Due to advances in diagnostic techniques, it has become possible to identify and manage ectopic pregnancies before they cause clinical symptoms in many developed countries. However, the situation appears not to be the same in developing countries. We carried out a cross-sectional study at Umtata General Hospital, which serves an underprivileged black South African population in order to document the incidence, risk factors, clinical presentation and complications of ectopic pregnancy. We found the incidence of ectopic pregnancy was 11 per 1000 reported pregnancies, and the mortality rate was 2.0%. Of 148 consecutive cases of ectopic pregnancy, 62.2% were in shock and two thirds were severely anaemic on arrival. About 71% of the cases had tubal rupture and 25% were chronic leaking ectopics. Only four intact unruptured ectopics were found in spite of the availability of modern diagnostic techniques such as ultrasonography and sensitive pregnancy tests. About 86% of the cases had evidence of previous pelvic infection, thus making pelvic inflammatory disease (PID) the most important risk factor for ectopic pregnancy. We conclude that most ectopic pregnancies in Transkei are associated with previous pelvic infection, and still present as acute emergencies. Preventive measures should aim at controlling sexually transmitted diseases and PID.