This study examines the leading causes of maternal mortality in Ghana, classifies the main causes of maternal deaths and suggests how maternal care can be improved. Design. Retrospective review. Setting. Komfo Anokye Teaching Hospital, Ghana. Sample. Three hundred and twenty-two maternal deaths with 30 269 live births in the period 1 January 2008 to 30 June 2010. Methods. Data on maternal mortality and morbidity were retrieved from the Biostatistics Unit of the hospital. Main Outcome Measures. Maternal mortality ratio (MMR), case fatality rate, leading causes of maternal deaths, duration of admission and staff/patient ratio. Results. The MMR was calculated to be 1 004 per 100 000 live births (95% confidence interval 895.0–1113.2). Of these, 71.1% were direct deaths, 22.4% were indirect deaths and 6.5% were unclassified. Hypertensive states of pregnancy were the leading cause of mortality (26.4%) and, together with hemorrhage, genital tract sepsis and early pregnancy deaths, accounted for 62.2% of all-cause maternal deaths and 87.3% of direct deaths. Infection and sickle cell disease accounted for 13.7% of all-cause maternal deaths and 61.1% of indirect deaths. Conclusions. Hypertensive states of pregnancy were the current leading cause of maternal mortality. Adopting a multi-pronged approach through reducing delays in access to emergency obstetric care, promoting contraceptive use, encouraging early, regular antenatal attendance and shared antenatal care with the medical team is essential to tackle the situation.