This thesis examines barriers to accessing health care and their effects on health service utilization for poor women, using Sierra Leone as a case study. Literature on access to health often focuses on one factor, such as financial barriers, and does not examine the range of socio-economic and health system factors that affect access to health services. This thesis analyses access from the perspective of women utilizing these services, examining the interface between women, their socio-economic context, and the health system. It develops a new analytical framework that illustrates this interface, enabling the development of solutions that more effectively improve access. This research found evidence of barriers related to availability, acceptability, geographic accessibility, financial accessibility and gender that prevented women from accessing care in Sierra Leone. Policy recommendations for reducing these barriers are based on the framework and address both the immediate and distal factors that influence access to health services.