Some residents now resort to self-medication while many women rely on TBAs for child delivery because the illegal sit-at-home order has affected operations of public health facilities in the region.
On a Monday morning in April 2022, Lawrence Obianozie, a resident of Umuaguma, Mgbidi, in Oru West Local Government Area of Imo State, accompanied his 35-year-old daughter in-law, Vivian, to a private hospital for "urgent" medical attention.
Vivian had been delivered of a baby the previous month, but had woken up on that fateful day with severe health complications. However, for more than one hour, the hospital authorities refused to open their gate.
"They said they don't open on Mondays due to the activities of unknown gunmen who enforce sit-at-home order," Mr Obianozie said.
By the time she was conveyed to another distant health facility, the mother of two had died.
"She was just buried some months ago," he said in agony.
Emeka Agbasi, a medical doctor based in Anambra State, said delayed access to medical care can bring "dire consequences" including death for both adults and infants.
"That's why we have emergency units (in health facilities) and in such units, a health worker must be around at all times," Mr Agbasi said.
Sit-at-home in South-east
The Indigenous People of Biafra (IPOB), in August 2021, introduced sit-at-home order every Monday across the South-east to pressure the Nigerian government to release its detained leader, Nnamdi Kanu, who is standing trial for alleged treason at the Federal High Court, Abuja.
The separatist group later amended the order to be implemented only on the days Mr Kanu appears in court. But despite this, many residents of the five South-east states, including Imo, have been observing the Monday sit-at-home order, mostly out of fear.
Some residents and motorists, including commuters, have been attacked lately by gunmen for stepping out of their homes on Monday and other days declared for sit-at-home by the armed groups.
Aside from millions of naira reportedly lost whenever the illegal order holds in the South-east, hundreds of people have been killed and others injured by gunmen who often enforce the order in the region.
IPOB had repeatedly disowned the Monday sit-at-home order, describing the enforcers as criminals attempting to blackmail the separatist group.
A leader of 'Autopilot,' a faction of the IPOB, Simon Ekpa, who has been suspended by the IPOB faction led by Mr Kanu, is behind the sustenance of the order.
Mr Kanu, through a letter made public in July by Aloy Ejimakor, his lawyer, had ordered Mr Ekpa to stop issuing the order in the South-east. But Mr Ekpa described the letter as "fake," claiming it was written by the State Security Service (SSS) and not the IPOB leader, and maintained that the illegal order would continue to be enforced until Mr Kanu speaks to him directly in Finland, where he (Ekpa) resides.
Messrs Kanu's IPOB and Mr Ekpa's Autopilot are agitating for the South-east and some parts of the South-south to be carved out of Nigeria to become Biafra.
Despite several efforts made by past and serving governors and other leaders of the South-east to stop the order, many parts of the region are usually on lockdown on Mondays. Aside from Mondays, Mr Ekpa-led faction of the IPOB had also repeatedly imposed weeklong sit-at-home orders in the region.
Sit-at-home and healthcare services in South-east
The situation has continued to restrict residents' movements, including access to healthcare facilities in the South-east. There is no data on the impact of the illegal order on mortality and morbidity rates in the region, especially with regards to pregnant women and children. However, media reports and figures from relevant agencies suggest that it has been affecting access to healthcare services in the region.
The South-east region, for instance, had the lowest percentage in the recommended vaccines intake in 2023 with about 61,000 children across the region not being vaccinated, according to the United Nations International Children Emergency Fund (UNICEF).
Private hospitals to the rescue as PHCs close on Mondays
On Mondays, nearly all Primary Health Centres (PHCs) in Imo State do not open, investigations by PREMIUM TIMES showed. Many health workers at the PHCs visited told this newspaper that they only "take risks" to open in the event of emergencies particularly when a pregnant woman is in labour.
But the pregnant women, during such emergencies, must phone a health worker before heading to the facility
PREMIUM TIMES' investigation also showed that the enforcers of the sit-at-home day order usually allow patients in emergencies to access healthcare unharmed, although fear prevents many from stepping out on those days.
"On sit-at-home days, aside from emergencies, everybody is afraid to go to any health clinic. We don't open on such days either," Ann Igbielo, the Officer in-charge of Ugbele PHC in Mgbidi, said.
"It's not only us. Every other person stays at home during the sit-at-home. Even the road construction workers here. So, are we the ones to risk our lives?" Angela Achinike, another official at the facility, added.
Like in Mgbidi, only private hospitals open on Mondays at communities in Okigwe Local Government Area of the state.
