Progress in family planning in Sierra Leone: a mixed-methods case study

Expanding access to voluntary family planning is a global health priority, yet progress has been uneven across low-income and middle-income countries. Despite being a fragile state with historically high fertility and limited health resources, Sierra Leone has achieved one of the fastest increases in modern contraceptive prevalence in sub-Saharan Africa. This study explores the drivers of this progress through a mixed-methods case study.

We analysed national-level data from urban and rural settings, and engaged diverse stakeholders including family planning professionals, healthcare providers, community leaders and service users. Quantitative data were drawn from Demographic and Health Surveys (DHS 2008, 2013 and 2019), and United Nations (UN) Population Division estimates (1990-2022). Qualitative insights were obtained through 33 key informant interviews and 12 focus group discussions. A systematic review of peer-reviewed articles, policies and programme documents was conducted to assess the broader implementation context.

Between 2008 and 2019, modern contraceptive prevalence among women aged 15-49 rose from 8.2% to 23.9% (+15.7 percentage points). Among married women, gains were larger in those aged 15-24 years (+12.6) than in women aged 25-49 years (+10.0). Unmarried women maintained substantially higher use, with gains of +19.5 and +16.9 points, respectively. Key drivers included expanded knowledge, higher education, delayed marriage and outreach by fieldworkers. Political commitment-particularly integration into the Free Health Care Initiative (FHCI)-together with women's empowerment policies, donor and non-governmental organisation (NGO) support, media and community engagement improved access, awareness and autonomy.

Sierra Leone's progress demonstrates the importance of holistic approaches combining political commitment, external financing, cross-sector partnerships and community engagement. Government leadership was most evident in integrating family planning into the Free Health Care Initiative, while educational and gender-sensitive strategies proved particularly effective. These drivers consolidated gains and offer lessons for fragile, high-fertility settings.