national efforts to reduce maternal mortality in line with the Sustainable Development Goals. Emerging data from the National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD) highlight significant gaps in anaesthesia reporting, with incomplete provincial participation and substantial underreporting in the Database for the Retrospective Analysis of Maternal Anaesthesia (DRAMA). These deficiencies limit the accuracy of national audits and hinder the identification of avoidable factors and system failures. Challenges are compounded by a workforce largely consisting of non-specialist providers with variable levels of experience and support. This article argues for strengthened anaesthesia involvement in the CEMD through formalised provincial assessor roles, improved data alignment, and structured feedback mechanisms. Enhanced anaesthesia support is essential to improve clinical governance and reduce preventable maternal morbidity and mortality.
As South Africa begins the next triennium of the Confidential Enquiry into Maternal Deaths (CEMD), it is essential to ensure adequate representation from anaesthesia. Anaesthesia is involved in approximately 30% of maternal death cases, and strengthening this component is critical if the country wants to contribute meaningfully to the Sustainable Development Goals (SDG) of the World Health Organization (WHO) to reduce maternal mortality to fewer than 70 deaths per 100 000 live births by 2030.
Emerging data from the 2024 National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD) anaesthesia summary indicate that significant gaps persist. Only five of the nine provinces contributed data to the Database for the Retrospective Analysis of Maternal Anaesthesia (DRAMA), raising concerns about the completeness of national anaesthesia reporting and the potential for missing trends.
Since the database began in 2017, the average number of cases per year captured in the DRAMA database has been steadily declining, but as indicated by the triennial reports, this is not due to improved Maternal Mortality Ratio (MMR). Current estimates suggest we are underreporting approximately 66% of cases, approximately up to 300 cases per annum, which is deeply concerning.
The NCCEMD anaesthesia reports constitute the only national annual perioperative audit informing obstetric anaesthesia care in South Africa. Their value, however, is entirely dependent on the accuracy and completeness of the data. High-quality anaesthesia reporting can directly inform healthcare planning, guide resource allocation, and support targeted training initiatives at both provincial and national levels. With structured anaesthesia input, contributory factors related to airway management, regional anaesthesia complications, haemodynamic instability, and perioperative system failures can be reliably identified.
A standardised anaesthesia assessment process guideline was updated in 2025 and published in the National Department of Health’s Newsletter for Provincial Assessors of Confidential Enquiries into Maternal Deaths (ACE).
These challenges must be understood in the context of those who provide obstetric anaesthesia in South Africa. The majority of caesarean section anaesthetics are administered by relatively inexperienced clinicians, including community service medical officers, family physicians, foreign-trained practitioners, and intermittently practising non-specialist anaesthetists.
Training initiatives such as Essential Steps in Managing Obstetric Emergencies (ESMOE)
We therefore argue that explicit and sustained anaesthesia support within the CEMD process is essential. This should include formally designated provincial anaesthesia assessors, alignment between DRAMA reporting and NCCEMD case review, and feedback mechanisms that translate enquiry findings into targeted training, clinical support, and system-level change. Strengthening anaesthesia’s role within the confidential enquiry is not an optional enhancement; it is fundamental to reducing preventable maternal morbidity and mortality in South Africa.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Esther Cloete: Conceptualisation, Data curation, Writing – review and editing. Jonathan L. Burke: Conceptualisation, Writing – original draft, Writing – review and editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.
This article followed all ethical standards for research without direct contact with human or animal subjects.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or the publisher. The authors are responsible for the article’s results, findings, and content.