There is a question I keep returning to when I think about women’s health in Lagos: when a woman is worried about a pregnancy or needs sensitive reproductive healthcare, where does she go?
Not where we assume she should go. Not where our policies say she should go. Where does she really go?
Recent evidence from a rapid assessment conducted by the Women Empowering Women Initiative (WEWIN) gives us reason to think more deeply about that question. The assessment engaged 154 people across Lagos State, including women of reproductive age, women with lived experience of sensitive pregnancy-related care, healthcare workers, pharmacists and Patent and Proprietary Medicine Vendors (PPMVs).
Among the access patterns captured, government hospitals accounted for only 5 percent, compared with 20 percent for private clinics and 45 percent for pharmacies and PPMVs. A further 30 percent involved self-managed, traditional or other potentially unsafe pathways. These figures are not estimates for every woman in Lagos. They are findings from this assessment. But even with that limitation, they raise an important public-health question: why might a woman choose somewhere else when a formal health facility exists?
The easy answer would be to question women’s choices. The more useful answer is to understand them.
For many women, healthcare decisions are made within the realities of cost, privacy, distance, family circumstances, and fear of being judged. Our assessment found concerns about judgement, exposure and discrimination when seeking care. Younger women faced concerns about confidentiality, while financial barriers were more pronounced among women from low-income communities.
Imagine being a young woman who needs help with a deeply personal health concern. You know the facility is there, but you are unsure who will see you, what questions will be asked, whether your information will remain private, or whether you can afford the care you may eventually need.
The pharmacy around the corner may suddenly feel easier.
This does not mean pharmacies and PPMVs are inherently the problem. In many Nigerian communities, they are among the most accessible and trusted points of healthcare. Our assessment found that trained PPMVs demonstrated appropriate practices and referral awareness. The concern was inconsistency: knowledge varied among untrained providers, while referral pathways were sometimes weak or absent.
That distinction matters.
A stronger health system should recognise where people are already seeking help and build safer connections between those entry points and formal healthcare. Community-level providers need appropriate knowledge and referral pathways. Formal facilities, meanwhile, must become places women associate not only with clinical expertise but also with confidentiality, dignity and respectful treatment.
Lagos already has an extensive health system and policy infrastructure. Primary healthcare facilities are intended to serve as accessible first points of care and connect people to higher levels of treatment when necessary. But infrastructure alone cannot create trust.
We also must pay attention to the experience of walking through the door.
Do women feel safe asking difficult questions? Is confidentiality protected? Are healthcare workers sufficiently supported to respond to complex reproductive health needs? Are referrals clear? When a woman feels poorly treated, does she know where to complain, and does anything happen afterwards?
These may sound like softer questions than medicines, equipment and staffing. They are not. They are health-system questions.
Because delayed care has consequences, when fear, cost or uncertainty pushes a woman away from appropriate healthcare, a manageable situation can become an emergency. The burden eventually returns to the same health system, only later and often more complicated.
Perhaps, then, we need to change the question.
Instead of asking why women are not using the services we have provided, we should ask what their choices are telling us about the services we have built.
A responsive health system listens to that answer.
Women’s healthcare choices do not happen in a vacuum. They are shaped by cost, trust, privacy, experience, and accessibility. If women are choosing other doors before the formal health system, the answer is not simply to close those doors. It is to understand why and make the formal system a door worth choosing.
Stella Peters is an Executive Director of WEWIN, a rights-driven organisation dedicated to advancing sexual and reproductive health and rights, empowering women, youth, and girls through advocacy, education, and community-centered interventions to end unsafe abortion, reduce maternal mortality, and create a future of dignity, autonomy, and equality