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Tunza Mama: Community Midwifery Increases FP/RH Access at Home in Kenya

Our colleagues at Amref share how the Tunza Mama network improves the socio-economic status of midwives while positively impacting the health indicators of mothers and children in Kenya.

Now more than ever, we need midwifery services in the community. With the COVID-19 pandemic, the availability of essential health services has been strained. Despite these challenges, we have increasingly seen nurses and midwives step up to offer care at the grassroots level. This piece summarizes how Tunza Mama, a health social enterprise by Amref International University, improves the socio-economic status of midwives while positively impacting the health indicators of mothers and children in Kenya. We assert to decision makers and technical advisors that midwives need support too and that we need to encourage their innovative methodologies to reach more mothers and children in the country, especially during these unprecedented times of COVID-19.

About Tunza Mama

Tunza Mama is a Swahili phrase meaning “to care for or nurture a mother.” The Tunza Mama network is a health social enterprise network, implemented in Kenya, geared at giving back to midwives while improving the health of mothers and their children. Tunza Mama has been in operation since May 2018, offering health education and accurate dissemination of health information to women of reproductive age in the comfort of their homes. The mothers/clients pay a small fee to have these services at their homes. Midwives are empowered with valuable skills in entrepreneurship, business development, and current maternal, newborn, and child health (MNCH) care—for example, professional coaching on childbirth preparation techniques, lactation, birthing, weaning, and postnatal self-care.

Tunza Mama is responsive to the current global, regional and national demand for Universal Health Coverage (UHC). Though this model has been in existence since 2018, it is now more useful than ever, as normal service delivery at health facilities have been disrupted due to the COVID-19 pandemic. This service is crucial to promoting health and preventing maternal, newborn and child ailments and mortality.

Marygrace Obonyo teaching mothers about breastfeeding practices in Kisii County.

Marygrace Obonyo teaching mothers about breastfeeding practices in Kisii County.

How Does Tunza Mama Work?

Midwives from both the private and public sectors join Tunza Mama to offer voluntary family planning and reproductive health (FP/RH) care to women in the comfort of their homes. The midwives first undergo additional training in newborn and child nutrition for the first 1,000 days, applied MNCH practices, and business and entrepreneurship skills. As there are few midwives to begin with, to ensure we do not create a further shortage by taking them away for training, we leverage technology. Training is done through mobile and eLearning formats, meaning the midwives can still build their skills even as they continue to offer care in their respective health facilities. Any demonstration sessions are held with trainers at their health facilities to improve skills such as IUD insertion.

The midwives then undergo mentorship sessions with trainers at a local health facility, where they learn how to interact with pregnant women, mothers, and infants to build their communication skills. In addition, they offer health education sessions as part of birth preparation classes as their mentor observes and guides them. During the pandemic, all midwives are adhering to the current guidelines provided by the Kenya Ministry of Health (MOH). For example, Tunza Mama midwives comply with infection prevention measures by wearing protective gear and maintaining social distance when they visit mothers at their homes. There is also a COVID-19 short course for health workers offered by the MOH and Amref Health Africa. The nurses/midwives earn up to 16 credit points for completing the course, bringing them closer to the 40 credit points required for license renewal.

Lydia Masemo demonstrating the use of a yoga ball to exercise during pregnancy.

Lydia Masemo demonstrating the use of a yoga ball to exercise during pregnancy.

Community Midwifery Regulation

Once the training and mentorship are completed, the Nursing Council of Kenya offers the midwives Community Midwifery licenses to enable them to offer services to mothers in their communities. The services offered by Tunza Mama include birth preparation classes, postnatal support, and complementary feeding support, as well as postnatal nursing care. So far, 558 women have benefited, and 62 mothers received these services over the past month.

The mothers served by Tunza Mama come from urban and peri-urban locations. The majority are working mothers who are also first-time mothers. They pay an average fee of KSh 2,000 (USD 20) for one session, which runs from 1.5 hours to 2.5 hours. Clients pay the fee out of pocket to the Tunza Mama bank account; the midwives then receive 95% of the fee, while 5% is retained to run the network. On a quarterly basis, the midwives offer free sessions to mothers from poor urban areas who cannot afford the full fee.

Susan Kerubo, a beneficiary of Tunza Mama services in Kisii, holding her son.

Susan Kerubo, a beneficiary of Tunza Mama services in Kisii, holding her son.

Putting Tunza Mama in Context

The project is embedded in a low- to middle-income country (Kenya) where 65% women have access to skilled birth attendants. In the same context, health facilities have a shortage of midwives (2.3 midwives per 10,000 people) because the government lacks the finances to employ the 3,000 comprehensive midwives who graduate annually from tertiary institutions. The limited access to skilled birth attendants is reflected in Kenya’s maternal mortality ratio of 362/100,000 live births and neonatal mortality ratio of 26/1,000 live births. This shortage of midwives in health facilities has pushed working women to seek highly specialised care from obstetric specialists in the private sector, denying them access to knowledge and skills on the basics of MNCH and self-care. According to WHO, in 2017 about 86% of global maternal deaths were from Sub-Saharan Africa and Southern Asia.

The expected outcome of the project is to reverse the emerging trend of limited access to quality health education and personalised MNCH care for working mothers. It also provides an entrepreneurship opportunity for midwives to individually reach women across all social-economic classes.

Marygrace Obonyo showing a mother how to perform back exercises during pregnancy.

Marygrace Obonyo showing a mother how to perform back exercises during pregnancy.

