Photo by Robert Yates / Department for International Development (CC BY 2.0)

In November 2025, Human Rights Watch (HRW) released “No Money, No Care,” a detailed report documenting obstetric violence in Sierra Leone’s public health system. Sierra Leone, which has one of the highest maternal mortality rates in the world, has long been plagued by delays or outright denial of care for patients unable to pay hospital staff, despite the establishment of a free healthcare initiative in 2010.

Obstetric violence refers to abuse experienced by pregnant women seeking maternal, sexual, and reproductive health services. It includes verbal humiliation, coerced or unconsented procedures, denial of information, refusal or delay of care, and neglect, even in life-threatening situations. In March 2025, the African Commission on Human and Peoples’ Rights recognized obstetric violence as a form of gender-based violence and a violation of fundamental human rights, including the rights to dignity, health, life, and freedom from torture or cruel, inhuman, and degrading treatment.

HRW found that Sierra Leone’s maternal health system is marked by chronic underfunding, severe shortages of essential medicines, and widespread reliance on out-of-pocket payments. Patients, in turn, face cost-based discrimination as staff solicit informal fees for access to care, drugs, and medical supplies. HRW found that providers often delay or deny care to women who cannot pay, resulting in preventable injuries and deaths. The Princess Christian Maternity Hospital (PCMH), the country’s main maternity hospital, has reported rising maternal mortality numbers since 2021, with 82 deaths in 2024.

Under international human rights law, Sierra Leone is obligated to respect, protect, and fulfill the right to health without discrimination. Meeting these obligations requires meaningful investment in maternal health systems and the elimination of coercive and discriminatory practices in healthcare settings.