The tragedy is not that medicine lacks the answers. It is that those answers still fail to reach millions of women in time.

In 2023, approximately 182,000 women died from pregnancy-related causes in sub-Saharan Africa alone.¹ From haemorrhage. From high blood pressure. From infection. From not reaching help quickly enough.

These conditions are well-understood and preventable. We already have the knowledge to address them. The real challenge is ensuring that this information reaches women who need it at the right time, in the right place, and delivered by someone trained to support her.

I have worked in environments where maternal mortality is not an abstraction. Where all four barriers play out in real time. Where a woman who finally reaches a tertiary facility can still face a bill she cannot pay. That reality sits quietly beneath most of the data, but it shapes outcomes just as powerfully as geography or staffing.

What Is Killing Women in Childbirth across Africa?

The leading causes of maternal death across sub-Saharan Africa are haemorrhage, hypertensive disorders of pregnancy, infection, obstructed labour, and complications from unsafe abortion.² Every single one is manageable with skilled care, the right resources, and the ability to reach a facility in time.

So what goes wrong? Research analysing maternal deaths across 25 African countries found that deaths cluster around four consistent points.³

Deciding to seek care. Women wait — sometimes because they do not recognise a warning sign, sometimes because a previous experience with the health system left them reluctant to return, sometimes because the decision is not theirs alone to make.

Reaching a facility. Distance, cost of transport, and the physical difficulty of travelling in labour mean that deciding to go does not always mean arriving in time. Nearly 16% of maternal deaths are linked to this delay alone.

Receiving treatment on arrival. Nearly half of all maternal deaths (45.7%) are linked to delays in treatment after a woman has arrived at a facility.³ Understaffed facilities, missing medications, and gaps in training mean the system is not always ready when she gets there.

Paying for care. This one rarely appears in the formal framework but it belongs here. In many settings, women are asked to pay for blood, for theatre, for drugs, at the most critical moment. Families who cannot pay face impossible choices. This barrier operates at every level of the system, including the tertiary.

What Is the Healthcare Workforce Shortage in sub-Saharan Africa?

You cannot talk about maternal mortality without talking about who is or is not in the room when a woman gives birth.

Sub-Saharan Africa averages approximately 1.55 doctors, nurses, and midwives per 1,000 population, well below the WHO threshold of 4.45 per 1,000 needed to deliver essential health services.⁴ The region is operating at roughly a third of what is required.

Only 65% of births across the African region are attended by a skilled health worker — the lowest proportion globally, and far below the 2030 target of 90%.⁴ A midwife or doctor who can recognise when something is going wrong, and act, is not a luxury. In most settings, they are the difference.

65% of births are attended by a skilled worker. The lowest proportion globally. The gap between that number and 90% is measured in lives.

How Did 5 African Countries Successfully Reduce Maternal Mortality?

This is the part of the story that does not get told enough.

Between 2000 and 2023, five sub-Saharan African countries reduced their maternal mortality by 75% or more.⁵ Not through new technology or external rescue. Through deliberate decisions about what to prioritise and consistent follow-through.

Rwanda tackled two barriers at once. It built a community health insurance scheme that meant women no longer had to choose between seeking care and paying for it. Alongside this, it invested in midwifery training and rural deployment. Maternal mortality fell from 210 deaths per 100,000 live births in 2014/15 to 105 by 2023, halved in under a decade.⁶

Ethiopia addressed the first delay at its root. A national network of community health workers — women trained to visit families at home during pregnancy and after delivery — identified risk early, promoted birth preparedness, and facilitated referrals. The system proactively reached out to women instead of waiting for them to arrive.

Mozambique invested in physical infrastructure and workforce simultaneously. Between 2017 and 2021, 106 new health facilities were opened and the health workforce grew by 15%. Community health workers were trained for early risk identification and timely referral. Maternal mortality fell by more than 50% from 2000 to 2023.⁷

Sierra Leone made one of the most direct policy decisions on this list: it removed user fees for pregnancy- and childbirth-related services entirely, addressing the fourth barrier head-on. Women no longer had to pay to deliver safely. Skilled birth attendance rose from 54% in 2010 to over 80%. Maternal mortality fell by more than 75%.⁸

Uganda trained and deployed village health teams — community health workers who conducted home visits during pregnancy and after delivery — to improve knowledge of danger signs, promote institutional delivery, and reduce the time between recognising a problem and reaching care. Facility deliveries in intervention areas rose from 65% to over 75%.

None of these are wealthy countries with unlimited resources. What they share is a decision to identify the specific barriers in their specific contexts and to address them with what they had.

They did not discover new interventions. They made sure existing ones actually reached women. That is the difference.

How Can Maternal Mortality Be Reduced? What the Evidence Says Works

The solutions are not theoretical. They are already proven, already available, and already working in some settings. What is needed is scale, commitment, and the willingness to do the unglamorous work of making systems function.

Train and deploy more midwives especially in rural areas. Rwanda’s results were built substantially on this. Midwives can provide 90% of essential reproductive and maternal health services.⁶ Investing in their education, regulation, and deployment is one of the highest-return investments in women’s health.

Build community health worker networks that go to women. Ethiopia and Uganda demonstrate this clearly. A trained community health worker who visits a pregnant woman at home, spots a warning sign early, and helps her reach care in time is not a workaround. In many settings, she is the system.

Remove or reduce cost at the point of care. Sierra Leone’s removal of user fees for maternity services produced a measurable rise in skilled attendance almost immediately. Cost at the point of care is a solvable policy problem. Where it has been solved, women come.

Stock facilities with what they need to act. Blood for transfusion. Medications for managing haemorrhage and hypertensive emergencies. Staff who are trained and present. A woman who reaches a facility should not die because it was not ready for her.

Strengthen referral pathways between levels of care. A tertiary hospital cannot do its job if women arrive too late, too sick, or unable to pay. Primary care needs to be strong enough to identify risk early and move women safely when needed.

What Can Women and Communities Do Right Now?

Systemic change takes time. But there are things that make a difference now at the level of the family, the community, and the health worker.

Start antenatal care early and attend consistently. Not just for attendance — for assessment. Blood pressure checked. Blood tests done. Risk identified before it becomes an emergency.

Know the warning signs in pregnancy. Severe headache. Blurred vision. Heavy bleeding at any stage. Fever. Reduced baby movements after 28 weeks. Sudden swelling of the face or hands. These are reasons to seek care the same day — not reasons to wait and see.

Prepare for birth before labour begins. Know where you will deliver. Know how you will get there. Have someone who can travel with you. Set aside what you can toward costs. These decisions made in advance have saved lives — and any family can make them.

If you are a health worker or community leader: the evidence is clear on what works. Home visits during pregnancy. Clear referral pathways. Facilities that are stocked and staffed. None of this requires a revolution. It requires consistency.

A Word From Me

I have worked in environments where a maternal death is not uncommon, where the system is working hard, under enormous pressure, with too little to work with. Where all four barriers can play out in a single case. Where a woman who finally reaches tertiary care may still face a bill that stops her treatment.

That reality does not make the evidence less true. Rwanda, Ethiopia, Mozambique, Sierra Leone, and Uganda did not have easy conditions. They faced the same constraints, the same pressures, the same resource limitations that much of Africa faces. What they had was a decision to prioritise this and to build solutions that worked within their actual context.

The gap between where Africa is and where it could be is not a gap in possibility.

It is a gap in priority and investment. And gaps like that can be closed.

With care,

Dr Adeniyi.

Sources

World Health Organization. Maternal mortality fact sheet. Updated April 2025. who.int/news-room/fact-sheets/detail/maternal-mortality. Muriithi FG, et al. A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa. PLOS Glob Public Health. 2024. doi:10.1371/journal.pgph.0002950. Nkurunziza T, Habonimana D, Muriithi A, Deganus S, Kayita J, Aderoba A, Mwinga K. Towards improving maternal and perinatal death surveillance and response in the African region: an analysis of 25 countries from 2015 until 2022. BMJ Glob Health. 2026 Feb 25;11(2):e018328. doi: 10.1136/bmjgh-2024-018328. Ahmed S, Ali M, Shah I, Tsui A. Effect of maternity care improvement, fertility decline, and contraceptive use on global maternal mortality reduction between 2000 and 2023: results from a decomposition analysis. Lancet Glob Health. 2026 Jan;14(1):e33-e48. doi: 10.1016/S2214-109X(25)00409-7. UNFPA Rwanda. Maternal Health — Rwanda’s progress. 2025. rwanda.unfpa.org/en/topics/maternal-health. WHO Regional Office for Africa. Mozambique: Driving down maternal mortality. 2024. afro.who.int. WHO Regional Office for Africa. Sierra Leone’s determination to stem maternal and child mortality. 2023. afro.who.int

Most women with fibroids will be fine. Fibroids are the most common non-cancerous growth in women of reproductive age, and most of them cause no symptoms, need no treatment, and simply exist without ever becoming anyone’s problem.

