Caesarean section rates and obstetric practices in Sierra Leone before, during, and after the Ebola epidemic: Results from a nationwide household study.

BackgroundThrough health system reforms Sierra Leone has achieved reductions from 1,603 to 354 maternal deaths per 100,000 live births between 2000 and 2023, but progress has been uneven and severely disrupted by the 2013-2016 Ebola virus disease (EVD) outbreak. National surveys track key maternal health indicators but provide limited insight into assisted vaginal delivery and women's access to emergency obstetric care, including caesarean section, during and after health system shocks.ObjectivesTo describe patterns of caesarean section and assisted vaginal delivery, place and mode of transport for childbirth before, during, and after the EVD outbreak from a community perspective, and assess changes compared with earlier nationwide household study data.DesignCross-sectional household survey.MethodsA district and urban-rural weighted random cluster design selected enumerator areas with probability proportional to population size. Women aged 12-50 years provided obstetric histories. Data were compared with the 2012 household survey using the same methodology and interpreted in the context of national health system initiatives and the EVD outbreak timeline. Descriptive statistics and chi-square tests examined differences across time periods.ResultsAmong 914 women with 2,094 pregnancies, caesarean section rates rose from 1.6% pre-to 3.7% post-EVD, while assisted vaginal delivery dropped to zero during the outbreak and re-emerged at 2.9%. Facility births increased from 57.6% pre-to 73.8% post-EVD, with home deliveries declining to 16.3%. Almost half of women delivering post-EVD reached facilities on foot, and ambulance use remained minimal. No substantial improvement was observed in girls' education and literacy over the decade.ConclusionObstetric service use in Sierra Leone continued to improve after the EVD outbreak, but transport barriers and low assisted vaginal delivery and caesarean section rates persist. Strengthening girls' education, referral systems, emergency obstetric capacity and skills retention remain essential for resilient, equitable maternal care.