It’s the week after Mother’s Day and we just finished 3 weeks of exploring Under-5 Mortality Rate with South Sudan, Estonia, and Rwanda. So naturally, it’s time to tackle the maternal mortality ratio (MMR) next. OK, terrible segue, but a crucial topic no less. While we celebrate mothers and mother-like figures, let’s not lose sight of the fact that 712 women are dying each day from complications in pregnancy and childbirth, which is equivalent to one every two minutes.
From what? Mostly preventable causes. That’s what’s maddening.
Source: UNICEF using data from Cresswell et al 2025)
Notes: *Nearly all (99 per cent) of abortion deaths are due to unsafe abortions. **Includes deaths due to obstructed labour or anaemia. *** Indirect causes are medical causes such as pre-existing conditions aggravated by pregnancy.
Maternal death can be caused directly by postpartum haemorrhage, pre-eclampsia and hypertensive disorders, pregnancy-related infections, and complications of unsafe abortion, as well as indirectly by pre-existing medical conditions aggravated by the pregnancy. The complications leading to maternal death can occur without warning at any time during pregnancy and childbirth. However, some can be screened and prevented. That is why UNICEF and the partnering organizations are working to ensure that monitoring and identifying high risk pregnancies through antenatal care are available for every pregnant girl and woman. Most maternal deaths can also be prevented if births are attended by skilled health personnel such as doctors, nurses or midwives. As complications require prompt access to quality obstetric services, these skilled health personnel, who are regularly supervised and have the proper equipment and supplies, can avert maternal death by providing life-saving drugs such as antibiotics, blood transfusions, caesarean sections, and other surgical interventions.
There are many social, economic, and environmental factors which influence the risk of maternal mortality. This includes social determinants of health, such as income, education, and environmental exposures; access to high-quality health care with sufficient numbers of competent, skilled providers, equipment, and medication; gender norms that devalue women and girls and limit their access to sexual and reproductive health care; and external factors such as political instability, conflicts, and climate change. These factors require intersectoral collaboration to improve maternal health and well-being at every stage.
UNICEF (2025)
The trajectory of maternal health in Sierra Leone represents one of the most complex case studies in global health. It’s not the country with the highest MMR: Nigeria holds that title currently, we covered the country with respect to life expectancy in week 5. Countries in orange below are those that have the highest MMRs, with most located in sub-Saharan Africa, many of which we have covered in previous posts on different demographic indicators.
Source: WHO
Source: Data from World Bank’s portal
That said, Sierra Leone has made remarkable progress in reducing MMR but is still in the top 20 in the world for the highest. It has seen a reduction in MMR of 79% starting from a very high base: from 1,682 deaths per 100,000 live births in 2000 to 354 in 2023. Last year, the Health Minister attributed this drop to four pillars: expanding primary health care, strengthening secondary and tertiary health facilities, improving referral systems, and ensuring emergency preparedness. This progress is striking. Still, 354 deaths per 100,000 live births is far too many, averaging to about three maternal deaths per day. Keep in mind that the global target (marked by the Sustainable Development Goals) is to reach less than 70 deaths per 100,000 live births by 2030.
As always, there’s more going on. There’s reasons Sierra Leone has made the progress it has, and some reasons why progress may seem to stall. Here’s to unpacking some of that today.
But First, Definitions
Maternal death is defined as: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from unintentional or incidental causes.
Direct Obstetric Deaths: Result from obstetric complications of the pregnant state (pregnancy, labor, and the puerperium), from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of the above (e.g., postpartum hemorrhage or eclampsia).
Indirect Obstetric Deaths: Result from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy (e.g., cardiac disease etc.)
There’s also Late Maternal Death - This refers to the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy. These are often excluded from standard maternal mortality ratio (MMR) calculations to maintain international comparability but are important for understanding long-term health outcomes.
[I’m getting fully in the weeds here, but since we did spend a few weeks talking about fertility rates, if you are wondering how those connect to MMR - that’s determined by the lifetime risk of maternal death. Demographers: we think of everything! Essentially, that is the probability that a 15-year-old girl will die from complications of pregnancy or childbirth over her lifetime; it takes into account both the maternal mortality ratio and the total fertility rate (TFR). Thus, in a high-fertility setting, a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting. Similar to maternal mortality ratio, the lifetime risk of maternal death varies largely across countries. In 2023, the lifetime risk of maternal death in low-income countries as a whole was 1 in 66, compared to 1 in approximately 8000 in high-income countries.]
The Three-Delay Framework
To understand the unique goings-ons in Sierra Leone, I thought of using the three-delay model as an explanatory device. It is essentially this: delay in seeking care, delay in arrival at a health facility, and delay in receiving adequate care.
