By Chika Nwosu
Introduction
Abia State has taken a bold step toward improving maternal and child health care by functionalising additional Primary Health Centres (PHCs) under its flagship Project Ekwueme. Governor Alex Otti announced the commissioning of two upgraded PHCs—Okpuhu Nkpa and Umuenyere Alayi—in Bende Local Government Area and warned that untrained Traditional Birth Attendants (TBAs) and those who patronise them could face arrest.
This article examines the facts behind these announcements, investigates their context within Nigeria’s broader maternal health crisis, and explores the potential consequences of criminalising unskilled birth attendants. It provides evidence-based analysis for readers seeking to understand both the promise and the pitfalls of this policy direction.
Verifying the Facts
On September 20, 2025, Abia State officials reported that Governor Otti, represented by his Health Commissioner, commissioned the two Bende PHCs as part of Project Ekwueme. According to state communications and local media, the governor declared that these facilities were now fully equipped and ready to provide services to the public.
State officials further announced that these additions bring the number of functionalised PHCs under the project to 42. Project Ekwueme’s goal, first introduced earlier in the year, is to rehabilitate or retrofit as many as 200 PHCs across the state. In recent updates, the government has highlighted completed renovations at dozens of facilities, though only a fraction are currently classified as “functionalised,” meaning fully equipped and staffed.
Equipment lists shared by the government for these PHCs include multi-parameter monitors, automated external defibrillators, oxygen cylinders, delivery beds, and neonatal incubators—important upgrades meant to improve emergency obstetric and neonatal care.
At the same commissioning event, Governor Otti warned that untrained TBAs and individuals who use their services would face arrest. He cited the danger of deliveries handled by unskilled attendants as a major contributor to maternal deaths in the state. Multiple credible Nigerian news outlets reported these remarks, making it clear that the statement was not a misquotation but an explicit policy warning.
Nigeria’s Maternal Mortality Challenge
Understanding the context of Otti’s remarks requires a close look at Nigeria’s maternal health crisis.
Nigeria continues to record one of the highest maternal mortality ratios in the world. United Nations and World Health Organization data indicate that the country contributes nearly 28–29 percent of global maternal deaths, a staggering figure given Nigeria’s share of the world’s population. The primary causes include hemorrhage, eclampsia, sepsis, obstructed labor, and complications from unsafe abortions.
Three critical delays often determine maternal outcomes: the delay in deciding to seek care, the delay in reaching an appropriate health facility, and the delay in receiving adequate treatment once at the facility. Unskilled birth attendance exacerbates these delays because complications may not be recognized promptly or referred to higher-level care in time.
The State’s Approach: Project Ekwueme
Project Ekwueme is Abia State’s flagship initiative to tackle these systemic challenges. The project aims to renovate, equip, and staff at least 200 PHCs, ensuring that pregnant women and newborns have access to skilled care at the community level.
So far, the government claims to have retrofitted more than 140 facilities and made 42 fully functional. Each functionalised centre is supposed to provide 24-hour services, essential drugs, and trained midwives or nurses, though independent verification of round-the-clock operations and staffing consistency remains limited.
The addition of the two new PHCs in Bende represents progress in scaling the initiative. Equipping centres with emergency obstetric equipment is a critical step toward reducing maternal deaths and improving child survival rates.
The Governor’s Warning: A Policy Crossroads
While the commissioning of new PHCs is widely welcomed, Governor Otti’s threat to arrest untrained TBAs and those who patronise them has sparked debate among health professionals, legal experts, and community leaders.
The rationale behind the warning is straightforward: births attended by untrained TBAs significantly increase the risk of maternal and neonatal mortality. By discouraging families from using TBAs and steering them toward PHCs, the government hopes to ensure that trained personnel handle deliveries and complications.
However, the method—threatening arrest—raises critical questions. There is no publicly available Abia State law that explicitly criminalises the practice of untrained birth attendance or penalises women who choose such services. Without a clear legal framework and published enforcement guidelines, the threat risks being perceived as arbitrary or even unconstitutional.
Potential Legal and Ethical Complications
Legal scholars point out that any enforcement action would require a specific statute or executive order. Absent such a law, arrests could be challenged in court as a violation of personal liberty and due process. Even if the state enacts a regulation, it would need to clearly define who qualifies as a TBA, what constitutes “untrained,” and how enforcement would occur.
Ethically, criminalising the choices of pregnant women—especially those in underserved rural areas—raises concerns about autonomy and equity. Many women rely on TBAs not by preference but out of necessity. PHCs may be too far, transportation inadequate, or official health services unaffordable.
If the government cannot guarantee that every pregnant woman can access 24/7 skilled delivery care within a reasonable distance, punishing those who seek help from TBAs could amount to penalising poverty and marginalisation.