That is worth saying clearly, because a lot of women are frightened by the word “fibroid” when they first hear it. You do not need to be.

But I also need to say what does not get said clearly enough in the other direction.

For some women, particularly Black women, fibroids are not a minor finding. They are a condition that disrupts daily life, complicates fertility, and leads to major surgery. And the way medicine has responded to that reality, for decades, has not been good enough.

The women who carry the heaviest burden of fibroids are the ones medicine has studied least and listened to last.

That is what I want to talk about today. Not to frighten anyone. But knowing this makes you a better advocate for yourself.

So what are fibroids, really?

Fibroids are non-cancerous growths made of muscle and fibrous tissue that develop in or around the uterus. They can be tiny, smaller than a pea, or grow quite large. They can be solitary or multiple. Most women who have them never know.

When fibroids do cause symptoms, the most common are:

Heavy periods — the kind that soaks through protection within an hour, or that sends you home from work.

Long periods — lasting seven days or more.

Pelvic pressure or fullness.

Frequent urination.

Pain during sex.

Tiredness that does not lift — often from the blood loss.

Difficulty getting or staying pregnant.

These symptoms matter. They are not normal just because they are common. And they are not things to wait out indefinitely.

Why fibroids and Black women, what the research actually says

If you are a Black woman, you are two to three times more likely to develop fibroids than a white woman.¹ You are also more likely to develop them younger, to have more of them, and to have symptoms severe enough to need treatment.

That much has been known for a long time. What has been studied far less carefully is why.

A 2022 systematic review — one that looked not at fibroids themselves but at the research on fibroids found something telling. Despite the disparity being well established, there was still no consensus on its cause, because the question had never been studied with the attention it deserved.¹

For too long, researchers have viewed race as a biological trait. However, it is not. Rather, race mainly represents lived experience, both in this context and beyond. Factors such as chronic stress, environmental exposures, access to healthcare, and whether a doctor acknowledged someone’s symptoms play significant roles.

A 2023 review was direct about this: the causes of the disparity are structural and environmental, not biological.⁴ The gap is not about Black women’s bodies. It is about the world those bodies live in, and how the medical system has treated them.

For years, the research has asked what was different about Black women’s bodies. The better question was what was different about their world and whether medicine was paying attention.

What new research shows about treatment and where the gaps are

A 2025 systematic review looked at surgical outcomes for fibroids across 14 studies, and more than 2.3 million women.7. What it found was not surprising.

Black women are less likely to be offered minimally invasive surgery the kind with smaller incisions, shorter recovery, and fewer complications. They are more likely to end up with open abdominal surgery instead.

They are more likely to stay in hospital longer after their procedure. They face higher rates of complications.

And here is the part that stopped me: these differences persisted even in healthcare systems where cost and insurance were not barriers. Even when Black women were in the same hospitals, accessing the same tier of care, the disparities remained.

The review also found that the type of insurance plays a significant role. Women on Medicaid who are disproportionately Black are more likely to be offered a hysterectomy than less invasive alternatives. Not because hysterectomy is necessarily the right choice. But because it is the one most readily available within that coverage.⁷

This is what structural inequality looks like in a clinical setting. It does not always announce itself. It shows up in what gets offered and what does not.

A treatment that could narrow the gap

The same 2025 review identified one procedure where the outcome gap between Black and non-Black women largely disappeared.

It is called MR-guided focused ultrasound surgery (MRgFUS). It uses targeted sound waves to reduce fibroids without any incision. No open surgery. Faster recovery. And in the studies where both Black and non-Black women had access to it, the differences in outcomes were minimal.⁷

The problem is access. MRgFUS is not widely available. Many hospitals do not offer it. Many clinicians are not trained in it. And the eligibility criteria are currently quite narrow.

I raise it not to add to anyone’s frustration, but because knowing it exists means you can ask about it. And asking is where things sometimes change.

What you are entitled to ask for

Whether or not any of the above applies directly to you, here is what I want you to take away.

Your symptoms are worth investigating.

If you are soaking through protection, passing clots, or losing so much blood that you are exhausted, that is not something to push through. Ask for a pelvic ultrasound. Ask for your iron levels to be checked. These are reasonable, basic requests.

Hysterectomy is not the only option.

It is the right choice for some women. But it should not be the default, especially for women who may still want to conceive. If it is the only thing being offered, ask specifically about:

Myomectomy — surgical removal of the fibroids, leaving the uterus intact.

Uterine artery embolisation — a procedure that cuts the blood supply to fibroids.

MRgFUS — targeted sound wave treatment, where available.

Hormonal and non-hormonal medical management.

You are allowed to push back.

A field that has consistently been under-studied concerning this condition, and recent evidence indicates that it has resulted in poorer surgical outcomes for Black women specifically, does not merit being disregarded. If something feels wrong or if you feel unheard, you are allowed to ask again. You are allowed to seek a second opinion. You are allowed to expect a full conversation about your options.

A word from me

I started this piece by saying most women with fibroids will be fine. I meant that.

But I have been doing this for years, and I have sat with enough women who were not fine who were dismissed for years before someone took them seriously, to know that “most” is not enough.

The new surgical data does not change what fibroids are. It changes what we know about how they are being treated and for whom. That knowledge belongs to the women affected by it.

You are entitled to truthful information. You warrant a physician who attentively listens, and you have the right to be informed that if a condition has persistently felt amiss, there exists evidence elucidating the reasons and evidence indicating that circumstances can be altered.

If this was useful, please share it with someone who needs to read it.

Sources

Charifson MA, et al. Why are Black individuals disproportionately burdened with uterine fibroids? F S Rev. 2022;3(4):256–279. Yang Q, et al. Comprehensive review of uterine fibroids. Endocr Rev. 2022;43(4):678–719. Eltoukhi HM, et al. The health disparities of uterine fibroid tumors for African American women. Am J Obstet Gynecol. 2014;210(3):194–199. Katon JG, Plowden TC, Marsh EE. Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context. Fertil Steril. 2023;119(3):355–363. doi:10.1016/j.fertnstert.2023.01.022. Khan NH, McNally R, Kim JJ, Wei JJ. Racial disparity in uterine leiomyoma: new insights of genetic and environmental burden in myometrial cells. Mol Hum Reprod. 2024;30(3):gaae004. doi:10.1093/molehr/gaae004. Goosby BJ, Winkle-Wagner R, Zhang A. The Uterus Keeps the Score: Black Women Academics' Insights and Coping with Uterine Fibroids. J Health Soc Behav. 2025 Jun;66(2):212-227. doi: 10.1177/00221465241268434. Reid D, Noel B, Lam J, et al. Racial Disparities in Surgical Outcomes for Uterine Fibroids: A Systematic Review. Arch Obstet Gynecol. 2025;6(1):1–10.

Health note

This article is for health education only and does not replace medical advice. If you have symptoms that concern you, please see a qualified healthcare provider.

With care and in support of women who deserve more than attendance counted on paper,
Dr Adeniyi

More women are now failed inside the system than outside it.

This pattern—attendance without content—was observed in every region studied.

The gap between attending antenatal care and receiving it is now larger than the gap created by not attending at all. That is the central finding of the most comprehensive analysis of antenatal care ever conducted.

What the guideline says

The WHO 2016 recommendation specifies a minimum of eight antenatal contacts. At each visit, specific clinical activities are expected: blood pressure and weight measurements, blood and urine tests, and iron supplementation.

These five items are not advanced care. They are the minimum required to detect pre-eclampsia, anaemia, infection, and nutritional risk in time to act.

The Lancet study focused on these items because they are globally applicable, consistently reported, and evidence-based. They represent a conservative floor of competent antenatal care.

In 2023, only 69.3% of women with a livebirth received all five items. Among those who attended at least one visit, 73.8% did. Roughly one in four women who attended antenatal care did not receive the minimum care the visit was designed to provide.

Nigeria: attendance without content

But even when women do attend, care is often incomplete.

In Nigeria in 2023:

• 91% of women attended at least one antenatal visit

• 31% initiated care in the first trimester

• 74% received all five basic items

• Mean number of visits: 5

Nine in ten women attend antenatal care. Yet fewer than a third start early, and one in four who attend do not receive the minimum recommended care.

This is not primarily a problem of access. It is a problem of delivery.

What booking late actually costs

None of this means attendance no longer matters. It does, and the consequences of not engaging with antenatal care remain severe.