Delay 1: Seeking Initial Care
Ebola and medical mistrust
In many parts of the world, a delay in seeking care is related to a deep mistrust in the healthcare system and health workers. In Sierra Leone, this was compounded during the Ebola outbreak in 2014-15. A qualitative study many years later found that fears and misperceptions of the Ebola response system were strong:
Most participants feared that calling the national hotline for someone they believed had Ebola would result in that person’s death. Many stated that if they developed a fever they would assume it was not Ebola and self-medicate. Some thought the chlorine sprayed by ambulance workers was toxic. Although most knew there was a laboratory test for Ebola, some erroneously assumed the ubiquitous thermometers were the test and most did not understand the need to re-test in the presence of Ebola symptoms.
Yamanis, Nolan & Shepler (2016)
In total, about 41% of those infected died; of which 6% were healthcare workers themselves.
Pregnant women were particularly vulnerable during the outbreak, because the symptoms of pregnancy look a lot like Ebola symptoms (don’t worry - if you are reading this and are pregnant, you are probably just pregnant and not experiencing Ebola. Although, on my worst days of pregnancy-related vomiting etc, I was convinced I had Ebola too.) According to Partners in Health who worked with the government to set up the world’s first maternity-specific screening and isolation system, conditions were challenging to begin with. Before Ebola struck, many women in Sierra Leone were delivering at home, because they couldn’t pay for care or didn’t fully trust a medical system that was gutted by a lack of resources, staffing, and even electricity at hospitals and clinics, following the country’s civil war. Travel restrictions further hurt women’s ability to reach hospitals, and risks didn’t end when they arrived. Expectant mothers unknowingly infected with the virus could be placed in the maternity ward among healthy women. Home deliveries accounted for more than 50% of childbirths in Sierra Leone before Ebola, and the percentage worsened during the epidemic.
The trust in healthcare workers and the health system was so low that this resulted in worse care-seeking behavior. There was a sharp decline in service utilization during the Ebola period. Antenatal care visits dropped by a third in the first few months while postnatal care visits (those that are meant to happen within 48 hours) decreased by 21%. Misconceptions proliferated, and continued to do so even after the epidemic ended. So much so that there was a continued (and increased) preference for home-based deliveries in some rural areas. Without skilled birth attendants to manage complications like preeclampsia and others, and a drop in ANC visits, you can imagine what likely happened. I did not see a data-related spike in MMR for that time period however, and that could be because of poor quality of death records and data. A qualitative study suggested that communities and health workers were reluctant to report deaths. This was ascribed to a fear of the investigation process which was perceived to be recriminatory and punitive, as well as health workers’ concerns over admitting to “failure.”
Bondo society and FGM/C
The Bondo (or Sande) society is an all-female group which is a dominant force in the lives of women in the country, serving as guardian and protector, and regulates social behavior including the rites of passage into womanhood. They are often called ‘secret societies’ because of their role in guarding, mobilizing, and transmitting esoteric knowledge; they are the institutions through which societies are organized and governed. This society yields enormous influence in Sierra Leone, with a whopping 90% of women identifying themselves as members, representing 17 ethnic groups (minus just one, the Krio) and Muslim and Christian communities alike. Here comes the tricky part:
The first step in joining the Bondo Society requires a girl to undergo FGM (female genital mutilation or cutting): uncut girls participate in a ritual in which senior members of the Bondo Society, known as soweis, lead them to a secluded area to perform the procedure. During the recovery period, the soweis and other members of the Bondo Society discuss topics ranging from sexuality, marriage, family life, and their expected roles in the community. Afterwards, the girls return to their communities as the newest members of the Bondo Society. They are rewarded with gifts, festivities, and public recognition to celebrate how FGM has transformed them into respectable women and community members.
Girls in Sierra Leone face enormous social pressure to undergo FGM and join the Bondo Society to fulfill expected gendered, social, and cultural expectations. Girls who partake in the Bondo initiation ceremony receive positive attention and attain higher social standing in their communities. However, girls who refuse to undergo FGM and by extension not join the Bondo Society risk social stigmatization. Communities across Sierra Leone view FGM as milestone in female and societal life, as it links a girl to her mother, grandmothers, sisters, and other female friends and relatives in the community, and is portrayed as a way to honor the girl’s cultural heritage. Furthermore, some Sierra Leoneans believe that removing a girl’s external genitalia will lessen her desire for sex, which will help her maintain her virginity and remain faithful to her husband after marriage. Therefore, uninitiated girls are frequently ostracized for rejecting their “natural duties” and face accusations of being ignorant of cultural norms and traditions, as well as being sexually unrestrained. In short, the Bondo Society plays a critical role in perpetuating FGM throughout Sierra Leone, and shifting such long-standing cultural values poses a challenge towards ceasing the procedure in the country.