The PREMIUM TIMES' reporter who visited some PHCs in the area on a Monday morning, met the facilities under lock and key.
But at St. Michael Hospital & Maternity, a private clinic in the area, a few patients were seen receiving treatments from nurses on duty.
"The truth is that this sit-at-home has been affecting healthcare services because patients coming from a far distance can't come to access healthcare services due to the lockdown," Deborah Mgbeokwere, a nurse, told this newspaper.
She said to avoid possible death of patients, the hospital management uses an ambulance to pick up patients in emergencies during the sit-at-home order as soon as they reach out to the hospital management.
Another health worker at the facility, Basil Nacemo, said unlike other days with over 10 patients, only a few patients come to the hospital for treatment on Mondays as a result of fear of being attacked.
"Sometimes we treat only two patients on Mondays. And those are people from within this hospital vicinity," he said, adding that a high population of patients throng the facility on Tuesdays.
Mr Nacemo said some patients even skip their treatment dosages like injections by failing to come to the hospital as a result of the lockdown on Mondays.
"For instance, some have injections today (Monday), but can't come today. They will skip it and come the next day. And it affects their recovery because they have abused the drugs.
"And once they abuse the drugs, we will have to change the drugs so that we can handle the causes effectively," Mr Nacemo stated.
The situation was the same at Eve Specialist Women Clinic, another private clinic in the area.
The chief medical director at the clinic, Eve Charles, lamented that patronage is usually very low on the days of the illegal order.
"You can see for yourself. I have been here since morning. People aren't coming," he said at about 2 p.m. on the day.
Self-medication
At Ofeinyi Amuro, another community in the council area, PREMIUM TIMES found that residents often resort to self-medication to manage health emergencies due to IPOB's illegal order.
"When we have emergency sickness on a sit-at-home day, we usually buy drugs from a chemist shop to sustain ourselves until 5 or 6 p.m. when movements will resume so that we can then visit a hospital," Ikechukwu Onyiro, a leader in the community, told PREMIUM TIMES.
"Nobody will be able to step out on a sit-at-home day because you won't see any vehicle (on the road) and you can't trek because hospitals are far from here," Mr Onyiro explained in Igbo language.
He added that on occasions when drugstores are closed, residents would beg their neighbours for drugs even without a doctor's prescription.
'We're worried about our safety'
Save for a Sienna vehicle parked at an entrance, there was no indication that health workers were at work in Orlu Primary Health Centre when PREMIUM TIMES' reporter visited the facility on a Saturday morning in July.
Doors and windows were also shut. There was pin-drop silence.
"We are living in fear here o," said Loveth Mbaoma, a nurse, who opened a door after peeping through an opening.
Mrs Mbaoma said that apart from the IPOB's sit-at-home days, attacks by gunmen on other days in the area were scaring both health workers and patients.
"Here, the problem is that we don't know when it is gunmen or Ebubeagu or even soldiers. Sometimes people would start scampering for safety when we hear gunshots," she said.
Before now, health workers at the facility felt safe. But after gunmen, believed to be the Biafran agitators, repeatedly attacked the Orlu Police Area Command near the facility, the workers became scared.
"Unknown gunmen are always shooting here (near the area command). Bullets usually fly here. There is nobody at that area command again. They all fled when the attacks became unbearable," she said.
Mrs Mbaoma said residents stay indoors during the illegal order in the area and that sometimes when they open the facility, they lock themselves inside out of fear.
"All our patients, especially pregnant women, have our numbers and usually call us during emergencies. Many times, we would use shortcuts to come to work," she said.
Anambra
Chiamaka Ikebundu, a pregnant woman, registered for her antenatal care services at the only PHC in her community, Mbarampaka in Ihiala Local Government Area of Anambra State.
The PHC is about 30 minutes' drive from her residence.
Mrs Ikebundu also registered at a nearby private maternity clinic, which a PREMIUM TIMES reporter discovered is being managed by a traditional birth attendant (TBA).
TBAs are community-based healthcare providers, mostly unskilled and untrained, who care for pregnant women before and during childbirth.
Like other pregnant women, Mrs Ikebundu's reason for visiting the TBA was to avoid travelling a long distance to the PHC, during emergencies or on a sit-at-home day when some gunmen enforce the illegal order.
The mother of two said residents are forced to stay indoors on sit-at-home days in the area.
"We don't go to clinics on Mondays for antenatal, except in the evening from 4.p.m. or 5.p.m.," she said.