A study I co-authored at Olabisi Onabanjo University Teaching Hospital in Sagamu examined outcomes among booked and unbooked women delivering between 2017 and 2018.

Maternal mortality was 2.6% among unbooked women, compared to 0.4% among booked women (P<0.001). Maternal morbidity was 8.1% versus 2.5% (P<0.001). Fetal death was 40.6% among unbooked women, compared to 6.3% among booked women (P<0.001).

These differences reflect what happens when antenatal care is not accessed in time.

Why do women book late

A second study at the same institution examined booking patterns between 2016 and 2020. Of 6,899 pregnancies, only 23.9% were booked in the first trimester. Most (64.6%) booked between 14 and 26 weeks. A further 11.5% booked between 27 and 36 weeks.

The mean gestational age at booking was 17 weeks—well beyond the window in which first-trimester screening is most effective.

Younger age and higher education were associated with earlier booking. Previous complications were not.

Women who had experienced complications were not booking earlier. Many were waiting for a problem to appear.

The implication is clear: antenatal care is still widely perceived as reactive rather than preventive. Women are coming when they feel something is wrong. The message that antenatal care is most valuable precisely when nothing is wrong yet has not fully reached them.

The measurement problem

For decades, antenatal care coverage has been measured globally as ANC4 — the proportion of women attending at least four visits. This is the metric tracked by the Sustainable Development Goals (SDGs).

The Lancet study compared ANC4 with the actual content of those visits as predictors of health outcomes. In every comparison, the mean care content was more strongly associated with lower maternal mortality, neonatal mortality, and stillbirth rates than the sheer number of visits.

We have been counting visits rather than what happens during them. Increasing visits without improving care risks wasting resources — for both women and health systems. A woman who attends eight visits but receives no blood pressure monitoring, no urine testing, and no iron supplementation has not received eight contacts of care. She has received eight missed opportunities.

A WHO Bulletin paper published in April 2026 describes this as the “know–do gap”: the distance between what medical evidence recommends and what health systems actually deliver. The evidence is not the problem. Implementation is.

What must change

The evidence points to three priorities:

1. Antenatal care content must be measured alongside attendance. Counting visits without measuring what was delivered creates the appearance of progress where critical gaps remain. Quality metrics must be integrated into successor frameworks to the SDGs.

2. First-trimester booking must become the norm. The WHO recommends first contact within 12 weeks. In Sagamu, only 23.9% met this threshold. Health education must reposition ANC as an active tool for wellness, not a destination for illness.

3. The five basic items must be delivered at every eligible visit. These are not complex interventions. Gaps reflect administrative and structural failures in supply chains, staffing, equipment availability, and strict adherence to clinical guidelines.

What does this mean if you are pregnant?

The quality of care you receive matters more than how many times you attend. And when you start, it determines what can be safely detected and managed. If you are pregnant or planning a pregnancy:

Book before 13 weeks if possible. This is the vital window where baseline screenings, early blood tests, and pre-eclampsia risk assessments are most effective.

At your first visit, ensure these five happen: Blood pressure, weight, blood test, urine test, and a discussion of iron supplementation. These are the WHO minimum standards. If they are missed, ask your provider directly for them.

If you have had a previous complication, book earlier, not later. Past delivery issues are a clear clinical indication for monitoring from the start of the first trimester.

Do not wait for symptoms. Antenatal care is most effective before problems develop. High blood pressure or anaemia, if found early, can be managed effectively before they affect you or your baby.

A clinician’s perspective

As an obstetrician, I have seen firsthand the serious consequences of late booking and incomplete care.

These findings reflect what many clinicians already know deep down. The issue is not that women do not value their pregnancies. It is that systems measure attendance instead of delivery, and that antenatal care is still widely misunderstood as something you seek only when something is wrong.

The medical evidence says the exact opposite. Antenatal care is most powerful when nothing is wrong yet. The first trimester is the window. The five basic items are the floor. What happens at the visit is what matters.

Attendance has improved substantially over the past three decades. But as the Lancet study concludes, missed opportunities during visits now outweigh gaps caused by non-attendance.

We have spent decades asking whether women attended antenatal care.

The more important question is whether they received it.

We have made attendance the story. Content is the story that matters.

Sources

Gage A et al. Measuring antenatal care timing and content across 131 low-income and middle-income countries, 1995-2023: a systematic analysis of trends. Lancet Glob Health. 2026;14:e702-13. doi: 10.1016/S2214-109X(26)00010-0. Funded by the Gates Foundation. — Sule-Odu AO, Akiseku AK, Jaiyesimi OE, Adejumo AO, Odelola OI. Ante-Natal Care Utilization and Comparison of Obstetric Performance of Pregnant Women Attending Tertiary and Secondary/Primary Health Facilities in South West Nigeria. West African Journal of Medicine. 2020;37(4):334-340. — Oloyede OA, Adefuye PO, Akiseku AK. Trend of Antenatal Bookings in a Teaching Hospital in South Western Nigeria. Journal of Health and Medical Sciences. 2022;5(2):68-73. doi: 10.31014/aior.1994.05.02.213. — WHO. WHO recommendations on antenatal care for a positive pregnancy experience. WHO Bulletin. Closing the know-do gap: adapting WHO recommendations for antenatal and postpartum care. Bull World Health Organ. Published online 16 April 2026. doi: 10.2471/BLT.25.295382.

Health note

This article is for health education only and does not replace medical advice. If you are pregnant, speak to a qualified healthcare provider about antenatal care that is appropriate to your individual circumstances and health history.

With care and in support of women who deserve more than attendance counted on paper,
Dr Adeniyi

By the time the diagnosis is made, it is often no longer in doubt. The cancer is advanced, the anaemia is severe, and the question that hangs in the room is not what this is, but why so late.

She came too late. We already knew why.

The evidence explaining why women are diagnosed late with cervical cancer has existed for years. So has the evidence on what prevents it.

The gap between knowing and doing is where lives are lost.

In a study I led at a tertiary hospital in southwestern Nigeria, 56% of women diagnosed with cervical cancer presented at a late stage. More than three-quarters had clinically significant anaemia. Most were postmenopausal.

These women had not simply failed to seek care. Many had interacted with health services before their diagnosis. The pathways that should have found them earlier had either not been built, had not reached them, or had not been designed with them in mind.

That distinction is important. Framed as an individual failure (she did not attend, she lacked awareness), the problem produces small solutions that do not scale. Framed as a systems and equity gap, it yields a different, more useful set of questions.

The evidence here is not new. What is overdue is the move from documenting the problem to designing the response.

What the evidence shows

Cervical cancer is the fourth most common cancer among women globally. In Nigeria, it accounts for 14.8% of all cancer-related deaths among women. In sub-Saharan Africa, cumulative mortality over two to five years ranges from 65% to 68%. These outcomes do not demonstrate the limitations of medicine; rather, they illustrate the constraints in access.

In my study, two factors were independently linked to late-stage presentation. Women with no formal education had 4.4 times higher odds of late diagnosis compared to those with tertiary education, and postmenopausal women had 4.5 times higher odds than premenopausal women. These findings align with data from Uganda, Ghana, Ethiopia, and the region.

The postmenopausal finding is worth examining carefully, because it points to something structural rather than individual. Younger women interact with health services regularly for contraception, antenatal care, and menstrual concerns. Those interactions create opportunities for incidental screening, for clinicians to ask questions, and for early findings to be made. Postmenopausal women, by contrast, often have no routine reason to attend. When gynaecological screening is not formally integrated into postmenopausal care, a significant proportion of women simply fall out of the pathway. It’s not due to their choice; rather, the pathway wasn’t extended enough to reach them

.

Why this is a systems problem and not an individual one

A 2025 scoping review published in The Breast examined diagnostic delays among women with cancer across 22 studies from high-income countries, using Bronfenbrenner’s ecological model. Its central finding is relevant far beyond high-income settings: delayed diagnosis is not caused by a single factor but by multiple overlapping layers of individual psychology, social networks, cultural context, structural access, and broader health system policies operating simultaneously.

Women often wait longer and receive alternative diagnoses more frequently than men. Their somatic symptoms are more often described as unexplained or less specific. The review confirmed that diagnostic delay causes more psychological distress in female than in male cancer patients, meaning the harm of delay is compounded.

In lower-resource settings, the structural layer is even more determinative. Prolonged investigation times, facility-based delays, limited availability of specialist care, and inconsistent documentation of screening history each add time between symptom onset and diagnosis. Each week of additional delay in an already late-presenting patient changes outcomes in measurable, preventable ways.

High-income and low-income settings converge on the same conclusion: improving outcomes means intervening at multiple levels simultaneously, not one after another. Awareness without access is not enough. Access without follow-up is not enough. Follow-up without a system to find who was missed is not enough.

