From invisibility to imperfect visibility: the emergence of stillbirth and neonatal death surveillance in Sierra Leone’s electronic Integrated Disease Surveillance and Response system, 2021–2025

Abstract

In 2021, Sierra Leone added stillbirth, early neonatal death (END), and late neonatal death (LND) fields to its electronic Integrated Disease Surveillance and Response (eIDSR) system. The scale, distribution, and stability of reporting had not been assessed against expected deaths. We compared the first five years of notification with benchmarks: deaths expected under published neonatal and stillbirth mortality rates. We conducted a retrospective ecological analysis of aggregate eIDSR data from 16 districts, 2021–2025. The notification-to-benchmark ratio (NBR) was recorded notifications as a percentage of rate-based expected deaths. Expected neonatal deaths used a neonatal mortality rate (NMR) of 31.1 per 1,000 live births. Expected stillbirths used a survey-derived stillbirth rate (SBR) of 15.6 per 1,000 total births. An NBR of 100% means the counts are equal; it does not estimate completeness. We examined annual change, district concentration, the published NMR and SBR confidence limits, and an alternative SBR of 20.2 from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Maternal notifications provided secondary comparison for the 2025 decline. Across 2021–2025, eIDSR recorded 10,002 stillbirth and neonatal death notifications against 60,688 expected deaths (cumulative NBR 16.5%). Annual NBR rose from 6.8% in 2021 (822 notifications) to 24.6% in 2024 (3,000), then fell to 17.9% in 2025 (2,190). The six highest-notifying districts contributed 69.6%-87.2% of stillbirth notifications. The alternative SBR reduced the cumulative NBR to 15.0% and narrowed the stillbirth-neonatal difference. Maternal notifications declined less nationally and remained unchanged in Bo, where the three newer fields declined sharply. eIDSR made stillbirths and neonatal deaths visible nationally, but that visibility is partial. Notifications stayed far below benchmark-expected deaths, came mainly from a few districts, and fell in 2025. Maternal notifications changed less, so the decline was not uniform across mortality fields. National totals therefore show what entered the system, not what occurred. Sierra Leone should link and routinely reconcile eIDSR notifications with facility, community, death-review, and civil-registration records, so the same deaths can be traced across sources. Countries with fragmented mortality systems need common definitions, identifiers, and linkage to build one interpretable record.