Background: Perinatal asphyxia is a leading cause of neonatal morbidity and mortality and it is responsible for about a third of neonatal deaths in Sierra Leone. Identifying and addressing the various risk factors associated with perinatal asphyxia could reduce this burden. This study was therefore done to determine the incidence, risk factors and outcome of perinatal asphyxia among neonates delivered at the Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Freetown, Sierra Leone. Methods: This is a case control study, conducted from 1st May 2024 to 30th June 2024. Neonates diagnosed with perinatal asphyxia (Apgar score < 7 at 5th minute) were considered as “cases” (N = 110) while neonates born either with normal vaginal delivery or by cesarean section having no abnormality were considered as “control” (N = 110). Results: The incidence rate of perinatal asphyxia was 7.60%. Young maternal age <18 years (p = 0.031), lower maternal educational status (p = 0.040), primigravidity (p = 0.028), primiparity (p = 0.007), abnormal amniotic fluid (p = <0.001), labour duration ? 12 hours (p = <0.001) and prolonged rupture of membranes ? 24 hours (p = 0.028), were related to the occurrence of perinatal asphyxia. Out of the 110 asphyxiated neonates, 7 died giving a case fatality of 3.4%. Conclusion: Various risk factors led to the high incidence of perinatal asphyxia in this study. Improving the quality of antenatal care; labour monitoring; and strengthening capacity of healthcare workers on neonatal resuscitation, are crucial in reducing morbidity and mortality associated with perinatal asphyxia.