What the evidence says works

The solutions are not unknown. They are documented and worth naming plainly because this is where the conversation should land.

Integrating screening into existing contact points.

Women who are postmenopausal, or who have completed their reproductive years, have fewer routine reasons to interact with gynaecological services. Integrating cervical screening, breast examination, and basic gynaecological review into well-woman clinics and postmenopausal care programmes changes this. It does not require building new infrastructure; it requires extending the mandate of existing ones.

Literacy-focused health education that reaches women where they are.

The association between lower educational attainment and late-stage diagnosis is not immutable. It reflects health literacy knowledge of what symptoms to act on, what screening involves, and why it matters. Radio programmes, community workshops, peer health educators, and mobile health platforms have all demonstrated effectiveness in improving cervical cancer screening uptake in low-resource settings. The technology required is not sophisticated. The commitment required is sustained.

Consistent documentation and follow-up systems.

One of the most preventable contributors to late-stage diagnosis is a woman who was screened, whose result was abnormal, and for whom no follow-up was recorded or actioned. Building simple, reliable follow-up systems into primary and secondary care, identifying who has not returned, ensuring results reach the clinician, and creating a mechanism to act on what is found closes a gap that technology alone cannot bridge.

HPV vaccination as primary prevention.

Nigeria has taken steps to introduce the HPV vaccine into its routine immunisation system, targeting girls aged 9 to 14. This is the most powerful upstream intervention available. The evidence on vaccine effectiveness against HPV-16 and HPV-18, which are responsible for approximately 70% of cervical cancers, is unequivocal. High coverage vaccination will change the incidence figures in the next generation if the programme is sustained and expanded.

The reality gap — and what women can do now

Structural change takes time. Women navigating health systems today cannot wait for it. So alongside the systemic argument, there is a practical one about what women can do within the systems they currently have access to, wherever those systems are.

WHAT YOU CAN DO — wherever you are

If you are a woman in your reproductive years or beyond, these are the conversations worth having now, regardless of where you live: Cervical screening does not stop at menopause. In many health systems, routine reminders for cervical screening are linked to reproductive-age care. Once those reminders stop, screening stops — unless you actively seek it. Ask your clinician specifically whether cervical screening is still relevant for you and when your last screen was. If you have never been screened, ask now. There is no age at which cervical cancer becomes irrelevant. A woman in her fifties or sixties with no screening history is at higher risk, not lower. The conversation can begin with your GP, a community health worker, or a well-woman clinic. Postcoital bleeding is not something to normalise. Bleeding after sexual intercourse was reported in 35% of women in our study at the time of cervical cancer diagnosis. This symptom is not always serious, but it is always worth investigating. If you experience it, name it explicitly in your next consultation. Know what HPV is and whether your daughters have been vaccinated. HPV vaccination before sexual debut is the most effective prevention available. If you have girls aged 9 to 14, ask specifically about HPV vaccination. In your local health system, availability varies, but the question is always appropriate. If a symptom has been dismissed once, it can be raised again. A second appointment, a written list of symptoms, a request for a referral — these are not confrontational acts. They are appropriate responses to a health concern that deserves investigation.

A clinician’s perspective

I have practised obstetrics and gynaecology for fifteen years. The women I think about most are not the ones with unusual presentations or rare conditions. They are the ones whose conditions were entirely predictable, whose diagnoses should have been made earlier, whose outcomes would have been different if the system had reached them sooner.

The research I conducted was not clinically surprising to me. It confirmed what I had observed: that the women arriving late were not, by and large, women who had ignored warning signs. They were women the health system had not adequately served, whose postmenopausal status meant no clinician was routinely looking, whose educational background meant the information had not reached them in a form they could act on, whose anaemia told a longer story about neglected health needs.

The evidence base for what improves outcomes in cervical cancer is strong. The distance between evidence-based and implementation, especially in low-resource settings, remains the central challenge. Closing that distance is not primarily a scientific task. It is a policy, funding, and systems task. And it is solvable.

The goal is not to moralise about who should have done what differently. The goal is to build health systems that identify women earlier, before late-stage diagnosis, before severe anaemia, and before outcomes that did not have to happen.

That is what the evidence points toward. That is what the work requires.

The women arriving late are rarely invisible. More often, they have become invisible to systems that were never designed to keep looking.

We already know how to reduce the rate of late diagnosis. We know the value of screening, the impact of HPV vaccination, the importance of follow-up systems, and the role of health literacy. We know that postmenopausal women cannot be left outside routine pathways of care.

The challenge is no longer discovery. The challenge is implementation. And that challenge is solvable.

Sources

Akiseku AK, Adenuga TO, Jagun OE, Popoola MA, Olatunji AO. Individual-level determinants of late-stage cervical cancer diagnosis and their implications for prevention and control. ecancermedicalscience. 2025;19:2008. doi: 10.3332/ecancer.2025.2008. — Hoveling LA et al. Diagnostic delay in women with cancer: What do we know and which factors contribute? The Breast. 2025;80:104427. doi: 10.1016/j.breast.2025.104427. — WHO. Cervical cancer. Fact sheet, 2025. — WHO. Global Strategy to Accelerate the Elimination of Cervical Cancer. Geneva: WHO, 2020. — Singh D et al. Global estimates of incidence and mortality of cervical cancer in 2020. Lancet Glob Health. 2023;11(2):e197–e206. — The Lancet. Endometriosis: addressing the roots of slow progress. 2024. — Appiah-Kubi A et al. Factors associated with late-stage presentation of cervical cancer in Ghana. Ghana Med J. 2022;56(2):86–94.

Health note

This article is for health education only and does not replace medical advice. Symptoms such as postcoital bleeding, abnormal vaginal discharge, pelvic pain, or unexplained weight loss deserve clinical assessment. If you have never had cervical screening or have not attended in several years, speak to a healthcare provider about when and how to access it.

With care and in support of people navigating difficult and often invisible journeys,

Dr Adeniyi.

There is a particular kind of loneliness that comes with infertility.

Not always because people are cruel, although sometimes they are. Not always because medicine has no answers, although sometimes it does not. But because infertility is one of the few forms of grief people expect you to hide while continuing to function normally.

You still attend weddings.

You still smile at baby showers.

You still answer questions from relatives who think they are being helpful.

“So when are you having children?”

For many couples, infertility is not a single moment of bad news. It is a long season of waiting, calculation, disappointment, and emotional negotiation that spreads into work, marriage, friendships, and faith.

And yet people still misunderstand it badly.

Infertility is more common than most people realise

Many people imagine infertility as rare. Something that happens to others, in unusual circumstances.

The evidence says otherwise.

According to the World Health Organisation’s most comprehensive global analysis, published in 2023, approximately 1 in 6 adults worldwide, around 17.5%, experience infertility at some point in their reproductive lives. That figure is broadly consistent across high-income and low-income countries alike, which tells us something important: infertility does not discriminate by wealth or geography.

Some couples conceive after years of difficulty. Some experience repeated miscarriages. Some become pregnant but cannot carry pregnancies to term. Some have unexplained infertility, where standard tests appear normal, but pregnancy still does not happen. Others discover infertility accidentally, after years of assuming they had time.

This is part of what makes infertility so disorienting. The body often gives no dramatic warning. Menstruation may still occur. Sexual function may appear normal. There may be no pain at all.

Sometimes the first symptom is simply absence:

month after month,

nothing happens.

Infertility is not mainly a woman’s problem

This is one of the most persistent and damaging misunderstandings women face.

Globally, male-factor infertility is a significant cause of fertility challenges, either alone or alongside female factors. Research consistently estimates that the male factor contributes to approximately 50% of all infertility cases, either as the sole cause or as a contributing factor.

But in many societies, women still bear most of the social blame.

Women are investigated first.

Questioned first.

Meanwhile, some men refuse semen analysis entirely because infertility is read as an attack on masculinity rather than a medical question that needs an answer.

This delay has consequences, medical and emotional both. Assessing one partner alone wastes months and points the investigation in the wrong direction.

Relaxing will not fix a blocked tube

People often say, “Just relax, and it will happen.”

This is usually intended as comfort. But for many couples, it lands as dismissal.

Stress can affect reproductive health. Severe or prolonged stress may influence ovulation, hormonal regulation and sexual function. That much is supported by evidence. But infertility is not usually resolved by reducing stress alone.

Blocked fallopian tubes do not clear because someone stopped worrying.

Severe endometriosis does not resolve through optimism.

Abnormal sperm parameters are not corrected by positive thinking.