Ekstrom (2024)
Most girls are cut before the age of 15, but about 21% are cut before that. Attitudes toward the practice are shifting among the younger generation (72% of those 45-49 believe that the practice should be conducted with only 47% of those aged 15-19 agreeing. Baby steps.) There are many local feminist activists and groups that are working with communities to end this practice, although there is much resistance because efforts to eradicate the practice have been perceived as cultural imperialism. There is also a push to advocate the government to pass a law prohibiting FGM/C. I thought this video was really nicely done that touches on all of these things, do watch it if you can here.) FGM/C is decreasing and projected to decrease further moving forward:
Source: Orchid Project (2025)
I did not set all this up just to tell you about Bondo, although, I’m glad I did. The widespread acceptance of FGM/C as an initiation rite, even among some health professionals, can delay the recognition of, and response to, medical needs. Thus, it has meaningful linkages with the high MMR. Recent research has found that a 50% increase in the number of girls subject to FGM (globally, not just in Sierra Leone) increases their 5-year mortality rate by 0.075 percentage points. This increased mortality rate translates into an estimated 44,320 excess deaths per year across countries where FGM is practised. FGM is a leading cause of the death of girls and young women in those countries where it is practised accounting for more deaths than any cause other than enteric infections, respiratory infections, or malaria. Additionally, the most common type of cutting practiced in Sierra Leone is Type 2 (cut and flesh removed), which can lead to long-term complications including obstructed labor and increased risk of hemorrhage.
Delay 2: Reaching Initial Care
At the end of last week’s post on Rwanda, I mentioned a study that talked about climate change and poor infrastructure that leads to births occurring outside of health facilities. In Sierra Leone, there is a spike in maternal deaths during rainy season (May to October) compared to other months:
Source: Ministry of Health (2020)
This is linked to the deterioration of the road network; during the rainy season, many rural communities are effectively cut off, and primary health facilities become unreachable. As a result, there is a massive delay in reaching initial or referral care. This is the area where the government (in partnership with NGOs) has invested in some really cool things, and likely helping curb this delay and its impacts. When you imagine an ambulance, you likely think of a small van. What if you were put on a motorcycle ambulance instead? I was imagining a woman in labor being carted off as a pillion rider, but it looks something like this (thank goodness!)
These ambulances (and riders?) are known to the communities, are acceptable and accessible, and valued by those it serves. They are suited to remote areas and can function on poor roads inaccessible to other vehicles. Regular motorbikes are also used for other purposes from transporting samples to labs, medical supply chain logistics and more. And if you were wondering, yes, regular ambulances are also available. But, prior to roughly 2018, ambulances could take up to 2 DAYS to arrive. For context, that wait time is approximately 4-6 mins in the US. I am curious about this stat by country broken down for urban/rural areas but can’t find it. Does anyone know?
Anyway, in 2018 the National Emergency Medical Service (NEMS) was established. It spurred action to actually use the small quantities of ambulances in Freetown and training paramedics and other staff. This has led to safer childbirth for hundreds of women. In Tanzania, there is another innovation on top of all this (and maybe it exists in Sierra Leone as well, but I couldn’t find documentation): m-Mama. It works like this: When a community healthcare worker identifies an emergency—maybe it’s severe bleeding after delivery, or a premature baby who can’t breathe—they call a free hotline. A trained nurse dispatcher uses an app to figure out what kind of care is needed and where it’s available, then coordinates whatever transportation makes sense for that location (a community driver with a car where there are good roads, a motorcycle where there aren’t, a boat for island communities, even a horse for mountainous terrain.) The dispatcher stays on top of everything, tracking the journey, alerting the receiving facility, and handling payment at the end. About 58% of the deliveries transported by m-mama end up requiring a C-section, compared to the 10-15% you would expect in the general population. These are genuinely high-risk cases that would have likely ended in tragedy without emergency transport.
If you have been reading my various posts leading up to this one, you might be thinking, “sure, but where are the community health workers (CHWs) or skilled birth attendants that may be able to resolve some of the non-major complications?” The answer is quite interesting. In 2010, the government launched the Free Health Care Initiative (FHCI) which abolished health user fees for pregnant women, lactating mothers, and children under five years of age. This action was taken in response to very high mortality and morbidity levels among mothers and children in Sierra Leone and reports that financial costs were a major barrier to health service uptake and use by these groups. This is excellent, and did so much to improve child and maternal health and outcomes. BUT, this meant that births had to take place in a health facility, and not at home to get access to these benefits. Trained Birth Attendants (TBAs) were thus banned from practicing, and women were fined if caught using them. These TBAs are a critical lifeline amidst strained infrastructure that rural women have trouble accessing. This article does a nice job summarizing the pros and cons of TBAs. Either way, banning TBAs does not mean it stopped the practice - it likely just forced it underground. Which then has implications for monitoring and getting care for complications.
