Women giving birth in public healthcare facilities in Sierra Leone face demeaning, dangerous, and potentially deadly neglect, abandonment, and abuse by healthcare providers if they cannot pay for health care, Human Rights Watch said in a report released today.
The 75-page report, "No Money, No Care: Obstetric Violence in Sierra Leone," documents cases of verbal abuse, medical neglect, and abandonment of women and girls facing serious obstetric complications, practices that experts interviewed say are common. Many women interviewed said they were shamed and mistreated by healthcare providers for expressing pain, needing help, or for not having enough money to pay fees. Others described humiliating experiences in which healthcare providers treated them brusquely or withheld important health information. Some cases documented constitute obstetric violence, a largely unaddressed form of gender-based violence prevalent across the world.
"Women giving birth in some government hospitals face shame, long waits, untreated pain, and suffering, and even risk losing their or their newborn's lives, said Skye Wheeler, a senior women's rights researcher at Human Rights Watch. "Sierra Leone's government is failing to address harmful practices in its public health care system, leaving providers to resort to extracting money from extremely vulnerable patients."
Obstetric violence is a globally pervasive but underrecognized spectrum of abuses against women in reproductive health care settings. It includes violations of bodily autonomy, such as forced sterilization and other operations or medical interventions carried out without the patient's consent. It also includes harmful labor and delivery room practices that are often seen as routine, such as tying women to hospital beds while they give birth, verbal abuse, neglect or abandonment, and the denial of pain medication.
Human Rights Watch interviewed over 50 postpartum women and 50 health care providers. Some hospital staff reported regularly seeing women and more often newborns die or suffer serious health complications because of delayed and denied care caused by the inability to pay hospital staff adequately. Human Rights Watch also spoke to women whose newborns had died or were born with acute health conditions after the women waited hours or even days to receive care at the Princess Christian Maternity Hospital (PCMH), the country's primary obstetric hospital, in Freetown, the capital.
One woman, who had no money when her son was born there, attributed his death to the poor care she received. "They only focused on the ones who had money and because I lacked money I had to suffer," she said. She said because she could not pay for soap and plastic sheeting, she was abandoned for two hours while in labor, during which her husband desperately collected money from their community. Eventually a midwife appeared. "I heard the baby, but then it died," she said.
Another pregnant woman waited for treatment at PCMH for almost three days, sleeping on the ground, before she was finally seen by healthcare providers. Her condition at that point required major surgery, but it was too late to save her baby. The doctor who did her cesarean section told her that the baby had died because of her delayed care, which she attributes to her inability to pay. "He was so angry," she said. "He said it was the fault of PCMH that my baby died."
All women interviewed said that fees levied by hospital staff, which are often indistinguishable from opportunistically solicited bribes, determined their access to and the timeliness and quality of the care they received. They said the demands were often exorbitant and highly coercive and often made while they were under extreme physical and mental duress. The women and their families had no access to a complaints system or other form of accountability or redress.
Maternal mortality rates remain high in Sierra Leone despite a 70 percent decline between 2013 and 2023, falling from what was once believed to be the highest in the world. The under-5 mortality rate, the probability that a newborn will die before reaching age 5, was among the highest in the world in 2024.
Sierra Leone has acknowledged the urgency of improving the quality of maternal health care and has created training on respectful maternity care, which some healthcare providers interviewed said had reduced harmful practices. The Anti-Corruption Commission of Sierra Leone, under the Ministry of Justice, has also acted to reduce medical corruption in public healthcare facilities.
In 2010, the government announced a policy, the Free Health Care Initiative, requiring free health care for pregnant and lactating women and children under 5. Around the same time, Sierra Leone also barred traditional birth attendants from assisting home deliveries. But women and healthcare providers interviewed said the program was a "ghost" or "mirage" and that all the women had paid for some aspect of their care.
Human Rights Watch found that the government's inadequate financial support of the public healthcare system drives many abuses. As many as 50 percent of Sierra Leone's public healthcare workers are unpaid volunteers. Public healthcare facilities face chronic shortages of even basic healthcare commodities, including essential medicines. All healthcare facilities Human Rights Watch visited had major gaps, pressing patients to use commodities purchased by providers.
Sierra Leone is a very low-income country, but it can do more to meet its right to health obligations including its laudable goal of achieving universal health coverage, Human Rights Watch said. Publicly acknowledging the human rights harm including obstetric violence should be an important first step. The government also needs to procure needed drugs and other commodities and reduce the number of volunteer health workers. Women and their families also need accessible complaints systems and effective redress mechanisms when abusive treatment occurs in public healthcare facilities.
Other countries and international institutions should take action to help ensure that Sierra Leone's high international debt repayments do not undermine its ability to raise and allocate public financial resources toward the realization of human rights, including maternal and newborn healthcare.
"Without action, Sierra Leone's significant progress in reducing maternal deaths is at risk," Wheeler said. "But this is not just about public health statistics. The government should listen to the stories and experiences of women and recognize how obstetric violence has caused deep harm to girls and women's rights."