The reverse is also true. Infertility is not always permanent. Modern reproductive medicine can help many couples through ovulation treatment, surgery, hormonal intervention, lifestyle changes or assisted reproductive technologies. Not every fertility journey ends the same way.

People need the truth, delivered with care. Not false hope, and not false despair.

Social media has distorted the fertility conversation

There is now a strange pressure surrounding fertility online.

Some spaces promote panic: “If you are over 30, your fertility is disappearing immediately.”

Other spaces promote fantasy: “Everyone can conceive eventually if they try hard enough.”

Neither is completely honest.

Age does matter biologically, especially for women, because ovarian reserve and egg quality decline over time. Male fertility can also decline with age, although usually more gradually. But fertility is not experienced the same way by everyone at the same age.

A healthy 38-year-old woman is not automatically infertile. A 26-year-old woman is not automatically protected from fertility problems.

The internet flattens fertility into two false extremes, because fear and certainty spread faster than nuance.

Infertility changes more than the body

Research consistently shows that infertility is associated with significant psychological distress, affecting identity, self-esteem, relationships, and emotional well-being.

It can affect intimacy. Some couples begin to experience sex less as connection and more as scheduled obligation attached to disappointment. It can produce shame that people struggle to explain logically.

In some communities, motherhood is treated almost as proof of womanhood. Childlessness may attract pity, gossip or suspicion. Men may experience private humiliation they never discuss openly.

Even among educated professionals, infertility can create deep emotional isolation, because reproductive success is assumed to happen naturally for everyone else.

But reproductive biology has never been perfectly fair.

Money shapes the fertility journey more than most people admit

Infertility is also an inequality issue.

Fertility investigations, hormone testing, imaging, surgery and assisted reproductive treatments can be financially overwhelming. In many countries, IVF remains out of reach for large parts of the population. Not because the technology does not exist, but because the cost places it beyond most families.

So when people casually ask, “Why don't they just do IVF?” they often underestimate the financial burden involved. Evidence from low- and middle-income countries shows that fertility treatment costs can exceed what many households can reasonably afford, placing some families at risk of significant financial hardship.

Some couples drain savings.

Some travel abroad.

Some stop treatment midway because they cannot continue financially.

Some never begin at all.

And in many low-resource settings, preventable causes of infertility (untreated infections, complications from unsafe procedures, delayed access to reproductive healthcare) cause fertility loss that earlier, equitable care would have prevented.

Not every fertility journey ends with pregnancy

Medicine is powerful, but it is not omnipotent.

This is one of the hardest truths to hold, for patients and clinicians alike. Modern health culture implies that with enough effort, technology, or determination, biology should eventually cooperate. Sometimes it does. Sometimes it does not.

That truth deserves sensitivity. It also deserves honesty. People navigating infertility deserve an accurate picture of what medicine can offer, not a curated version built to protect hope at the expense of reality.

Some eventually conceive. Some adopt. Some rebuild their lives differently than they imagined. All deserve to be met with honesty and care, whatever the outcome.

What people navigating infertility most need

They need space to speak without feeling defective.

They need clinicians who explain clearly and without judgement — who take time with the uncertainty rather than rushing to reassurance. They need partners who remain emotionally present even when the journey is long. Families who stop turning reproduction into public performance. Friends who understand that infertility is not always visible simply because someone is still functioning, still smiling, still showing up.

And they need society to stop treating fertility as a moral achievement.

Pregnancy is not proof of superior character. Infertility is not proof of failure.

The conversation about infertility should not only be about whether pregnancy occurs. It should be about dignity, emotional survival, equitable access to care, and the way people carry grief no one can see.

A clinician’s perspective

Infertility is one of the most emotionally misunderstood areas of healthcare because the focus so often falls only on the outcome — whether pregnancy occurs.

But for many patients, the real suffering begins much earlier: the waiting, the uncertainty, the monthly disappointment, the social pressure, the quiet fear that time is moving and nothing is changing.

In 15 years of practice in obstetrics and gynaecology, I have sat with couples at every stage of this journey. What people need most is rarely a more aggressive treatment plan. It is someone willing to slow down, explain honestly, and treat the whole person, not just the clinical problem.

That part of the work is not optional. It is the work.

Health note

This article is for health education only and does not replace medical advice. Infertility can involve female factors, male factors, combined factors or unexplained causes. If you have been trying to conceive without success for 12 months (or 6 months if you are over 35), speak to a qualified healthcare professional for proper evaluation and guidance rather than relying solely on online information or social assumptions.

Sources

World Health Organization. Infertility prevalence estimates, 1990–2021. Geneva: WHO; 2023. Available at: www.who.int/publications/i/item/9789240068520. World Health Organization. Infertility. Fact sheet, updated 2023. Available at: www.who.int/news-room/fact-sheets/detail/infertility. Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol. 2015;13:37. doi:10.1186/s12958-015-0032-1. Agarwal A, Baskaran S, Parekh N, et al. Male infertility. Lancet. 2021;397(10271):319-333. doi:10.1016/S0140-6736(20)32667-2. Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007;22(6):1506-1512. doi:10.1093/humrep/dem046. Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues Clin Neurosci. 2018;20(1):41-47. Njagi P, Groot W, Arsenijevic J, et al. Financial costs of assisted reproductive technology for patients in low- and middle-income countries: a systematic review. Hum Reprod Open. 2023;2023(2):hoad007. National Institute for Health and Care Excellence (NICE). Fertility problems: assessment and treatment. Clinical guideline CG156. Updated 2023. Available at: www.nice.org.uk/guidance/cg156. European Society of Human Reproduction and Embryology (ESHRE). Unexplained infertility guideline. Hum Reprod Open. 2023. Available at: www.eshre.eu/Guidelines-and-Legal/Guidelines. Leslie SW, Soon-Sutton TL, Khan MAB. Male Infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated February 2024. Available at: www.ncbi.nlm.nih.gov/books/NBK562258

With care and in support of people navigating difficult and often invisible journeys,

Dr Adeniyi.

A patient told me this some year back. She is educated, articulate, and had no clinical reason to be afraid.

And yet.

Her body remembered something her mind had tried to move past.

The numbers are not small

72% of women have delayed a gynaecology visit at some point. 54% said fear or discomfort was the primary reason. This is from a Harris Poll survey of over 1,100 women conducted in 2024.

In the UK, nearly 1 in 3 women missed their cervical screening in 2023 to 2024. Among the youngest eligible age group, attendance dropped to 55.5%.

These women are not indifferent; the majority are aware of the importance of screening. Nevertheless, they continue to abstain from attending.

This is human, not irrational.

Why the gynaecology clinic is different

Most medical consultations involve conversation. Gynaecology involves intimate examinations, deeply personal questions, exposure of the body, and discussions about sex, fertility, menstruation, miscarriage, pregnancy, or trauma.

Even highly educated, confident women can feel unexpectedly vulnerable.

Because intelligence does not erase discomfort.

Professional status does not erase fear.

Being a healthcare worker does not make you immune to feeling like a patient.

The fear of being judged

Many women worry about being judged for their sexual history, their number of partners, a previous abortion, delayed childbearing, a sexually transmitted infection, their body weight, or their contraception choices. In some cultures, reproductive health is still linked to morality. A consultation can begin to feel less like healthcare and more like an evaluation of personal character.

Subtle clinician reactions—dismissive tone, a shocked look, a careless comment—can affect patients for years.

Clinicians rarely remember these moments.

Patients rarely forget them.

Previous pain changes everything

For some women, the fear comes from earlier experiences that were physically or emotionally distressing — painful pelvic examinations, traumatic childbirth, complicated miscarriage, sexual assault, female genital cutting, or medical neglect.

The body remembers vulnerability even when the mind tries to move forward. A woman may know rationally that a Pap smear lasts a few minutes and still feel overwhelming anxiety before the appointment. That is the body protecting itself.

A systematic review published in Psycho-Oncology in 2017 confirmed that a single negative gynaecological experience can lead a woman to avoid all future screening.

The effect of one difficult consultation can last for years.

Sometimes the fear is about the diagnosis itself

Not the clinic. Not the examination. What might be found.

“You may have cancer.”

“You may struggle to conceive.”

“This pregnancy is not progressing.”

Fear makes uncertainty feel safer than confirmation. At least for a while.

But delayed presentation can turn manageable conditions into serious ones. A cervical cancer caught early carries a five-year survival rate of over 90%. Caught after it has spread, that figure drops sharply. The gap between those two outcomes is often the gap between attending and not attending.

Many women are tired of not being believed

Some fear the clinic not because of what might be found, but because they expect to be dismissed before anyone looks properly.

“It’s normal.” “Just take painkillers.” “You are overthinking.” “It’s probably stress.”

