High rates of maternal mortality remain a persistent problem in Sierra Leone. Efforts to reduce these high rates have included initiatives to encourage more women to deliver at health facilities. Despite the introduction of free health care for pregnant women, many women still continue to deliver at home, with few having access to a skilled birth attendant. In addition, inequalities between rural and urban areas in accessing and utilising health facilities persist. Further insight into how and why women and their communities make decisions around childbirth will help guide future plans and initiatives in improving maternal health in Sierra Leone. This qualitative study explores the decision-‐making process during childbirth in rural Sierra Leone. It has particular focus on examining the thoughts and experiences of mothers living in rural areas, the perceived risks associated with pregnancy and delivery, and who and what influences the decision-‐making process. The study draws on 13 in-‐depth interviews, three group interviews, eight focus group discussions and informal interviews with rural Sierra Leonean women, their family members, traditional birth attendants, health workers and other key informers. The results of this study demonstrate that the decision-‐making process during childbirth in rural Sierra Leone is dynamic and intricate, and needs to be understood within the broader social context that it takes place in. Decisions are rarely independently made and are usually socially negotiated. The amalgamation of past experiences, social expectations and relationships of those involved, as well as the perceived risks of the individual and their community influence how decisions are made. Preferences regarding where to give birth and with whom assisting, are weighed up against the complexity of enabling, supportive and inhibitory factors that are present within the health care systems and social context. Decisions are often pragmatic and rational, made within the constraints of poverty and other social determinants out of the direct control of the individuals involved. Final decisions can be ad hoc at times as new and unexpected circumstances or events occur.