Conference Abstract | Volume 9 (ConfPro8): Abstract 21 | Published: 05 Oct 2026
Gideon Bandor1, &, George Akowuah2, Setina Martey1, Courage Anku1, Magdalene Akos Odikro2, Samuel Sackey2
1Ejura Sekyedumase Municipal Health Directorate, Ejura, Ghana; 2Ghana Field Epidemiology and Laboratory Training Programme, Accra, Ghana
&Corresponding author: Gideon Bandor, Municipal Health Directorate, Ejura, Email: bandorgideon00@gmail.com
Received: 11 Mar 2026, Accepted: 28 Aug 2026, Published: 05 Oct 2026
Domain: Maternal and Child Health
Keywords: Maternal mortality, root cause analysis, critical cause, fishbone diagram, audit recommendations
©Gideon Bandor et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Gideon Bandor et al., Beyond the zero: A root causes analysis of rising maternal mortality in Ejura Sekyedumase Municipal, Ghana, 2023 to 2025. Journal of Interventional Epidemiology and Public Health. 2026;9(ConfPro8):21.https://doi.org/10.37432/JIEPH-CONFPRO8-0021
Despite achieving zero institutional maternal deaths in 2021 and 2022, the Ejura Sekyedumase Municipal experienced a resurgence of maternal mortality, with ratios rising to 94.74, 26.08, and 43.46 per 100,000 live births in 2023, 2024, and 2025, respectively. This trend threatened the municipality’s progress toward national and global maternal health targets. A root cause analysis was conducted to identify contributing factors and the critical underlying cause of this resurgence.
A qualitative operational research design using the Ishikawa (fishbone) root cause analysis framework was employed. A multidisciplinary team of health workers, including midwives, public health nurses, disease control officers, health information officers, laboratory technicians, and the municipal health director, participated in a structured brainstorming session. Contributing factors were categorized into thematic areas. Each factor was classified using the Total, Partial, and Not under control (TPN) framework to determine the level of local administrative control. Results were presented using a fishbone diagram.
A total of 18 health workers participated in the process. Thirty-seven contributing factors were identified across four categories: client and family factors (12), staff factors (10), management factors (10), and environmental factors (5). Using the TPN framework, 11 (29.7%) factors were classified as totally under administrative control, 18 (48.6%) as partially under administrative control, and 8 (21.6%) as beyond administrative control. The critical cause identified was poor implementation of maternal death audit recommendations, a total control factor with the highest leverage across the maternal care pathway.
Maternal mortality in Municipal is driven by a combination of health system and community-level factors. Poor implementation of maternal death audit recommendations emerged as the critical cause, influencing clinical management, emergency preparedness, supervision, and logistics. Strengthening audit enforcement through supervisory monitoring, routine performance reviews, and continuous professional development.
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