Mostly in the rural areas of developing countries, where women have little access to high quality reproductive health care and are more likely to have home delivery, alone or with only an untrained assistant, over half a million maternal deaths occur each year. Studies have shown that skilled birth attendance is the most promising avenue to curb maternal mortality. Maternal mortality ratios for the past three years in Bolgatanga Municipality were 822/100,000 LB in 2005, 844/100,000 LB in 2006, and 165/100,000 LB in 2007. This study aimed at assessing the determinants of skilled birth attendance in rural communities of Bolgatanga municipality, Upper East region, Ghana. The study was a descriptive cross-sectional survey in Bolgatanga municipality; it took place between July and October, 2008. A total of 263 women (aged 15 to 49 years) who had given birth not more than a year prior to the survey, were studied using a structured questionnaire and a focus group discussion guide. Even though 99.97% registered at ANC, only 48.67% delivered at the health facility. Delivery at health facility was associated with: the number of ANC visits (OR = 1.20, 95% CI: 0.23-0.83, p = 0.011), level of education (OR = 7.3, 95% CI: 1.68 - 31.72 p = 0.008), religion (OR = 0.28, 95% CI: 0.12 - 0.68, p = 0.005), distance to reproductive health facility (OR = 0.18, 95% CI: 0.09 - 0.36, p = 0.001), duration of first ANC visit (OR = 2.44, 95% CI: 1.18 - 5.04, p = 0.016), and level of awareness of pregnancy danger signs (OR = 0.16, 95% CI: 0.04 - 0.56, p = 0.004) Coverage of skilled birth attendance in the municipality is below the target set by Municipal Health Administration and International Conference on Population and Development +5. The study recommends improving education for the women and the girl child, strengthening outreach services and community based approaches, and development of effective referral systems to improve skilled attendance