Understanding the Sierra Leone DHS: Key Findings You Should Know

The 2019 Sierra Leone Demographic and Health Survey (SLDHS) is the country's most recent, nationally representative health and population survey. Its headline truths are straightforward and stark: fertility is falling but remains high in rural areas; childhood malnutrition and under-five mortality have improved compared with earlier rounds but remain unacceptably common, with one in three children chronically stunted; maternal-health service coverage---antenatal care and facility delivery---has risen sharply; and persistent social vulnerabilities, including gender-based violence and unequal access by province and wealth, continue to shape those health outcomes. These are not abstract indicators; they are the everyday facts that shape court dockets, budgets, district plans and the life chances of Sierra Leoneans.

1 --- Demography and reproductive health: a country in demographic transition, unevenly

Sierra Leone is moving through a slow demographic transition. The SLDHS reports a national total fertility rate (TFR) of 4.2 children per woman, down from 5.1 in 2008 and 4.9 in 2013; the decline is real and policy-relevant, but it is uneven --- rural women average 5.1 children while urban women average 3.1, a gap of roughly two children over a lifetime. Adolescent childbearing remains a public policy concern: births per 1,000 women aged 15--19 stand at 102, and age-specific fertility peaks in the early twenties. Contraceptive uptake among married women is improving but still limited; 21 percent of currently married women report using any family-planning method, of which nearly all are modern methods (injectables account for 9 percent, implants for 7 percent, the pill for 4 percent). Policy implication: the demand for family planning is rising and service coverage has improved, but inequities by residence, education and wealth point to where public resources must be targeted.

2 --- Child health and nutrition: gains that still leave many children behind

The nutrition picture is mixed. The SLDHS documents meaningful progress compared with earlier years but a high ongoing burden: 30 percent of children under five are stunted (chronic undernutrition), 5 percent are wasted (acute malnutrition), and 14 percent are underweight. Stunting rises with age and concentrates in rural and poorer households; the highest prevalence appears among children aged 24--35 months and among families in the lowest wealth quintiles. Early childhood mortality has declined: the under-five mortality rate for the five years preceding the survey was 122 deaths per 1,000 live births, and infant mortality 75 per 1,000, yet these rates still place Sierra Leone off track for many SDG child-survival targets. In plain terms: fewer children are dying now than a decade ago, and fewer are malnourished than before, but one in three children is too short for age and the geographic and socioeconomic patterns of malnutrition demand subnational, multisectoral responses.

3 --- Maternal care and health-system contact: dramatic improvements, but equity gaps persist

One of the more encouraging technical stories is the rise in maternal-health service contact. According to the SLDHS, 98 percent of women who gave birth in the five years before the survey received antenatal care from a skilled provider at least once, and 79 percent achieved four or more visits. Skilled attendance at birth rose to 87 percent and facility births to 83 percent --- large gains compared with previous surveys. Yet national averages mask an uneven landscape: urban mothers and better-educated mothers are far more likely to deliver with a skilled attendant and in a facility than rural, less-educated women. For practitioners and judges considering standards of care and accountability, the important analytic pivot is to move beyond national means and examine district-level coverage, facility readiness, and out-of-pocket barriers that still prevent full, equitable utilization.

4 --- Social determinants and violence: health statistics as social testimony

Health indicators do not float free of social context. The SLDHS and complementary analyses document that intimate-partner and other forms of physical and sexual violence remain widespread, contributing to mental health burdens, reproductive coercion, and poorer maternal and child outcomes. The same survey framework shows stark correlations between low maternal education, poverty and poorer child nutritional and survival outcomes. For citizens, lawyers and policymakers, the data are clear: health results are as much about social rights, gender relations and education as they are about clinical inputs. Addressing these requires coordinated legal, social-protection and service-delivery measures --- not only more clinics.

Practical takeaways for practitioners, policy-makers and the public

First, treat the SLDHS as the authoritative national baseline: 4.2 children per woman, 30 percent child stunting, under-five mortality of 122 per 1,000, and high maternal-care contacts but clear equity gaps. Second, design interventions to close geographic and socioeconomic gaps: rural populations and poorest quintiles experience the highest burdens. Third, make family planning and adolescent sexual-and-reproductive-health services core to district plans --- unmet need and method mix show where scale-up will have the greatest impact. Fourth, use the SLDHS to build legal and budgetary accountability: the improvements in facility delivery and ANC establish that service expansion is possible; the work now is to secure quality and equitable access.

Q&A explainer

Q. Is Sierra Leone improving on child survival?

A. Yes --- under-five and infant mortality have fallen since previous DHS rounds, but the 2019 under-five rate (122 per 1,000 live births) remains high and requires concentrated efforts on the preventable causes of death (diarrhoea, pneumonia, malaria, neonatal complications). Evidence-to-action should focus on emergency obstetric/neonatal care and effective community case management.

Q. How serious is adolescent pregnancy, and what should the state do?

A. The SLDHS shows that roughly one in five girls age 15--19 has begun childbearing. This pattern has legal, social and economic consequences. The state should harmonize laws on consent and sexual-and-reproductive health services with school-retention policies; invest in adolescent-friendly services; and ensure that adolescents can confidentially access contraception and counselling.

Q. Should the government reallocate resources from family planning to neonatal care since ANC coverage is already high?

A. No --- this is a false choice. Both are needed. The SLDHS shows high first-contact antenatal coverage (98%) but not uniformly high quality; family planning uptake remains low (about 21% of married women), leaving avoidable pregnancies in place. Strategic reallocation should strengthen quality of ANC, invest in emergency obstetric and neonatal capacity, while expanding family planning supplies and outreach to meet existing demand.

Q. Can policymakers rely on the 2019 DHS now (in 2025)?

A. The 2019 SLDHS remains the most recent nationally-representative DHS round and a vital baseline; but planners should triangulate with more recent national nutrition surveys, routine health information system data and program monitoring to detect short-term trends or shocks (for example, the 2021 National Nutrition Survey and 2023--24 administrative data). Use the DHS for structural planning and the routine systems for near-term course correction.

Short methodological note

The figures above come from the SLDHS 2019 Key Indicators and final reports, which present nationally representative estimates collected between May and August 2019 and analysed using standard DHS procedures. Where I mention trends I rely on the comparative series reported in the SLDHS (2008, 2013, 2019). Complementary national reports (for example nutrition and health accounts) add useful, more recent programmatic context but do not replace the SLDHS as the canonical household survey.

Selected bibliography

Statistics Sierra Leone and ICF. Sierra Leone Demographic and Health Survey 2019: Key Indicators; Sierra Leone DHS 2019 final report. Statistics Sierra Leone (SLDHS 2019).

The DHS Program / ICF. Sierra Leone DHS 2019 (Final Report listing and dataset). (DHS Program)

UNICEF Sierra Leone. Situation Analysis of Children and Adolescents in Sierra Leone (executive summary citing SLDHS findings, GBV and child outcomes). (UNICEF)

Sierra Leone Ministry of Health and Sanitation. Sierra Leone National Nutrition Survey 2021 (SMART survey, contextual nutrition trends). (Ministry of Health and Sanitation)

Global Nutrition Report. Sierra Leone country profile and nutrition trends (useful for cross-national comparison and policy framing). (Global Nutrition Report)