This paper describes the maternity monitoring system in Botswana, developed in 1998, and the main methods used: maternal death and morbidity reviews at service delivery level, analysis by the National Maternal Mortality Audit Committee of data from the reviews as reported on two forms, perinatal reviews and surveys using process indicators. We carried out a study of these findings to examine whether the system was working well. Surveys using process indicators in 2001 and 2006 were analysed. Other data examined were from 2004–2006 and early 2007. The Maternal Death Notification Form was found to be comprehensive but not all health facilities were submitting them and some gave incomplete information. In 2001, 70% of pregnant women attended antenatal care but access to emergency obstetric care was uneven. In 2006, 28 facilities with maternity services surveyed were providing 24-hour delivery care, but laboratory, theatre and blood supplies were more limited, and only 50% of doctors and 67% of midwives had life-saving skills. Antibiotics were widely available, but there were shortages of magnesium sulphate, diazepam, oxytocics and manual vacuum aspiration kits. Recommendations for improvements have been made, training for skilled attendants is ongoing and a medical school has just opened at the University of Botswana.