Purpose
– The purpose of this paper is to identify organisational, technical and individual factors leading to maternal deaths in non-citizen women in Botswana.

Design/methodology/approach
– A sub-analysis was conducted comparing non-citizen women to citizens in a case record review of maternal deaths in 2010. Feedback on the results to health professionals was provided and their comments were noted.

Findings
– In total, 19.6 per cent of 56 case notes reviewed to establish contributory factors to maternal deaths were in non-citizens. This is lower than health professionals perceptions that most maternal deaths are in non-citizens. Non-citizens were significantly less likely to have been tested for HIV and less likely to have received antenatal care, so did not receive interventions to prevent transmission of HIV to their infants or anti-retroviral therapy. They were more likely than citizens to have miscarried or delivered before 28 weeks gestational age at death. Delays in seeking health care were a major contributory factor to death.

Research limitations/implications
– Incomplete record keeping and missing details, with 30 per cent of the notes of maternal deaths missing, a common problem with retrospective case-note studies.

Practical implications
– Botswana is unlikely to meet Millennium Development Goal five target to reduce the maternal mortality ratio by 75 per cent. To make progress non-citizens must be given the same rights to access maternal health services as citizens. Rationing healthcare for non-citizens is a false economy since treatment of subsequent obstetric emergencies in this group is expensive.

Originality/value
– Discrimination against non-citizen women in Botswana, by denying them free access to maternal health services, extends into loss of life because of delays in seeking healthcare especially for obstetric emergencies.