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Maternal mortality remains a critical public health issue in South Africa, with systemic challenges persistently hindering the provision of quality obstetric care. Understanding the specific barriers within the healthcare system is essential for developing effective interventions. This study aimed to identify and analyse the systemic challenges affecting maternal healthcare delivery within the South African public health sector, focusing on structural, resource, and operational barriers. A qualitative, instrumental case study design was employed. Data were collected via in-depth, semi-structured interviews with 24 healthcare professionals and through analysis of key policy documents and facility reports from a purposively selected tertiary hospital and its referral network. The analysis revealed three primary, interlinked systemic challenges: critical staff shortages, inconsistent supply chain management for essential medicines, and fragmented referral pathways. A prominent theme was the strain on human resources, with a reported midwife-to-patient ratio frequently exceeding 1:15 on the labour ward, directly impacting care quality. Systemic failures in human resources, logistics, and coordination continue to undermine maternal healthcare delivery in the studied context. These challenges are entrenched and require multifaceted, systemic solutions. Prioritise the development of a national human resources for health plan with specific retention strategies for midwives. Strengthen pharmaceutical supply chains through improved forecasting and distribution. Formalise and monitor integrated referral protocols between primary and tertiary care facilities. Maternal health, healthcare systems, case study, South Africa, midwifery, health services accessibility This research provides an in-depth analysis of the interconnected systemic barriers in a South African maternal healthcare context, offering evidence for policymakers to design integrated improvements.