Lessons Learned from Tunza Mama

  • Innovative learning methods: Use of digital learning (mobile and eLearning) by the midwives has enabled them to interact with the content at any time, which has enhanced their learning and reduced face-to-face session time by 75%. This way, learning happens and no artificial shortage of midwives occurs.
  • Mentorship: This is important in the training of a midwife. Mentoring provides support to the midwives during real-life experiences with the clients (mothers), which builds their confidence and improves their skills.
  • A midwife is a mother’s ally: In the past, the midwife was feared: She represented a tough, harsh professional, especially during hospital deliveries. This perception contributed to Kenya’s low rate of skilled birth attendants. A positive image of the midwife is important for uptake of voluntary family planning and RH care and attracting mothers to Tunza Mama’s services. The midwife is viewed as an ally/caregiver or Perinatal Educator who is accessible, available, and affordable.
  • The power of social media: Over 70% of mothers have come to know of Tunza Mama through Facebook, Twitter, and Instagram; therefore, they can dial a midwife or reach out for assistance easily.
  • Better maternal outcomes: More mothers are prepared for childbirth—for example, they can breathe through labour as guided by the midwife. Challenges such as cracked nipples during breastfeeding have been reduced. Mothers’ anxieties during weaning have been alleviated, since the midwife prepares the baby’s first meal with the mother present during the first feed.
“She (the midwife) has been amazing—she gave me assurance that everything will be fine…I [purchased] the full package because I believed [in] it and I love it: It is personalized, accessible, and offers me confidence thanks to a mother figure.” — Elsie Wanjiku, young mother of a 2-month-old boy and a Tunza Mama client in Nairobi County.

“She (the midwife) has been amazing—she gave me assurance that everything will be fine…I [purchased] the full package because I believed [in] it and I love it: It is personalized, accessible, and offers me confidence thanks to a mother figure.” — Elsie Wanjiku, young mother of a 2-month-old boy and a Tunza Mama client in Nairobi County.

Challenges

Personalized MNCH care is not common in the Kenyan context; therefore, uptake of Tunza Mama’s services has grown slowly. This is also a paid program for which the mother needs to pay a fee to the midwives, and so only the middle class can currently afford to utilize it. There is a need for technical advisers and decision makers to ensure this service is subsidised to reach all marginalised communities. As Tunza Mama is also available in only two counties (Nairobi and Kisii), there is a need for scale-up.

Final Thoughts

Community midwifery care is important to mothers, especially during the current COVID-19 pandemic. Inasmuch as we hope for continuity of essential care at health facilities, mothers are shying away from hospitals: the number of antenatal care appointments has dropped, home deliveries have increased, and unplanned pregnancies are inevitable. Midwives should therefore adapt the Tunza Mama model to offer voluntary FP/RH care in the comfort of mothers’ homes, and the government should incentivize these midwives for the extra care they are offering.

Marygrace Obonyo showing a mother how to perform back exercises during pregnancy.
Sarah Kosgei

Networks and Partnerships Manager

Sarah is the Networks and Partnerships Manager at the Institute of Capacity Development. She has over 10 years’ experience providing leadership to multi-country programs geared towards strengthening the capacity of the health system for sustainable health in Eastern, Central, and Southern Africa. She also part of the Women in Global Health – Africa Hub secretariat domiciled at Amref Health Africa, a Regional Chapter that provides a platform for discussions and a collaborative space for gender-transformative leadership within Africa. Sarah is also a member of the Universal Health Coverage (UHC) Human Resources for Health (HRH) sub-committee in Kenya. She has degrees in Public Health and an Executive Masters in Business Administration (Global Health, Leadership and Management). Sarah is a passionate advocate for primary health care and gender equality in sub-Saharan Africa.

Priscilla Ngunju

Project Coordinator

Priscilla Ngunju is the Project Coordinator for the Kenya Innovative and Sustainable Solutions for Midwives Education and Employment (KISSMEE) project at Amref International University. In her role, Priscilla leads a team of dedicated staff in the initiation and registration of the Tunza Mama Network and ISOMUM institute, the “babies” of the KISSMEE project. Priscilla holds a Bachelor’s degree in Nursing Sciences and a Master’s degree in Public Health from the University of Nairobi. She is also an alumna of the prestigious Women in Leadership Program from Strathmore Business School. Priscilla is driven by the results of impactful work, especially among women and children.

Alex Omari

East Africa KM Officer, Knowledge SUCCESS

Alex is the Technical Family Planning/Reproductive Health Officer at Amref Health Africa’s Institute of Capacity Development. He works as the Regional Knowledge Management Officer (East Africa) for the Knowledge SUCCESS project. Alex has over 8 years’ experience in adolescent and youth sexual and reproductive health (AYSRH) program design, implementation, research, and advocacy. He is currently a Technical Working Group member for the AYSRH program at the Ministry of Health in Kenya. Alex is a website contributor/writer for Youth for Change and the outgoing Kenya Country Coordinator for the International Youth Alliance for Family Planning (IYAFP). He holds a Bachelor of Science (Population Health) and is currently pursuing his Master of Public Health (Reproductive Health).

Diana Mukami

Digital Learning Director and Head of Programmes

Diana is the Digital Learning Director and Head of Programmes at Amref Health Africa’s Institute of Capacity Development. She has experience in project planning, design, development, implementation, management, and evaluation. Since 2005, Diana has been involved in distance education programmes in the public and private health sectors. These have included the implementation of in-service and pre-service training programmes for health workers in countries such as Kenya, Uganda, Tanzania, Zambia, Malawi, Senegal, and Lesotho, in partnership with Ministries of Health, regulatory bodies, health worker training institutions, and funding organisations. Diana believes that technology, used the right way, contributes significantly towards the development of responsive human resources for health in Africa. Diana holds a degree in social sciences, a post-graduate degree in international relations, and a post-baccalaureate certificate in instructional design from Athabasca University. Outside of work, Diana is a voracious reader and has lived many lives through books. She also enjoys traveling to new places.

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