In recent years, there has been a pivot in how TBAs are integrated into the formal system - reimagined as trust brokers or referral agents. One of the most innovative ideas yet is that of “silent ambulances”:
By placing an emphasis on building trust between the TBAs and the hospitals, the new system overcomes longstanding barriers that hindered TBAs from making referrals. For example, the district is now using “silent” ambulances so that community members are unaware of where women are being transported from and, thus, do not judge the TBA and the care she is providing. Importantly, the Project Aisha team also addressed the negative attitudes that hospital staff had toward TBAs, reinforcing their critical role as ‘trust-brokers’ within the community and encouraging collaboration.The combination of training, the new referral system and shifting attitudes has led to a significant increase in the proportion of prompt referrals of pregnant women with complications for expert care – from only 13% in January 2024 to 77% a year later.
AlignMNH (2025)
Delay 3: Receiving Initial Care
Alright so we have gone past the reluctance to seek care, navigated the harsh terrain and have made it to the health facility. Our final barrier is receiving initial care. What to expect? For starters, in Sierra Leone, the ratio of skilled health workers (doctors, midwives, nurses) is 6.4 per 10,000. The “goal” for a country (like Sierra Leone) hoping to achieve universal health coverage is 44.5. To complicate things further:
Sierra Leone has been informally recruiting ‘surplus’ health workers as unsalaried volunteers since 2010. This has resulted in over half of its primary healthcare staff, predominantly auxiliary nurses, working without pay, waiting for salaried employment. This backlog slows the absorption of recently graduated skilled health workers, delaying UHC achievement and creating barriers to access to care.
Pieterse and Saracini (2025)
There’s efforts underway to increase the number of trained workers. UNFPA just launched a program to accelerate the training, employment and support provided to midwives in Sierra Leone and other countries.
That said, health workers are doing a lot with very little (health spending is ~5% of GDP). One of the coolest innovations that is leading to improved quality of care within facilities is called Janitri, a simple yet powerful fetal monitoring device. It allows clinicians to closely track both fetal and maternal heart rates in real time during labor, helping to identify complications before they become life-threatening. They allow nurses in low-resource settings to identify early signs of fetal distress or maternal hemorrhage before they become fatal. Not only that, it allows limited staff to multitask:
“The workload is heavy. Sometimes I have to monitor up to six women at once,” King explains. “I can connect some of them to Janitri, and while it records their data, I can attend to another patient. It really helps with multitasking.”
Partners in Health (2025)
Amazing. Next in the journey from delay 1, 2 to now at the facility: you might need blood. This is because postpartum hemorrhage is a leading cause of maternal death in the country, yet the supply of safe, screened blood is chronically low. In many rural hospitals, the blood bank is often empty, and the time required to find a blood donor and screen them can exceed the window of time for survival for a bleeding mother. And if a functional blood bank does exist, often clinicians lack the training on how to perform the transfusion properly. This is changing, slowly but surely, with active blood banks and electricity generators to ensure 24-hour supply to hospitals. Blood donation (and screening) is also improving, with homegrown initiatives like LifeBlood, which increase public awareness and the number of voluntary blood donations, along with improving the efficiency of blood banks by digitising the systems used to track the availability of blood.
Looking ahead
Sierra Leone’s journey from a maternal mortality ratio of 1,682 in 2000 to 354 in 2023 is a monumental demographic achievement. It proves that even in the wake of civil war and the trauma of Ebola, evidence-based pillars like expanding primary care and strengthening referral systems can move the needle. That said, just this week, this NBC news video on the impact of the foreign aid cuts on maternal health in Sierra Leone was released. It shows how much is at risk moving forward.
Additionally, the three-delay framework reveals that the last mile is not just a medical challenge, but a structural and cultural one. Sierra Leone has shown brilliance through adaptation and innovation. But to bridge the MMR gap from 354 to 70, perhaps there is a need to also move beyond emergency interventions. We must treat demographic literacy and the ability to see the connections between fertility, climate, and infrastructure as a life-saving drug in its own right.
In demography, survival should never be a matter of luck, or the weather.
The Food!
We made fish huntu (basically steamed fish balls) which tasted better than they looked. I got something wrong and they looked more like cutlets instead of laddoos. We ate that with the very cutely named punky stew which was a mashup of veggies, beans, and coconut milk. It was soooo good! Ekim made a delicious couscous salad on the side and everyone was happy. Both kids did their research (!) Kimaya told us that the country is named Sierra Leone because it is supposed to mean “lion mountians,” and Eymir informed us that the Mende people from Sierra Leone are some of the oldest inhabitants of the Earth (!) We danced to a whole lot of good music, and added Sabi Road by Drizilik to the rotation.
