Background <p>Health facility delivery is a critical intervention for reducing maternal and neonatal mortality. Although notable progress has been made globally, Sierra Leone continues to face high maternal and neonatal mortality rates, with disparities in access to health facility delivery across regions and socio-economic groups. This study examined the regional trends, spatial patterns, and factors associated with health facility delivery among women of reproductive age in Sierra Leone using data from the 2008, 2013, and 2019 Demographic and Health Surveys .</p> Methods <p>This cross-sectional study utilized data among 19,809 women aged 15–49 who participated in the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys. Descriptive statistics were used to analyze health facility delivery utilization trends across survey years and regions. Spatial analysis, including Moran's I and Getis Ord GI statistics, was performed to identify the spatial clustering of health facility delivery. A pooled multilevel logistic regression model was employed to identify individual and community-level factors associated with health facility delivery.</p> Results <p>The prevalence of health facility delivery increased from 24.6% in 2008 to 83.4% in 2019. Spatial analysis revealed clustering of health facility delivery, with hotspots in the Eastern and Southern regions and cold spots in the Northern and Northwestern regions. Our pooled multilevel analysis revealed that women aged 20–29, those with primary education, those with secondary education, those with higher education, those from middle-wealth households, those from rich households, those who attended at least four antenatal care visits, and those exposed to media had higher odds of health facility delivery. Additionally, women who were Muslims, those practicing traditional/other religions, those who were employed, those with higher parity, those residing in rural areas, those who reported distance to health facilities as a medium problem, those who reported distance to health facilities as a high problem, those from Northern, those from Northwestern, those from the Southern, and those from the Western Area had lower odds of health facility delivery. Health facility delivery odds were higher during the 2013 and 2019 surveys compared to 2008.</p> Conclusion <p>Despite improvements in health facility delivery utilization in Sierra Leone, major regional and socio-economic disparities remain. Targeted interventions to enhance maternal education, reduce geographic barriers, and address community-level inequalities are essential for equitable access to health facility delivery and better maternal and neonatal health outcomes.</p>