Carshon-Marsh R, Aimone A, Ansumana R, et al. - In order to ascertain the causes of child and maternal mortality in Sierra Leone, the Sierra Leone Sample Registration System (SL-SRS) of births and deaths was launched. In this work, cause-specific mortality from the first SL-SRS round, representing deaths from 2018 to 2020, has been reported.

• SL-SRS establishment involved carrying out electronic verbal autopsies in 678 randomly chosen villages and urban blocks throughout the country.

• For capturing verbal autopsies on deaths from 2018 to 2020, people were enrolled and deaths of individuals younger than 70 years were ascertained in 2019–20 by 61 surveyors, in teams of four or five.

• Centrally, causes of death were assigned according to the International Classification of Diseases (tenth edition) by two trained physicians independently.

• A total of 343,000 people were enrolled and 8,374 deaths of individuals younger than 70 years were ascertained.

• In 2020, 22% of all deaths were assigned to malaria, and malaria was identified to be the leading cause of death in all age groups except neonates.

• An additional 16% of deaths were assigned to other infectious diseases.

• Overall maternal mortality ratio of 510 deaths per 100,000 livebirths, and neonatal mortality rate of 31·1 deaths per 1,000 livebirths were recorded.

• The major cause of maternal mortality was hemorrhage and the major cause of neonatal mortality was birth asphyxia or trauma.

• There appeared no excess deaths in the months of 2020 corresponding to the peak of the COVID-19 pandemic.

• Half of the deaths occurred in rural areas and at home.

• Premature death occurs in over 60% of individuals in Sierra Leone, most from preventable or treatable causes.

• Observations support the great utility of nationally representative mortality surveys such as the SL-SRS, in attaining reliable cause-of-death information to set public health priorities and target interventions in low-income countries.