Maternal mortality trends, causes and delays in care in the Upper West Region of Ghana, 2021–2025: a retrospective observational study

Background Contemporary regional evidence on maternal mortality trends, causes and care-related delays in northern Ghana remains limited. This study examined maternal mortality trends, causes of death, the Three Delays, and clinical, obstetric and health-system contributory factors in Ghana’s Upper West Region from 2021 to 2025. Methods We conducted a retrospective observational study using routinely collected maternal death surveillance and audit records from health facilities in the Upper West Region. All 110 recorded maternal deaths were included in the mortality-trend analysis; 94 cases with sufficiently complete audit information were included in detailed analyses. Causes of death were classified using the WHO International Classification of Diseases–Maternal Mortality (ICD-MM) framework, and delays were assessed using the Three Delays Model. Classifications were derived from audit information and case narratives and finalised through multidisciplinary review and consensus. Annual institutional maternal mortality ratios (MMRs), causes of death, delays, referral characteristics and contributory factors were summarized descriptively, with cross-tabulations used to examine delays across ICD-MM cause groups. Results Overall, 110 maternal deaths occurred among 138,031 live births, corresponding to an institutional MMR of 80 per 100,000 live births. The MMR declined from 100 per 100,000 in 2021 to 59 in 2022, before progressively increasing to 93 in 2025. Among the 94 cases with detailed information, 61.7% were direct maternal deaths. Non-obstetric complications were the largest ICD-MM cause group (38.3%), followed by obstetric haemorrhage (27.7%) and other obstetric complications (25.5%); pulmonary embolism was the most frequently recorded specific diagnosis (21.3%). At least one delay occurred in 81.9% of cases, with Delay 3 most frequent (64.9%), followed by Delay 1 (43.6%) and Delay 2 (18.1%). Prominent contributory factors included delayed intervention (43.6%), inadequate equipment or consumables (38.3%), anaemia in pregnancy (35.1%), and inadequate clinical knowledge or skills (29.8%). Conclusions Maternal deaths in the Upper West Region involved substantial obstetric and non-obstetric morbidity and frequent delays across the care pathway, particularly after women reached health facilities. Strengthening emergency obstetric and medical readiness, timely clinical intervention, referral coordination and management of high-risk pregnancies should be priorities for maternal health quality improvement.