Twelve women died every month giving birth in a Freetown hospital in 2010, in a country with one of the world's worst maternal mortality rates, a government study showed Tuesday.
Akim Gibril, chairman of an 11-person committee set up to probe challenges at the Princess Christian maternity hospital in Freetown, said the figure was "unacceptable."
"Unless the unfortunate shortcomings including poor post-delivery conditions are urgently addressed, the situation will continue to be the same for 2011," said Gibril, as he handed the report to the country's health minister Hawa Bangura.
In reality the number of deaths during childbirth is much higher per month.
In the west African nation of just over 5.5 million people, one in eight women risk dying during pregnancy or childbirth, according to Amnesty International which launched a campaign in 2009 to reduce maternal deaths in the country.
The majority of these women never make it to hospital and die giving birth at home, or on their way to a health facility.
According to Amnesty, less than half of deliveries are attended by a skilled birth attendant and less than one in five are carried out in health facilities.
The report recommended "a change in the management structure with a strong executive leadership."
"Unless other actions ranging from personnel, infrastructure, maintenance and utilisation are appropriately put in place, the situation will remain challenging," the report said.
Bangura said the report's recommendations would be taken seriously as they raised several ways to improve maternal health care, including improving the working conditions of health staff.
Sierra Leone's troubled health care system was devastated by a 10-year civil war that ended in 2001.
The government launched a free health care program for women and young children in April 2010 in an effort to bring down death rates.
The World Bank estimated there were 192,3 deaths per 1,000 children younger than five in Sierra Leone in 2009.