And sometimes women have heard those words repeatedly for years, before finally receiving diagnoses of endometriosis, adenomyosis, PCOS, fibroids, or pelvic inflammatory disease. Research across healthcare settings increasingly shows that women’s pain, especially when it is chronic, complex, or not immediately visible, is sometimes minimised or investigated less thoroughly than it should be.

Once trust is damaged, avoidance becomes easier than returning. Many women who appear non-compliant are not refusing care. They are protecting themselves from an experience that has already hurt them.

Many women who appear avoidant are not refusing healthcare because they do not care. They are protecting themselves from an experience that has already hurt them.

The internet has changed the emotional atmosphere

Before appointments, women now search online. Sometimes this helps find the right questions to ask, understanding what a procedure involves, and feeling less alone. Sometimes it intensifies fear dramatically. A woman with mild pelvic symptoms may spend an evening reading worst-case scenarios about ovarian cancer, infertility, or surgical complications before she has spoken to anyone clinically.

Some women now arrive at consultations already tense and frightened before a single word has been spoken. That is the emotional environment in which many gynaecology appointments now begin, and it is worth acknowledging rather than ignoring.

Cultural silence still shapes women’s health

In many societies across sub-Saharan Africa, South Asia, parts of Latin America, the Middle East, and within diaspora communities in Europe and North America, girls are not raised speaking openly about menstruation, sexual health, or reproductive symptoms.

Some grow up learning these topics are private, hidden, or shameful. By adulthood, many women have never developed a comfortable language for discussing their own bodies with a clinician. A woman who cannot comfortably describe pelvic pain, abnormal discharge, or painful intercourse may delay seeking help until symptoms become severe. And if health systems are rushed, impersonal, or judgmental, that silence deepens further.

A clinician’s perspective

One of the easiest mistakes in medicine is to become too familiar with what patients still experience as deeply intimate.

For clinicians, pelvic examinations and reproductive consultations become routine through repetition.

For patients, they rarely feel routine.

Good healthcare does not only investigate symptoms. It also understands the emotional reality patients bring into the room.

Fear is not irrational simply because it is invisible.

Health note

This article is for health education only and does not replace medical advice. If you are experiencing persistent pelvic pain, abnormal bleeding, breast changes, menstrual concerns, painful intercourse, or other reproductive health symptoms, seek assessment from a qualified healthcare professional. Delaying care out of fear or embarrassment can allow treatable conditions to worsen.

Sources

BD/Harris Poll. Survey of 1,100+ adult women on gynaecology visit avoidance. November 2024. NHS England. NHS Cervical Screening Programme, England 2023-2024 Annual Report. November 2024. Chorley AJ et al. Experiences of cervical screening and barriers to participation: a systematic review and thematic synthesis. Psycho-Oncology. 2017. Wearn A and Shepherd L. Determinants of routine cervical screening participation in underserved women. Psychology and Health. 2024. Higgs LLP. Misdiagnosis: The Overlooked Crisis in Women’s Health. Research report, 2024.

With care and in support of women who deserve respectful, compassionate healthcare.

Dr Adeniyi

That is exactly why it should not be reduced to slogans.

For some people, the central issue is the life of the unborn child. For others, it is the woman’s autonomy, safety, and dignity. For many clinicians, families and faith communities, the reality sits painfully between those positions.

Pregnancy is not an abstract debate. It happens inside a body, within a life, under medical, emotional, spiritual, social and financial pressures. If we are going to speak morally about abortion, we must be willing to speak honestly about all of that.

The moral case against abortion

The strongest argument against abortion begins with a simple claim: human life has value, and that value does not begin only when life becomes convenient, visible, independent or wanted.

For those who hold this view, the unborn child is not a “potential life” in a casual sense, but a developing human life with moral significance. From this perspective, abortion is not only a medical procedure. It is the ending of a life that deserves protection.

This argument is often rooted in religion, but not only religion. Some people oppose abortion from a philosophical or human-rights position: that societies should protect the most vulnerable, including those who cannot speak for themselves.

There is also concern about where moral lines are drawn. If abortion is accepted broadly, some ask: at what stage does society say no? Is it at viability? At consciousness? At birth? If the line moves depending on law, technology or social opinion, critics worry that the value of unborn life becomes unstable.

There is another argument too: abortion may sometimes arise from failures we should have prevented earlier. Poverty. Poor contraception access. Sexual violence. Lack of male responsibility. Fear of shame. Weak family support. Poor maternity protection.

In that sense, some who oppose abortion argue that society should not solve social failure by ending unborn life, but by supporting women enough to continue pregnancies safely. This is not a foolish argument. It deserves to be taken seriously.

A society that claims to care about women but treats pregnancy as disposable is morally incomplete. But a society that claims to care about unborn life while ignoring the woman carrying that life is also morally incomplete.

The moral case for abortion access

The strongest argument for abortion access begins somewhere different: with the woman.

A pregnancy does not happen outside her. It happens inside her body. It can affect her health, education, income, safety, relationships, future fertility, mental wellbeing and even her life. To force a woman to continue every pregnancy, regardless of circumstance, is not a small moral act. It is the state, family or society taking control of her body and future in a profound way.

This argument becomes especially sharp in cases of rape, incest, serious fetal anomaly, severe maternal illness, or pregnancies that threaten the woman’s life. But it does not stop there. Even outside extreme cases, pregnancy is physically and socially demanding. Childbirth carries risk. Parenting requires resources.

The moral question is not only what about the unborn child?

It is also: what are we asking this woman to carry, and who will carry the consequences with her?

This matters because when abortion is unsafe, women suffer.

Usually, it is poor women. Young women. Women in rural areas. Women without private doctors. Women without money to travel. Women who cannot quietly access safer care.

So the moral case for abortion access is not only about choice. It is about dignity, safety, inequality and the reality that women with fewer resources often pay the highest price for laws made in the name of morality.

Where both sides often fail

Both sides can become dishonest.

Some abortion-rights arguments speak as if the unborn child has no moral weight at all. That is too easy. Many women who choose abortion still grieve, hesitate or carry emotional conflict. Not every abortion is experienced as liberation. Some are experienced as survival.

Some anti-abortion arguments speak as if the woman is merely a container for the fetus. That is also too easy. A woman is not a location. She is a person. Her life, body, history, fear, health and future matter.

This is where the debate becomes painful. There are at least two moral claims in the room: the value of unborn life and the dignity of the woman. Any serious conversation must hold both, even if it gives different weight to each.

The African and global health question

For many African settings, abortion cannot be separated from health-system failure.

If contraception is hard to access, if sex education is poor, if rape survivors are shamed, if pregnant teenagers are abandoned, if maternity care is unsafe, if poverty makes another child unbearable, and if women with complications cannot reach emergency care — then abortion becomes part of a wider moral failure.

The question is not only: should abortion be legal?

The question is also:

Why are so many women facing pregnancies they did not plan? Why are men so often absent from the consequences? Why are girls punished more than the people who exploit them? Why is contraception still surrounded by fear and misinformation? Why do we defend unborn life loudly, but fund maternal care weakly? Why do we moralise pregnancy more than we support pregnant women?

A society serious about women’s autonomy must also be honest that abortion is not the only answer women need. Women need contraception, counselling, protection from violence, safe maternity services, childcare support, education, income security and respectful healthcare.

What would a more honest position look like?

A more honest position would start with humility.

It would admit that abortion involves real moral tension. It would not mock people who care about unborn life. It would not dismiss women who feel trapped by pregnancy. It would not pretend that criminalisation solves the problem. It would not pretend that access alone removes grief, pressure or inequality.

It would ask better questions.

Can we prevent more unintended pregnancies? Can we make contraception safe, affordable and free from stigma? Can we protect girls and women from sexual violence? Can we make pregnancy and childbirth safer? Can we support women who want to continue pregnancies but feel unable to? Can we ensure that when abortion happens, women do not die from unsafe care? Can we create laws that recognise both moral seriousness and medical reality?

The American College of Obstetricians and Gynecologists states that legal and accessible abortion care is part of comprehensive healthcare, and argues that restrictions can interfere with the patient-clinician relationship — especially for people with low incomes or those who live far from care.

People may disagree morally with that position. But the clinical concern is real: when law enters the consultation room too rigidly, doctors may hesitate, patients may delay, and the poorest women may lose safest access first.

A clinician’s perspective

I do not think abortion should be discussed casually. Something morally serious is involved.

But I also do not think women’s lives should be treated casually. That, too, is morally serious.

The hardest truth is this: many abortions happen not because women are careless, but because life has become complicated, frightening, unsafe or unsupported. If our moral concern begins only after pregnancy occurs, it has started too late.

