Background: Sierra Leone has one of the highest fertility rates in West Africa (TFR=4.2). Understanding fertility determinants in urban settings is essential for targeted programming. This study examined demographic, educational, religious, marital, household, and socioeconomic factors associated with fertility and family planning (FP) use among married women in Bo City, Sierra Leone, with comparisons to other West African countries.
Methods: A cross-sectional study was conducted among 1,500 married women aged 15-49 years in Bo City (February 2025). Descriptive statistics, cross-tabulations, and binary logistic regression were employed. Outcomes included children ever born (CEB), age-specific fertility rate (ASFR), total fertility rate (TFR), contraceptive prevalence rate (CPR), unmet need, desired children, child marriage, polygamy, and household arrangement. Comparisons were made with Demographic and Health Survey data from Liberia, Ghana, Nigeria, Senegal, Côte d'Ivoire, and Guinea.
Results: Mean CEB was 2.16, mean desired children was 4.03, yielding a desired–achieved gap of 1.87 children. TFR was 4.67. Overall CPR was 61.6%, the highest in West Africa. Child marriage (18%) and polygamy (14.3%) were the lowest in West Africa. Female secondary+ enrollment (71%) was the highest in West Africa. Muslim women had higher fertility (CEB: 2.33 vs 1.96) and lower CPR (57.0% vs 68.0%) than Christian women. Adolescent fertility (125 per 1,000) was among the highest in West Africa. In adjusted analyses, bank access (AOR=1.85), healthcare decision-making autonomy (spouse alone vs self alone: AOR=0.31), and media access (AOR=1.21 per media type) were the strongest independent predictors of FP use.
Conclusions: Bo City presents a paradoxical profile: the highest CPR, lowest child marriage, and highest female education in West Africa, yet TFR remains elevated (4.7), and adolescent fertility is among the region's worst. This suggests that high CPR is recent and adolescents are being left behind. Faith-based engagement, school-based sexuality education, and youth-friendly services are urgently needed.