Traditional Birth Attendants: Role and Reality
In many Nigerian communities, TBAs are trusted figures with decades of experience. They often provide emotional support, cultural familiarity, and flexible payment options that formal health facilities cannot match. TBAs may also offer antenatal guidance and, when trained, can identify danger signs and refer clients to hospitals when necessary.
Blanket criminalisation risks alienating these community resources. Global health evidence shows that integrating TBAs into the formal health system—through training, supervision, and partnerships—can improve maternal outcomes more effectively than punitive measures.
Lessons from Other Countries
International experience underscores that reducing maternal mortality requires a multifaceted approach:
Ensuring skilled birth attendance with functioning referral systems for emergencies.
Providing 24-hour basic emergency obstetric care at primary facilities and ready access to comprehensive care at referral hospitals.
Engaging communities in birth preparedness and respectful maternity care.
Offering transport subsidies or ambulance services to overcome distance and cost barriers.
Training, certifying, and integrating community birth attendants into formal referral networks.
Countries that have focused solely on banning TBAs without simultaneously guaranteeing high-quality facility-based care have not achieved sustained reductions in maternal deaths. In fact, criminalisation can drive the practice underground, making births more dangerous.
Feasibility of Enforcement in Abia State
Despite significant progress under Project Ekwueme, questions remain about whether Abia’s PHCs can realistically serve all pregnant women around the clock. Equipment upgrades are important, but consistent staffing, reliable power supply, and emergency transport systems are equally critical.
If a woman in a remote village faces labor complications at night, can an ambulance reach her quickly? Are midwives on duty 24/7 at every functionalised centre? Without clear answers, the threat of arrest for using a TBA appears premature.
Furthermore, law enforcement agencies would need resources and training to enforce any new policy fairly. Arresting TBAs or their clients without providing accessible alternatives would likely meet resistance from communities and human rights advocates.
Recommendations for a Balanced Policy
For Abia State to reduce maternal mortality without causing harm, a more balanced approach is advisable:
First, the government should publish the legal framework and enforcement guidelines if it intends to criminalise untrained birth attendance. Transparency will help avoid perceptions of arbitrariness and build public trust.
Second, the state must guarantee that every functionalised PHC offers 24-hour skilled delivery services, essential drugs, and reliable referral systems. Equipment alone cannot save lives without trained personnel and operational readiness.
Third, rather than immediate punitive action, the government should provide accelerated training and certification opportunities for willing TBAs, integrating them as community health promoters or referral agents.
Fourth, community engagement is crucial. Collaboration with traditional leaders, women’s groups, and religious bodies can foster understanding and encourage pregnant women to use formal health facilities voluntarily.
Fifth, the state should implement a robust monitoring and evaluation system to track maternal and neonatal outcomes. Publishing monthly data on facility deliveries and maternal deaths would help identify gaps and adjust interventions in real time.
Community Perspectives: Voices Yet to Be Heard
Current reporting on the policy mainly reflects the government’s perspective. Missing from the public conversation are the voices of TBAs, pregnant women, and health workers who must implement these changes.
How do TBAs view the threat of arrest? Are they being offered training or integration into the health system? What challenges do health workers face in keeping PHCs fully operational? How do women in remote communities feel about the new policy?
Including these perspectives in future coverage will provide a more complete understanding of the policy’s impact and feasibility.
Broader Implications for Nigeria
Abia State’s efforts are part of a larger national struggle to improve maternal health outcomes. Nigeria’s federal and state governments have launched multiple initiatives aimed at increasing access to skilled birth attendance, but progress remains uneven.
If Abia successfully scales up Project Ekwueme while ensuring quality and community engagement, it could serve as a model for other states. Conversely, if the state pursues criminalisation without adequate preparation, it could spark backlash and worsen mistrust between communities and formal health systems.
Conclusion
The commissioning of two more PHCs under Project Ekwueme marks genuine progress in strengthening Abia State’s primary health care infrastructure. Equipping these centres with modern medical devices is a welcome development for maternal and child health.
However, Governor Otti’s threat to arrest untrained TBAs and those who patronise them introduces legal, ethical, and practical challenges. Without a transparent legal framework, 24/7 service readiness, and community buy-in, punitive measures risk undermining public health goals rather than advancing them.
A more sustainable approach would combine rapid PHC expansion with training and integration of TBAs, community engagement, and data-driven monitoring. Abia State stands at a crossroads: it can choose a collaborative path that saves lives or pursue an enforcement-heavy route that may drive essential maternal care further into the shadows.
Author Bio
Chika Nwosu is a Nigerian health policy journalist and senior contributor to SaharaNews247. With a background in public health reporting and over a decade of experience covering governance and community health issues, Chika focuses on evidence-based analysis of policies affecting women and children across West Africa. Contact: chika.nwosu@saharanews247.com.