The better society is not the one that shouts loudest about abortion. It is the one that makes fewer women feel abandoned, fewer girls feel trapped, fewer mothers feel unsafe, and fewer families face impossible choices alone.

The morality of abortion is not only about the moment of termination.

It is about everything that happened before it, everything that happens after it, and whether we are willing to build a world where women and unborn life are both taken seriously.

Sources

World Health Organization. Abortion. Fact sheet. Updated 8 December 2025. -World Health Organization. Abortion care guideline. Geneva: WHO; 2022. - Guttmacher Institute. Unintended Pregnancy and Abortion Worldwide. March 2022. - Bearak J et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. The Lancet Global Health. 2020;8(9). - American College of Obstetricians and Gynecologists. Increasing Access to Abortion. Committee Statement No. 16. February 2025.

Health note

This article is for health education and public reflection only. It does not replace medical, psychological, legal or spiritual guidance. Decisions surrounding pregnancy and abortion are often medically, emotionally, ethically and socially complex, and every woman’s circumstances are different.

If you are facing an unintended pregnancy, emotional distress, pregnancy complications, or uncertainty about your options, speak with a qualified healthcare professional who can assess your situation with compassion, confidentiality and evidence-based care.

With care and in support of women who deserve to be heard,
Dr Adeniyi

Evidence now strongly suggests that a woman’s menstrual cycle is one of the earliest windows we have into her cardiovascular future — and we are not using it.

Cardiovascular disease is the leading cause of death in women worldwide. And we have been missing one of its earliest warning signals for decades.

What the research shows

A landmark Harvard study, the Nurses’ Health Study II, followed 80,630 women for 24 years and asked a simple question: Does a woman’s menstrual cycle pattern predict her risk of cardiovascular disease later in life?

The answer was yes. Clearly and significantly.

They found that women who reported irregular or long menstrual cycles had a higher risk of cardiovascular disease compared with women who reported more regular cycles. This association remained even after adjustment for several established cardiovascular risk factors.

Another large UK Biobank study adds weight to this point: the menstrual cycle may be more than a monthly inconvenience; it may be a window into long-term health. Women whose cycles were shorter than 21 days or longer than 35 days had a 29% higher risk of cardiovascular disease overall, and a 38% higher risk of atrial fibrillation, compared with women whose cycles were 28 to 34 days. Atrial fibrillation is an irregular heart rhythm that can raise the risk of stroke. The message is not that every irregular period means danger. The message is that the body often whispers before it shouts, and menstrual patterns may be one of those early whispers.

Again, this does not mean every woman with an irregular period should panic.

It means the menstrual cycle may be more than a reproductive detail. It may be one of the body’s early signals that something deeper is happening in the hormonal, metabolic or cardiovascular system.

Why does this connection exist? The underlying mechanism is hormonal.

Oestrogen is not just a reproductive hormone — it plays a protective role in cardiovascular function. It influences how blood vessels dilate and contract, how inflammation is regulated, and how cholesterol is metabolised. When the menstrual cycle is irregular, it often reflects underlying hormonal disruption — including the insulin resistance and androgen excess associated with conditions like PMOS — that also drives cardiovascular risk through multiple pathways simultaneously.

The cycle, in other words, is a readout. Irregular means something in the system is not working as it should. And that something has consequences far beyond the reproductive system.

What happens at menopause

If the menstrual cycle is one early window into cardiovascular risk, menopause is the moment that window closes — abruptly, and with significant consequences.

The loss of oestrogen at menopause is not just about hot flushes and night sweats. It triggers a shift in cardiovascular risk profile. Blood pressure tends to rise. LDL cholesterol increases. Arterial stiffness accelerates. The protective effect that oestrogen provided throughout the reproductive years begins to withdraw.

This is why cardiovascular disease in women rises sharply after menopause. Before age 50, women have a lower cardiovascular risk than men of the same age. After 65, they caught up. The menopause transition is the inflexion point.

And then there is what is happening in the brain.

Research presented at the 2025 Annual Meeting of The Menopause Society confirmed what many women already know from experience: menopause is accompanied by measurable structural changes in the brain, including reductions in grey matter volume in regions associated with memory and emotional regulation. The brain fog that millions of women describe — the forgetfulness, the difficulty concentrating, the feeling of thinking through cotton wool — is not imagined. It is biological.

What most women do not know is that this cognitive shift is directly connected to the same hormonal changes driving cardiovascular risk. The same oestrogen withdrawal. The same inflammatory pathways. Brain health and heart health in menopause are not two separate conversations. They are one.

The African and diaspora gap

Much of the strongest evidence on menstrual cycle patterns and cardiovascular risk comes from large Western cohorts. These studies are valuable, but they do not fully answer what these patterns mean for African women, Nigerian women, or diaspora women living within different biological, social, environmental and healthcare contexts.

Black women in several high-income settings carry a higher burden of hypertension and cardiovascular disease than White women, and often experience cardiovascular risk earlier. If menstrual cycle patterns are early signals of metabolic or cardiovascular risk, then failing to study those signals properly in African and diaspora women could widen an existing blind spot.

It also matters culturally. In many Nigerian and diaspora communities, menstrual irregularity is either normalised — “it’s just how I am” — or managed with herbal remedies and prayer, without ever reaching a clinical conversation. Menopause is rarely discussed at all. The brain fog, the sleep disruption, the mood changes are endured quietly, attributed to stress or ageing, and never connected to the cardiovascular risk picture that is silently building underneath.

What this means for you — right now

This is not a reason to panic. It is a reason to pay attention.

• If your periods have been consistently irregular — always coming too early, too late, or unpredictably — mention this to your doctor as a cardiovascular risk factor, not just a gynaecological one. Ask whether your blood pressure, cholesterol, and blood glucose have been checked recently.

• If you are in perimenopause or post-menopause and experiencing brain fog, poor sleep, or memory lapses, know that this is a recognised, biological process — not a sign you are losing your mind. It is also a signal to take cardiovascular health seriously at this transition point.

• If you have PMOS (previously called PCOS), your risk is compounded. The hormonal and metabolic features of PMOS are independently associated with cardiovascular disease. Your menstrual irregularity is one thread in a larger picture that your clinician should be assessing holistically.

• If nobody has ever asked you about your cycle in the context of your heart health — you are not alone. And you are entitled to raise it yourself.

The menstrual cycle has been treated, for most of medical history, as a reproductive metric. Something relevant only when a woman wants — or wants to avoid — pregnancy. What the evidence is now making clear is that it is a vital sign. One that carries information about hormonal health, metabolic function, and cardiovascular trajectory across the entire reproductive lifespan and beyond.

The conversation needs to start earlier. In GP surgeries, antenatal clinics, and diaspora community spaces. Not after the heart attack. Before it.

Sources

Wang YX et al. Menstrual Cycle Regularity and Length Across the Reproductive Lifespan and Risk of Cardiovascular Disease. JAMA Network Open (2022). doi: 10.1001/jamanetworkopen.2022.38513. — Huang C et al. Associations of Menstrual Cycle Regularity and Length With Cardiovascular Diseases: A Prospective Study From UK Biobank. Journal of the American Heart Association (2023). doi: 10.1161/JAHA.122.029020. — The Menopause Society Annual Meeting 2025: brain structure and menopause review. ScienceDaily, October 2025. — Maki PM, Jaff NG. Brain fog in menopause: a health-care professional’s guide. Climacteric (2022). — Teede HJ et al. Polyendocrine metabolic ovarian syndrome (PMOS). The Lancet (2026). — IMS White Paper on cognition in menopause (2022).

Health note

This article is for health education only. It does not replace medical advice. If you have concerns about your menstrual cycle, cardiovascular health, or menopausal symptoms, speak to your GP or specialist.

With care,
Dr Adeniyi Akiseku

“It’s just period pain. Everyone has it. You’ll manage.”

Sometimes, that is the right answer. Mild cramping is common and does not always mean something is wrong.

But I have also sat with women in clinics for whom that sentence was the beginning of years of delay. Women who planned their entire lives around their cycles. Who took painkillers every month and still couldn’t function. Who were told repeatedly that their pain was normal, until someone looked properly and found endometriosis, fibroids, or adenomyosis that had been there for years.

This article explains four conditions that cause pelvic pain and period problems — what they are, what to watch for, and when pain deserves more than a painkiller prescription.

First: when should period pain be checked?

NHS guidance says to see a doctor if periods become more painful, heavier, or irregular — or if pain is stopping daily activities. The same applies to pain during sex, pain when passing urine or opening the bowels, bleeding between periods, or unexplained changes in your abdomen, appetite, or weight.

I would add one more: if your period is something you have learned to plan around, cancelling commitments, relying on strong painkillers, sleeping through the day — that adaptation itself is a signal worth investigating.

