By Emiola Osifeso
Women in Sierra Leone’s public hospitals are facing a silent horror in the middle of one of the most delicate and vulnerable moments of human life — childbirth. A new Human Rights Watch report titled “No Money, No Care: Obstetric Violence in Sierra Leone” has exposed disturbing patterns of abuse, neglect, abandonment, and extortion in maternity wards across the country, especially against women who cannot afford informal fees. The report, which interviewed over 100 women and healthcare providers, reveals the brutal reality of pregnant women being denied care, shamed, left in pain, and in the worst and most heartbreaking cases, losing their newborns or their own lives simply because they had no money to pay hospital staff.
Even though Sierra Leone has one of the most progressive policies in West Africa on paper — with maternal care officially free under the government’s Free Health Care Initiative — the lived reality for poor women is sharply different. The HRW report documents a system where the lack of drugs, chronic shortages of basic supplies, and underpaid or unpaid volunteer workers have created a dangerous culture of extortion, resulting in women being made to pay for soap, plastic sheets, gloves and other basic items before they are attended to. When they cannot pay, they are ignored, mocked, or left unassisted for hours.
One mother said she lost her son because she was abandoned in labour for two hours for failing to pay for soap and a plastic sheet. Another woman recalled waiting nearly three days lying on the floor before being attended to, only to be told her baby was already dead due to delayed care. In these cases, doctors themselves have admitted that delayed care caused by inability to pay was the direct reason for deaths.
The report notes that obstetric violence is not unique to Sierra Leone. Globally it is underreported and normalized in many health systems, manifesting as refusals of pain medication, shaming women during labour, tying women to beds, performing procedures without consent, and withholding information. But Sierra Leone’s situation is worsened by chronic underfunding and limited oversight. Up to 50 percent of the country’s health workforce are unpaid volunteers, a situation Human Rights Watch describes as a structural failure that sets the stage for abuses, as volunteer workers attempt to survive by extracting money from patients.
Sierra Leone has made progress — maternal mortality dropped by 70 percent between 2013 and 2023. But the risk remains one of the highest in the world. Under-five mortality is also among the worst globally. Experts warn that these gains could be reversed if obstetric violence continues unchecked. The government has tried to train staff on respectful maternity care and the Anti-Corruption Commission has made attempts to curb bribery in hospitals, yet the report says these interventions are still not enough to stop the systemic breakdown of trust and care.
The HRW findings call for the Sierra Leone government to urgently increase funding to public healthcare facilities, hire and pay more professional workers, supply adequate medical materials so hospitals are not asking women to buy basics, and strengthen complaints systems so women can report abuses and seek justice. It also calls on international partners to ensure Sierra Leone’s debt obligations do not drown its public health budget.
The voices of the women in this report are raw reminders that maternal healthcare reform is not just a policy issue. It is a human rights issue. It is an issue of dignity. It is an issue of life and death. And behind every statistic is a woman, a child, and a family who could have had a different story. Without urgent action, Sierra Leone risks reversing years of progress and leaving its most vulnerable women to die in silence in hospital corridors simply because they cannot afford to pay their way into basic care.
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