{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T20:36:14Z","timestamp":1792787774891,"version":"4.5.0"},"reference-count":40,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"name":"Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology","award":["90369500"],"award-info":[{"award-number":["90369500"]}],"id":[{"id":"https:\/\/ror.org\/05xg72x27","id-type":"ROR","asserted-by":"crossref"}]},{"name":"University of Amsterdam\u2019s Center of Tropical Medicine and Travel Medicine"},{"name":"Masanga Medical Research Unit"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Womens Health (Lond Engl)"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Through 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\u20132016 Ebola virus disease (EVD) outbreak. National surveys track key maternal health indicators but provide limited insight into assisted vaginal delivery and women\u2019s access to emergency obstetric care, including caesarean section, during and after health system shocks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Cross-sectional household survey.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A district and urban-rural weighted random cluster design selected enumerator areas with probability proportional to population size. Women aged 12\u201350 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 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\u2019 education and literacy over the decade.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Obstetric 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\u2019 education, referral systems, emergency obstetric capacity and skills retention remain essential for resilient, equitable maternal care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/17455057261487141","type":"journal-article","created":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T09:02:31Z","timestamp":1789981351000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Caesarean section rates and obstetric practices in Sierra Leone before, during, and after the Ebola epidemic: Results from a nationwide household study"],"prefix":"10.1177","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9151-5584","authenticated-orcid":false,"given":"Josien","family":"Westendorp","sequence":"first","affiliation":[{"name":"Norwegian University of Science and Technology"},{"name":"CapaCare NGO, Sierra Leone, Liberia, The Netherlands"},{"name":"Department of Obstetrics and Gynaecology, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanna M.","family":"Math\u00e9ron","sequence":"additional","affiliation":[{"name":"University of Amsterdam"},{"name":"Masanga Medical Research Unit"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alex J. van","family":"Duinen","sequence":"additional","affiliation":[{"name":"Norwegian University of Science and Technology"},{"name":"CapaCare NGO, Sierra Leone, Liberia, The Netherlands"},{"name":"St. Olavs Hospital HF"},{"name":"Trondheim University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Momoh L.","family":"Mansaray","sequence":"additional","affiliation":[{"name":"CapaCare NGO, Sierra Leone, Liberia, The Netherlands"},{"name":"Masanga Medical Research Unit"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lora","family":"Daskalska","sequence":"additional","affiliation":[{"name":"Medical College of Wisconsin"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Osman","family":"Sankoh","sequence":"additional","affiliation":[{"name":"Centre for Health Research and Training, University of Management and Technology, Freetown, Sierra Leone"},{"name":"Njala University"},{"name":"Bo Campus"},{"name":"University of the Witwatersrand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Risa","family":"Hoffmann-Lonn\u00e9e","sequence":"additional","affiliation":[{"name":"Norwegian University of Science and Technology"},{"name":"Department of Obstetrics and Gynaecology, St. Olavs Hospital HF, Trondheim University Hospital, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reinou S.","family":"Groen","sequence":"additional","affiliation":[{"name":"Alaska Native Medical Centre"},{"name":"Alaska Native Tribal Health Consortium \u2013 Southcentral Foundation (ANTHC\/SCF)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin P.","family":"Grobusch","sequence":"additional","affiliation":[{"name":"University of Amsterdam"},{"name":"Masanga Medical Research Unit"},{"name":"Centre de Recherches M\u00e9dicales en Lambar\u00e9n\u00e9 (CERMEL)"},{"name":"Institute of Molecular Medicine and Infectious Diseases"},{"name":"University of Cape Town"},{"name":"Institut f\u00fcr Tropenmedizin und Deutsches Zentrum f\u00fcr Infektiologie (DZIF)"},{"name":"Universit\u00e4t T\u00fcbingen"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H\u00e5kon A.","family":"Bolkan","sequence":"additional","affiliation":[{"name":"Norwegian University of Science and Technology"},{"name":"CapaCare NGO, Sierra Leone, Liberia, The Netherlands"},{"name":"St. Olavs Hospital HF"},{"name":"Trondheim University Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,9,21]]},"reference":[{"key":"e_1_3_10_2_2","doi-asserted-by":"publisher","DOI":"10.18356\/9789211071597"},{"key":"e_1_3_10_3_2","volume-title":"UNICEF, UNFPA, World Bank Group, UNDESA\/Population Division. 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