Report: Abortion Incidence and Severity of Related Complications in Sierra Leone

Maternal mortality in Sierra Leone is a major public health concern. Some modest improvements have been achieved, with the maternal mortality rate declining from 1,360 deaths per 100,000 live births in 2016 (the world’s highest in that year), to 717 death per 100,000 live births in 2019 (1), even though the WHO reported a rate of 1120 the same year (2). However, the 2019 rate is still relatively high compared to other countries in the African region and far above the sustainable development goal (SDG) target of less than 70 maternal deaths per 100 000 live births by 2030 (3). A 2011 study in Sierra Leone by Ipas found that unsafe abortions contribute 10% of maternal mortality, with a high abortion case-fatality rate of 1.7%. One in five women (21%) treated for post-abortion complications presented with clinically moderate or severe complications (4). The same study also showed that the Sierra Leone government spends an estimated USD 231,000 annually to treat women with abortion-related complications in public hospitals, a massive drain on already scarce health systems resources (4).

The legal status of abortion in Sierra Leone is likely contributing to the safety of abortion and the severity of post-abortion complications. Abortion in Sierra Leone is restricted, allowed only to save a pregnant woman’s life (5). As such, most women needing abortions resort to unsafe abortion methods and procedures. In addition, many women experiencing abortion-related complications often delay seeking care due to fears of prosecution (6). Evidence shows that healthcare workers face a dilemma between conforming to the legal restriction and their obligation to care for patients (7).

Further, Sierra Leone has one of the highest rates of teenage pregnancy in the world: 28% of girls between the ages of 15 and 19 have children, and unintended pregnancies are common (88 per 1,000 women of reproductive age) (8). About 25% of women have an unmet need for modern contraception, which is even higher among young women and adolescents. As of 2019, only 21% of women were using a modern method of contraception (1). Annually, close to 17% of births in Sierra Leone were either unwanted or mistimed in 2019 (1). Between 1990 and 2019, the share of unintended pregnancies ending in abortion rose from 34% to 51% (9). Until recently, when the return-to-school policy was reformed (10), most school-going girls who become pregnant faced exclusion from mainstream schools and their communities. This naturally increased girls’ desperation to secure abortions at all costs, notwithstanding safety.

In 2015, lawmakers in Sierra Leone successfully passed a Safe Abortion Bill, which would have improved access to safe and legal abortion and post-abortion care. However, the bill failed to become law as the president withheld assent. Even so, the persistence of unsafe abortion in public health matters has inspired new efforts to formulate the Safe Motherhood and Reproductive Health Bill and comprehensive post-abortion care clinical guidelines (2022). There is a need for robust and up-to-date evidence on the incidence of induced abortion, the severity of complications due to unsafe abortion and the quality and cost of care to contribute to these ongoing reforms. Such evidence could strengthen programs targeted at reducing unsafe abortions, improving the availability and quality of comprehensive abortion care services, bolstering policy engagement, and informing campaigns and advocacy around the abortion discourse in Sierra Leone. This study aimed to estimate the national and regional incidence of induced abortion and the severity of abortion-related complications in Sierra Leone. It provides the first nationally representative data on induced abortion in Sierra Leone.

Download