Middelburg was established as Nasareth, (root from dry land), in 1864 by the Voortrekkers on the banks of the Klein Olifants River. The name was changed in 1872 to Middelburg to mark its situation midway between the Transvaal capital Pretoria and the gold mining town of Lydenburg. A Dutch Reformed Church was built in 1890 and became a focal point in the area. The British built a large concentration camp in Middelburg during the Second Boer War. The Memorial Museum was built at the site next to the 1,381 graves of women and children died here.

Columbus Stainless, a large stainless steel plant, is situated here. For many years, the industrial activities of the steel plant and its peripheral activities such as coal and transport, provided much of the employment and largely drove the economy of the town, although other sectors such as agriculture have gradually grown to be important.

Hundreds of expatriates and their families, mostly from the United Kingdom and parts of Europe, moved in to the town in the 1950s, 60's and 70's to avoid the slump of the post WWII (and later the Thatcherian) industrial and manufacturing sectors in those countries. These families were attracted by the need for industrial expertise in the plant, and were often rewarded with company sponsored housing and discounted education. The children of those immigrant families have either moved to the larger nearby cities of Witbank, Pretoria and Johannesburg, seeking employment, or have remained to form part of the growing alternative economic activities in the area.

Crime has reportedly been on the increase in past years as a result of increasingly high levels of unemployment and poverty, especially in the previously disadvantaged African community. The town has one of the largest police forces in the region, a government (public) hospital and clinic, as well as a private hospital, and several public and private schools.

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