Maternal Health in Sierra Leone: Real Progress, Unfinished Danger

What the latest numbers say

The 354 figure comes from the UN Maternal Mortality Estimation Inter-agency Group, the modelling approach used to compare countries over time. It is the number the Ministry of Health and its partners cite to track the national trajectory toward the government’s target of fewer than 300 by 2025.

Behind that headline sit the survey numbers that explain how it moved. The Sierra Leone Demographic and Health Survey of 2019 found that 83 per cent of births took place in a health facility and 87 per cent were attended by a skilled provider, while 98 per cent of women saw a skilled provider for antenatal care at least once. More women are reaching professional care at the moment that matters most, and that is the main reason deaths have fallen even though the underlying risk of each pregnancy is still high.

One number lags the rest. Modern contraceptive use among women of reproductive age sits in the low to mid 20s per cent, depending on the source and year. Low uptake keeps fertility high, birth intervals short, and the lifetime exposure to pregnancy risk large. Until family planning catches up, it blunts the gains that better delivery care can otherwise deliver. Adolescent childbearing remains common, and both maternal and newborn deaths stay concentrated in the poorer provinces and wealth groups, which is why a falling national average can still sit on top of dangerous local pockets.

Why the ratio fell

The decline was built, not stumbled upon. The concrete inputs include training and deploying more midwives, strengthening emergency referral, expanding essential obstetric and newborn care, and making routine antenatal and delivery care more dependable. UNFPA’s midwifery work and its programme against obstetric fistula are part of this, as are the Ministry’s Child Survival Action Plan and the national RMNCAH strategy, which lifted maternal survival to the level of an emergency and pulled in funding for staff, commodities and facility upgrades. Those are the proximate reasons facility births and skilled attendance rose in the 2019 survey window and why the modelled ratio came down.

What decides whether the trend holds is the part of the system that is hardest to see. A skilled attendant at the bedside is not enough on her own. She needs a referral chain that works, blood for transfusion, safe anaesthesia, an operating theatre for a caesarean, and a reliable supply of oxytocin, magnesium sulphate and antibiotics. Where those fail, and they fail most in rural district hospitals and among the poorest women, the familiar direct causes still kill: haemorrhage, the hypertensive disorders of pregnancy, and sepsis.

Where progress is fragile

Three faultlines will decide whether the gains last. The first is inequality. The 2019 survey shows clear gradients by wealth, education and province, with women in the Western Area far more likely to deliver with a skilled attendant than women in several rural districts. The second is contraception, improving from a low base but slowly, with unmet need that follows poverty. The third is emergency capacity.

Pushing more women to deliver in facilities without also equipping those facilities to manage a catastrophic bleed or eclampsia risks a hollow victory, more deliveries in buildings that cannot save a woman when minutes count. The implication is plain enough: scale and quality have to move together, with specific money for blood services, theatres, surgical teams and incentives to keep midwives in the districts that struggle to hold onto them.

What to do in the near term

Three actions, each anchored in a budget line and a deadline, would consolidate the progress. Protect and expand the midwifery and surgical workforce, with retention packages and real emergency obstetric capacity at district level. Accelerate family planning through secure supplies and demand created among adolescents and poorer households, using the family planning investment case as the financing map.

And invest in accountability: make maternal death surveillance and response complete and timely, and publish sub-national dashboards so that leaders, and the public, can see which districts and facilities are moving and which are not.

The evidence at a glance

• Maternal mortality ratio: 354 per 100,000 live births (UN inter-agency estimate, 2023).
• Facility delivery: 83 per cent of births (Sierra Leone DHS 2019).
• Skilled birth attendance: 87 per cent for the most recent birth (Sierra Leone DHS 2019).
• Antenatal care from a skilled provider: 98 per cent for the most recent birth (Sierra Leone DHS 2019).
• Modern contraceptive prevalence: low to mid 20s per cent (DHS 2019 and FP2030 tracking).
• Sub-national inequality: wide variation by province and wealth (Sierra Leone DHS 2019).
• Programmes in place: midwifery accelerator and the national RMNCAH and Child Survival plans (UNFPA and Ministry of Health).

Frequently Asked Questions