Like the PHCs, the TBAs in the community usually lock their gates from inside on Mondays, but will open when patients phone them during emergencies, she noted.
Mrs Ikebundu's mother in-law, Ngozi Ikebundu, said during emergency labour, many seek medical assistance at any nearby maternity clinic.
But those who did not register at such clinics are forced to wait until evening before stepping out to seek medical care at the distant PHC in the area.
"Not many people like the private maternity clinic. So, people who don't like the private clinic will have to endure till evening. You know labour takes three to four hours (before eventual delivery)," Mrs Ngozi said.
"But even as you head to the health centre in the evening, you must follow shortcuts, not straight roads. That's how we survive here," she added.
Grilled by gunmen over sit-at-home violation
Ifenna Mmerigbo is a patent medicine dealer in Ubahuekwem, a neigbouring community in the Ihiala council area.
When some patients in emergencies are unable to visit his chemist shop on sit-at-home days, Mr Mmerigbo meets them at their residence. But sit-at-home enforcers would stop him on the road for interrogation.
"On one occasion, they (gunmen) stopped me and enquired why I was moving about on a sit-at-home day. I told them that I went to treat somebody in an emergency and showed them what I used for the treatment. They saw it and asked me to go," he narrated.
Mr Mmerigbo said the gunmen often attack shops that open on sit-at-home days in the area.
"There was a day they came and flogged many people who opened their shops. But when they came to my shop, they saw I was treating a patient and they asked me to lock my shop as soon as I was done with treatment," he said.
Fear persists
Like in many communities, some health workers across PHCs visited by PREMIUM TIMES' reporter in Obosi, another community in Idemili Council Area of the state, said they do not open on sit-at-home days except on emergencies.
The President-General of Obosi Town Union, Chukwudi Iwenofu, said many residents, especially nursing mothers seeking to immunise their children, would not step out on Mondays in the community out of fear.
"A man, earlier this year (2023), had slumped while being taken to a hospital because he could not go on a Monday due to the sit-at-home order," Mr Iwenofu recalled.
The community leader was unsure if the patient later died.
However, this newspaper found that the few PHCs that open on Mondays often lock their gates and only allow their patients inside during emergencies.
As a result, many stranded residents now turn their attention to private hospitals which, findings showed, usually open on Mondays in the community.
Kenneth Abosi, the chief medical director of Iruoma Hospital, a private hospital in the community, said despite the fear of gunmen, residents still troop into the facility on Mondays to access healthcare.
"At times, we treat more people on that Monday sit-at-home. More people come to our hospital than other days," Mr Abosi said.
Same situation in Enugu
Obeagu Model PHC, the only PHC in Obeagu, a community in Enugu South Local Government Area of Enugu State, looked deserted and abandoned when a PREMIUM TIMES' reporter visited in August.
The facility was also overgrown by plants. Virginia Nnaji, the only healthcare worker on duty, said many of her colleagues stopped coming to work on Mondays after IPOB enforcers invaded the PHC in 2022.
"We were at work when the gunmen came on a Monday sit-at-home. We ran in confusion because we didn't know where we were running to. I got to my house at about 7 p.m.," she narrated.
She, however, said they began to open on Mondays since the state government deployed security operatives to the community.
But several residents who spoke to PREMIUM TIMES refuted her claim.
A woman, Amarachi Nwonye, said most of the health workers at the PHC reside in Enugu Urban - about 30 minutes' drive from the community - and seldom report on Mondays.
Like in Anambra, Mrs Nwonye said, during emergencies on Mondays, indigent pregnant women seek assistance of the TBAs in the community during labour because health workers were rarely around in the PHCs.
"There was a woman in labour here. When she was taken to the (primary) healthcare centre they didn't see anyone there. That's why many prefer to go elsewhere. She was later assisted by the old woman I told you about to deliver her baby," she explained.
The "old woman" being referred to is a TBA.
Matthew Nnamani said because healthcare workers are rarely at the PHC , especially on Mondays, his wife prefers to access healthcare from a private maternity clinic, also operated by a TBA.
PREMIUM TIMES' investigations showed that the TBAs mostly conduct delivery sessions in their homes without requisite training and medical equipment.
A TBA in the community, who also owns a provision store, declined to speak with the PREMIUM TIMES reporter.
"The problem with TBAs is that most of them have limited expertise and knowledge when it comes to child birth," Laz Udeh, an Abuja-based public health consultant, said.
