Community Agency and Collaboration: A Qualitative Study of Local Engagement in Maternal Health Initiatives in Sierra Leone

Maternal mortality remains a significant public health challenge in West Africa. Sustainable improvements require moving beyond top-down approaches to actively engage local communities. This study examines community agency within maternal health initiatives in Sierra Leone. The purpose was to explore how local communities engage with and shape maternal health initiatives. The objectives were to understand forms of community collaboration, identify perceived enablers and barriers to local agency, and analyse how community actions influence programme implementation. This qualitative study employed a constructivist paradigm. Data were collected through 42 in-depth interviews and 12 focus group discussions with community health workers, traditional birth attendants, local leaders, and mothers in four districts. Thematic analysis was used. A central theme was the critical role of trusted local intermediaries, such as female community elders, in bridging cultural norms with formal healthcare systems. Engagement was most effective when initiatives were co-designed, with participants reporting increased service utilisation when traditional practices were respectfully integrated. However, community agency was often constrained by top-down funding structures and insufficient resource allocation to community-led components. Local communities in Sierra Leone are active agents in maternal health. Sustainable initiatives must move beyond consultation to genuine power-sharing in design and implementation, recognising and resourcing existing community structures. Programme funders and policymakers should mandate and fund co-design phases led by community representatives. Training for external health professionals should include modules on collaborative partnership. Monitoring and evaluation frameworks must incorporate community-defined indicators of success. Community participation, maternal health, qualitative research, Sierra Leone, health programmes, co-design This study provides an in-depth, contextual understanding of the mechanisms of community agency and collaboration in maternal health, offering evidence for more equitable and effective programme design in similar settings.