The big divide: When a child's future is dictated by birthplace and family wealth

The latest Mini Demographic and Health Survey released yesterday has exposed the truth about Kenyan ways and life decisions that many grapple with as they trudge along.

From more women delaying giving birth to prioritise education and financial security to 60 per cent of Kenyans who have to rely on other sources of money to get treatment outside insurance funding. The report by the Kenya Bureau of Statistics paints a worrying picture for planners but also gives relief on growth in the health sector.

Glaringly, Kenyan women are having fewer children, but maternal deaths remain high, despite improvements in access to healthcare, according to the survey. It also shows that between the ages of 20-34 there are more women in urban centres than men.

The country's total fertility rate has dropped to 3.1 children per woman, down from 3.4, reflecting a gradual shift in reproductive patterns.

The findings show that women in rural areas have an average of four children, compared with three, among their urban counterparts.

“Fertility rates in Kenya have dropped. There has been a declining trend, with women between 15 and 49 years having fewer children in their lifetime. For Kenya, 3.1, a drop from 3.4, with rural areas at 3.6 and urban areas at 2.6,” reads a section of the report.

Rosemary Bowen, Director of the Population and Social Statistics Directorate at the Kenya National Bureau of Statistics (KNBS), said women in urban areas have an average of three children, compared with about four in rural areas.

The decline in fertility is associated with increasing levels of education.

For instance, women with no education have an average of 5.4 children, compared with 2.7 among those with secondary education.

Similarly, fertility declines with increasing household wealth, from 4.5 children per woman in the lowest wealth quintile to 2.3 among those in the highest wealth quintile.

However,  fertility levels vary substantially across counties, reflecting differences in reproductive behaviour.

Mandera has the highest total fertility rate at 6.8 children per woman, while Embu has the lowest at 2.2.

Nyandarua follows with 3.8, while Nakuru, Kakamega and Vihiga each record 3.5 children per woman.

Other counties with relatively high fertility rates include Murang'a, Nandi and Bomet at 3.4 each, Kisumu and Nyamira at 3.2, and Uasin Gishu at 3.0.

“Thirty-one of the 47 counties have total fertility rates above the national estimate of 3.1 children per woman,” adds the report.

The survey also shows that the median interval between births has increased from 42.1 months in the 2022 KDHS to 46.3 months in the latest survey.

Fertility also varies by age, rising from 63 births per 1,000 women aged 15 to 19 years to a peak of 161 births per 1,000 women aged 25 to 29 years, before declining among older age groups.

The report notes that the number of children a woman bears depends on several factors, including the age at which she begins childbearing, the interval between births and her fecundity.

Postponing the first birth and extending the intervals between subsequent births have contributed to declining fertility in many countries.

These practices also have health benefits, as short birth intervals of less than 24 months can increase the risk of preterm birth, low birth weight and death among newborns and their mothers.

Despite the decline in fertility, maternal mortality remains a major public health concern.

Kenya has recorded a decline in maternal mortality, with the ratio dropping to 263 deaths per 100,000 live births, according to the survey.

The figure, however, remains far above the global target of fewer than 70 maternal deaths per 100,000 live births.

It is a decline from 362 deaths per 100,000 live births in the 2022 KDHS and 520 in the earlier 2003 KDHS.

Speaking during the release of the report, Principal Secretary for Medical Services Ouma Oluga said the decline was encouraging but insufficient to meet the country's target.

“The maternal mortality ratio, which we have been seeing in the 300s, for the first time we are going to start seeing a number that is lower, which means that we've made progress at 263 per 100,000. But that's not enough. Our target is to get to 70 and below,” said Oluga.

The improvement comes alongside an increase in the number of women delivering in health facilities, which has risen from 88 per cent to 91 per cent.

However, access remains uneven across the country, with facility based deliveries ranging from 47 per cent in Garissa to 100 per cent in Nairobi, Nyandarua and Nyeri.