Mr Udeh said pregnant women need to be delivered by skilled birth attendants because of the possibility of complications during child birth which the TBAs cannot handle.
"It is a lot of danger because we have more women at risk of having complications and even death," he said of reliance on TBAs for deliveries.
The public health physician said TBAs often "dump" their patients at point of death in nearby hospitals and "quickly disappear" in order to avoid the prospect of having the patients die in their facility.
He added that TBAs do not have the skill to monitor labour progress to avoid prolonged labour beyond acceptable time which has terrible consequences.
"When labour is not properly monitored and it lasts longer than usual, some babies come out and they don't cry because they are too weak. Some will have some level of brain damage which will affect them for the rest of their lives," he said.
Worrying statistics
A 2023 report from the World Health Organisation (WHO) revealed that Nigeria accounted for 12 per cent of global maternal deaths, stillbirths, and neonatal deaths -- the second largest in the world.
TBAs remain widely used by women in Nigeria, assisting in about two in every five births, especially for women with no education and from the lowest income quintiles, data from the 2018 Nigeria Demographic Health Survey showed.
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About 43.4 per cent of births in rural areas were assisted by a skilled healthcare provider, leaving just under three in every five women, giving birth with the assistance of TBAs, community-based birth attendants and other alternative healthcare providers, data from the survey further revealed.
In Ebonyi, a state in the South-eastern part of the country, a recent investigation revealed that deaths in the hands of TBAs contributed 36 per cent of recorded maternal deaths in 2022 in the state.
Slight difference
There was a huge crowd of women waiting to immunise their babies at Nsukka Health Center when PREMIUM TIMES reporter visited on a Wednesday morning in August.
One of them, Kelechi Ajibo, told this newspaper that they were many at the PHC because the management stopped holding immunisation sessions on sit-at-home days.
"Before now, they immunised children on Mondays and Wednesdays. But they stopped immunising on Mondays because of the sit-at-home," Mrs Ajibo said.
The mother of four said several others now struggle to get their children immunised because of the overwhelming population of patients at the facility, recalling the exercise used to be seamless before now with fewer patients.
"That's because some would come on Mondays, others would come on Wednesdays. But now, everybody is forced to come on Wednesdays or you won't immunise your child," she stated.
Like in other PHCs in Nsukka Local Government Area, PREMIUM TIMES found that although the facility opens on sit-at-home days, only skeletal services are usually available.
"Workers come to work here on Mondays for possible emergencies. But they render only skeletal services," said a staff of the facility, who identified himself simply as Kingsley.
"We have several units here. But none of them opens on Mondays except maternity unit," he stated, adding that patients in need of other services are usually referred to nearby health facilities.
Solution
The IPOB sit-at-home order has an enormous impact on healthcare services delivery in the South-east. Several efforts made by some state governments - like in Enugu, and Anambra states - to stop the illegal order in the region have not yielded desired results.
As a short-term solution, Nnamdi Anekwe, a security expert, suggested use of dialogue by community leaders to get the hoodlums to stop enforcing the illegal order.
"The long-term solution is to root out the militants or terrorists (enforcing the illegal order) because the state cannot continue to abdicate its responsibility to non-state actors," Mr Anekwe said.
Government responds
When confronted with findings by PREMIUM TIMES, the Commissioner for Health in Anambra State, Afam Obidike, said Governor Charles Soludo had stopped the illegal order in the state, but residents continue to stay indoors out of fear.
On closure of PHCs on sit-at-home days, Mr Obidike, a medical doctor, said some health facilities open on Mondays in Awka, the state capital, and the state government had developed measures to punish a few health workers who fail to go to work on Mondays.
"If you don't come to work any day, we will subtract salaries from you. We have electronic clock-in and clock-out devices installed in most of our general hospitals now," he said.
"Any day, when workers come to work, I see that and at the end of the day, we pay workers pro rata," the commissioner added.
Mr Obidike noted that some pregnant women unfortunately rely on TBAs mainly for economic reasons.
The commissioner, however, said to address the issue, the state governor had approved free antennal and delivery services in public health facilities across the state.
On his part, the Commissioner for Health in Imo State, Success Prosper-Ohayagha, claimed the "PHCs are not officially shut down on Mondays" in the state.
Mr Prosper-Ohayagha, a medical doctor, however, suggested that PHCs are only shut on Mondays in "hard-to-reach areas" of the state due to fear among residents and health workers on sit-at-home days.
Emmanuel Obi, the commissioner for health in Enugu State, did not respond to calls and text messages seeking his comments.
