“The doctor said, ‘don’t pay, it’s free,’ but if you don’t pay the nurses, you will suffer and die — they will just leave you to die.” — Former patient, Sierra Leone
When women in Sierra Leone enter maternity wards, they should find care, safety, and dignity. Instead, too many find fear, neglect, and extortion. A new report jointly released today by Human Rights Watch and Amnesty International, “No Money, No Care: Obstetric Violence in Sierra Leone,” reveals how thousands of women are subjected to abuse, abandonment, and dangerous delays in the very facilities meant to protect them.
A Promise Betrayed
In 2010, Sierra Leone’s government launched the Free Health Care Initiative (FHCI) with fanfare and hope. It pledged free maternal and newborn care for all pregnant women, lactating mothers, and children under five. The policy was a landmark in a country once ranked the deadliest place on earth to give birth.
Fifteen years later, that promise has been hollowed out by chronic underfunding, corruption, and gender-based discrimination. The report’s title — “No Money, No Care” — captures the stark reality: although care is supposed to be free, women must pay for everything from soap and plastic sheets to medicines, blood, or even urgent surgical interventions.
In practice, those who cannot pay are often ignored, humiliated, or left to die.
Abuse in the Name of Care
The report, based on more than 130 interviews with patients, healthcare workers, government officials, and public health experts between 2024 and 2025, documents widespread obstetric violence — acts of neglect, coercion, and abuse that occur in healthcare settings during childbirth.
Obstetric violence, recognized this year by the African Commission on Human and Peoples’ Rights as a form of gender-based violence, includes both physical abuse and systemic failures that strip women of autonomy, dignity, and safety.
“When a woman’s care is delayed because she cannot pay, that is violence,” said Amnesty International’s Women’s Rights Advisor for West Africa. “It is violence rooted in poverty, in patriarchy, and in a healthcare system starved of resources and accountability.”
The report recounts chilling examples:
- A woman in Freetown whose baby died after she was left unattended for hours because she could not pay for soap and plastic sheeting.
- Another forced to wait three days in a corridor before receiving an emergency C-section — too late to save her newborn.
- Families told to bring cash before nurses would change blood-soaked bedding or administer life-saving drugs.
- Women slapped or scolded in labor, shamed for “arriving late,” or mocked for their bodies.
These stories expose a system in which money determines who receives care — and who suffers or dies.
Poverty and Powerlessness
Sierra Leone’s healthcare system relies heavily on out-of-pocket (OOP) payments, which account for more than half of all health spending in the country. Half of the country’s health workers are reportedly unpaid “volunteers,” surviving on small “informal payments” from patients.
For women living in poverty — many already marginalized by low literacy, rural isolation, or male financial control — these costs are catastrophic.
One woman told investigators she lost her baby after being made to wait for hours in a hospital because her husband could not pay the requested fees. Another said she felt she “had no power” to ask questions when her baby was stillborn: “They had all the power, and I had none.”
A Crisis of Rights, Not Just Resources
The report makes clear that this is not just a public health emergency — it is a human rights crisis. Obstetric violence violates the right to health, the right to life, and the right to be free from torture, cruelty, and degrading treatment.
“Women are dying because of a system that treats their pain as a transaction,” said Amnesty International Sierra Leone’s Director. “When a woman’s worth is measured in banknotes, her rights are stripped away.”
Despite progress — Sierra Leone has reduced maternal deaths by nearly 70% since 2010 — the rates remain among the highest in the world. Many of these deaths are preventable.
The Gender of Neglect
The report highlights how patriarchal norms amplify women’s vulnerability. In many households, men control the finances, forcing women to seek permission or money to access care — even during life-threatening emergencies. Providers, themselves overworked and unpaid, often display contempt toward poor women, reinforcing cycles of silence and humiliation.
These abuses are not confined to individuals; they are the predictable outcome of a failing system. Overcrowded wards, shortages of medicines, extreme heat, and unpaid labor create an environment where disrespect flourishes and dignity is eroded.
Government and Global Accountability
The organizations call on the Government of Sierra Leone to take urgent, concrete steps:
- Publicly acknowledge obstetric violence as a major barrier to women’s rights.
- Increase public spending on health to meet international benchmarks.
- Pay all healthcare workers fairly and end reliance on volunteer labor.
- Create national complaint and redress systems accessible to all women, including those who cannot read or write.
- Ensure free or affordable access to maternal and newborn care for all.
But responsibility does not stop at Sierra Leone’s borders. The report urges international creditors, including the International Monetary Fund, to assess how debt payments and austerity measures restrict the country’s ability to meet its human rights obligations. Wealthy nations must support debt relief, progressive taxation, and fair global tax rules that allow Sierra Leone to fund its health system sustainably.
Reclaiming Dignity
Amnesty International emphasizes that every woman, regardless of income or status, has the right to give birth safely and with dignity.
“No woman should have to choose between her life and her wallet,” said Amnesty’s Regional Director for Africa. “Respectful maternity care is not a luxury — it is a human right.”
Despite the grim findings, the report notes that Sierra Leone has made meaningful progress and that many health workers continue to serve their communities under impossible conditions. With adequate resources, fair pay, and accountability, the Free Health Care Initiative could yet fulfill its promise of justice and safety for all mothers and newborns.
Until then, the phrase “No Money, No Care” remains an indictment — a reminder that for too many women in Sierra Leone, childbirth is not a moment of joy, but a test of survival.