The proportion of women attending at least four antenatal care visits has also increased from 66 per cent to 72 per cent.

However, early antenatal care attendance remains low, with only 36 per cent of pregnant women attending their first clinic during the first trimester, up from 29 per cent previously.

Only 9.5 per cent of women complete the recommended eight antenatal care contacts, raising concerns about missed opportunities to identify and manage pregnancy complications.

Experts say early initiation of antenatal care helps identify pregnancy complications and enables timely intervention to save the lives of mothers and babies.

Meanwhile, the proportion of births delivered through Caesarean Section has increased five-fold, from four per cent in 2003 to 20 per cent in 2025/26.

“Percentage of births delivered via caesarean section have increased five-fold since 2003, from four per cent in the 2003 KDHS to 17 per cent in the 2022 KDHS and further to 20 per cent in the 2025–26 KMDHS,” reads the report.

The proportion of Caesarean deliveries is twice as high in urban areas, at 29 per cent, compared with 14 per cent in rural areas.

The disparity is also evident across wealth groups, with 41 per cent of live births among women in the highest wealth quintile delivered through Caesarean section, compared with nine per cent among those in the lowest wealth quintile.

In 21 counties, Caesarean section rates exceed the recommended upper limit of 15 per cent.

Kiambu has the highest rate at 39 per cent, followed by Nyeri at 37 per cent and Murang'a at 36 per cent. Nairobi and Makueni record 31 per cent and 30 per cent, respectively.

The survey also highlights gaps in family planning, with modern contraceptive use reported at 56 per cent.

Although uptake has increased from 32 per cent in 2003, the latest findings suggest that progress has slowed.

Implants have become increasingly popular, rising from less than one per cent among currently married women before the 2003 survey to 23 per cent in the latest findings.

The use of injectables, however, has declined from a peak of 26 per cent in 2014 to 19 per cent in 2025/26.

Murang'a leads in modern contraceptive use at 76 per cent, followed by Makueni at 72 per cent and Embu at 70 per cent.

The report also highlights differences in emergency contraceptive use, which is twice as high in urban areas at six per cent compared with three per cent in rural areas.

Less than one per cent of women with no education use emergency contraceptives, compared with nine per cent of those with education beyond secondary school.

Machakos, Kericho, Kajiado and Kilifi are among the counties recording high use, while uptake remains below one per cent in Kwale, Lamu, Mandera, Garissa, Wajir, Siaya and Turkana.

On immunisation, Kenya's vaccination coverage stands at 80 per cent.

But uptake of the human papillomavirus (HPV) vaccine remains a concern, with 41 per cent of women aged 15 to 19 years having received no HPV vaccination.

The report indicates that 20 per cent of women in this age group have received one dose, while 39 per cent have received two doses.

Among women aged 20 to 49 years, only eight per cent have received at least one dose, while 92 per cent have never received the vaccine.

Malaria also remains a major public health problem, with some counties continuing to record high transmission rates.

The survey identifies Busia, Kakamega, Kisumu, Migori, Siaya and Vihiga as counties with a very high malaria burden, reporting an incidence of 748 cases per 1,000 people.

Transmission in these areas is classified as intense and perennial, with significant implications for health systems and socioeconomic wellbeing.

Malaria during pregnancy also remains a major public health concern, posing substantial risks to mothers, their unborn babies and newborns.

Other high-burden counties include Bungoma, Homa Bay, Kwale, Turkana and West Pokot, which report an incidence of 474 cases per 1,000 people.

“Malaria remains a major public health problem in these areas, contributing substantially to outpatient visits, hospitalisations and mortality, especially among children under age five and pregnant women,” reads the report.

Meanwhile, child mortality indicators have generally improved, with neonatal mortality declining from 21 to 19 and under-five mortality dropping from 41 to 37. Infant mortality, however, remained unchanged at 32.

The report also highlights mortality risks among adults, indicating that 1.7 women and 2.8 men out of every 10 die before reaching the age of 50.