The four conditions worth knowing about

1. Endometriosis

Tissue similar to the womb lining grows outside the womb — on the ovaries, bowel, bladder, or surrounding tissues. It affects roughly one in ten women of reproductive age globally (WHO). Symptoms include severe painful periods, chronic pelvic pain, deep pain during or after sex, and bowel or bladder symptoms that worsen around menstruation. Some women have no symptoms at all and only discover it during fertility investigations.

The most important thing to know: a normal ultrasound does not rule out endometriosis. NICE guidance is explicit on this — diagnosis requires direct investigation, and if your symptoms continue after a normal scan, it is entirely reasonable to say so and ask what the next step is.

2. Adenomyosis

Here, the tissue grows within the muscular wall of the womb itself. The womb can become enlarged and tender. It typically causes heavy, painful periods — pain that often intensifies over time rather than staying constant. A clinician may notice a bulky or tender uterus on examination, which is often the first clinical clue prompting further investigation.

3. Fibroids

Non-cancerous growths in or around the womb. They are common, and many cause no symptoms — but when they do, the symptoms can be significant: heavy periods, pelvic pain or pressure, frequent urination, pain during sex, and sometimes fertility difficulties. The fact that fibroids are common does not make these symptoms something to simply live with. When bleeding is affecting your quality of life, there are medical and surgical options — a referral is appropriate.

4. Pelvic inflammatory disease (PID)

Infection or inflammation of the pelvic organs — the womb, fallopian tubes, and ovaries. Symptoms include lower abdominal pain, unusual or smelly vaginal discharge, pain during sex, and fever. RCOG is clear that a delay in treating PID increases the risk of long-term complications, including damage that can affect fertility. It needs prompt assessment, not watchful waiting. And because stigma around PID causes delays, infection is a medical issue, not a moral one.

Why these conditions get confused

They share symptoms.

Painful periods, pelvic pain, and pain during sex can appear across all four conditions. The table below is not a diagnostic tool. It is a reason to insist on proper assessment rather than accepting generic reassurance.

A normal scan does not end the story. If symptoms continue, say so. Ask what happens next.

Track your symptoms before your appointment

Track these for two to three cycles.

This turns:

“My periods are bad”

into a clearer clinical picture your doctor can work with.

A symptom diary does not mean you need to prove your pain.

It simply helps show the pattern.

If you have been told to manage

Somewhere in the notes of every gynaecology unit is a patient who waited years before anyone looked properly. Pain that stops normal life is not a normal period. A normal scan is not the end of the investigation. Being told something is common is not the same as being told it is untreatable.

You are not exaggerating. You deserve a proper assessment — not a repeat prescription and a suggestion to come back if it gets worse.

These conditions are diagnosable. Most are treatable. The first step is being heard.

Health note

This article is for health education only. It is not a diagnosis and does not replace medical advice. If you have severe pain, heavy bleeding, fever, possible pregnancy, or feel very unwell, seek urgent care. Sources: NHS period pain guidance; NICE NG73 (endometriosis); NICE NG88 (heavy menstrual bleeding); NHS fibroids; RCOG PID patient information; WHO endometriosis fact sheet.

With care,
Dr Adeniyi Akiseku

If you have been diagnosed with polycystic ovary syndrome (PCOS), or you have been told you might have it, or you have been living with irregular periods and unexplained symptoms and wondering — this is for you.

PCOS has a new name. As of May 2026, following a global consensus process involving over 14,000 patients and clinicians from every region of the world, the condition previously called polycystic ovary syndrome is now called polyendocrine metabolic ovarian syndrome. The short form is PMOS.

The name change was published in The Lancet, one of the most respected medical journals in the world. It is not a minor update. It represents a fundamental shift in how the medical community understands and communicates this condition.

Here is what changed and what it means practically for the women living with it.

What was wrong with the old name?

The name PCOS has been known to be inaccurate for decades. The problem is right there in the words.

“Polycystic” means many cysts. But women with this condition do not actually have pathological ovarian cysts. What they have is a collection of small, immature follicles on the ovaries, which is a different thing entirely. Calling them cysts was always technically wrong, and it has caused real harm: women who were told they had PCOS spent years confused about what was actually in their ovaries, clinicians outside specialist settings misunderstood what they were looking at on ultrasound, and the name pointed attention toward the ovaries when the condition is far broader than that.

PCOS is not primarily an ovarian condition. It is a multisystem endocrine and metabolic disorder. It involves insulin resistance, androgen excess, neuroendocrine dysregulation, and metabolic dysfunction, and it carries elevated risks for type 2 diabetes, cardiovascular disease, depression, and endometrial cancer. The ovaries are part of the picture. They are not the whole picture.

Up to 70% of people with this condition remain undiagnosed. The name is one reason why.

When a condition sounds like an ovarian problem, it is investigated and managed as such. Metabolic features get missed. Cardiovascular risk goes unaddressed. Women are told to come back when they want to get pregnant, as if the condition only matters at that point. The name shaped the clinical response, and the clinical response has been inadequate.

What the new name means

Polyendocrine metabolic ovarian syndrome. Let me break that down plainly.

• Polyendocrine — the condition involves multiple interacting endocrine (hormonal) disturbances, not one isolated problem. Insulin, androgens, and the hormones governing ovarian function all interact in ways that drive the condition’s many features.

• Metabolic — metabolic dysfunction is central. Insulin resistance affects the majority of people with PMOS. The associated risks — type 2 diabetes, cardiovascular disease, liver disease — are not complications that might happen later. They are part of the condition itself.

• Ovarian — the ovaries are genuinely involved. There are real disturbances in how the ovaries develop and release follicles, as well as in their endocrine function. Ovarian is accurate. Polycystic was not.

Syndrome remains because this is a syndrome — a cluster of features that co-occur. Not every person with PMOS has every feature. That is what makes it complex, and why a name that signals multisystem involvement is more useful than one that points to a single organ.

How this change came about

The US National Institutes of Health raised concerns about the PCOS name as far back as 2012. Patient groups have been calling for a change for years. Multiple surveys and workshops were conducted — and repeatedly stalled, for lack of a coordinated global process.

What finally worked: a structured, three-year international process led by Monash University’s Centre for Research Excellence in Women’s Health, the Androgen Excess and PCOS Society, and Verity — a UK patient charity that reinvigorated the effort in 2023.

The process included 14,360 survey responses from patients and health professionals across all world regions, two rounds of global Delphi surveys, and two international workshops with representatives from 56 organisations. The consensus was reached in February 2026. The Lancet paper was published in May 2026.

Notably, patients were involved from the beginning in governance, survey design, workshop facilitation, and implementation planning. Their strongest priority was stigma avoidance. Many had experienced the name as harmful, particularly in cultural contexts where fertility carries heavy social weight.

What this means practically

For the next three years, PCOS and PMOS will be used alongside each other during the transition. The International Guidelines used in 195 countries will be updated in 2028. Electronic health record systems, ICD disease codes, and educational materials are all being updated as part of an eight-stage, coordinated global implementation strategy.

In practical terms:

• If you are currently diagnosed with PCOS, your diagnosis is the same condition under a new name. Nothing about your clinical situation has changed.

• If you are seeking a diagnosis, your symptoms should now be evaluated through a broader lens — not just as an ovarian or fertility issue, but as a multisystem endocrine and metabolic condition.

• If you are a clinician: your patients with PMOS need cardiovascular risk assessment, metabolic monitoring, and psychological support — not just reproductive management at the point of wanting to conceive.

The condition formerly known as PCOS affects one in eight women globally. The majority remain undiagnosed. The new name is one step toward closing that gap — by making the condition’s true nature visible in the name itself.

One final thought

Names shape how we think. They shape which questions get asked, which tests get ordered, and which risks get monitored. When a name is wrong, when it points to one organ and hides an entire metabolic picture, it shapes clinical decisions, research funding, and policy priorities in ways that accumulate over decades.

Polyendocrine metabolic ovarian syndrome seems more accurate. It is not a perfect name, no name for a complex syndrome ever will be. But it is a name that tells a clinician meeting a patient for the first time that this condition involves hormones, metabolism, and the ovaries, and that all of it requires attention.

That is progress.

Source

Teede HJ, Bahri Khomami M, Morman R, et al. Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process. The Lancet. Published online May 12, 2026. doi: 10.1016/S0140-6736(26)00717-8. Open access.

Health note

This article is for health education only. It does not replace medical advice. If you have symptoms suggestive of PMOS or have not yet been evaluated, discuss this with a clinician who can assess your full metabolic and hormonal picture, not only your reproductive symptoms.

With care and in support of women who deserve to be heard,
Dr Adeniyi