In some parts of the country, women have many children over their lifetime. In others, they have far fewer. These places are governed by the same systems and policies, but everyday life looks very different. In one setting, women can plan when and how many children to have because services and information are within reach. In another, choices are limited by poverty, long distances to health facilities, and a lack of support. 

In Mandera County, in Kenya’s far north-east, a woman will, on average, give birth to 7.7 children over her lifetime. That single figure places Mandera not just at the top of Kenya’s fertility table, but in the company of Niger, Mali, and Chad, nations that consistently rank among the highest fertility rates on earth. Yet Mandera shares a constitution, a Ministry of Health (MoH), and a national development agenda with Nairobi City, where a woman will bear an average of 2.6 children, fewer than in many parts of Europe a generation ago. 

This is not a tale of two countries. It is a tale of two counties, separated by a few hundred kilometres and a chasm that cuts across education, wealth, healthcare access, and opportunity. The 2022 Kenya Demographic and Health Survey captures this divide in unprecedented county-level detail, covering total fertility rate, the percentage of women currently pregnant, and mean children ever born among women aged 40 to 49 across all 47 counties. What it reveals is a country of profound and persistent inequality, where a woman’s reproductive life is shaped less by personal choice than by where she was born. 

A nation pulling in two directions: Women in rural areas have 3.9 children, compared to 2.8 in urban areas 

Kenya’s overall fertility rate has declined from 3.9 children per woman in 2014 to 3.4 in 2022. Modern contraceptive use among married women has risen from 18 per cent in 1989 to 57 per cent in 2022. According to MoH, 98 per cent of mothers now receive antenatal care from a skilled health provider, a remarkable achievement for a country of Kenya’s size and geographic complexity. The World Bank’s global total fertility rate currently stands at 2.3 as of 2024 and 2025. 

But national averages conceal as much as they reveal. Women in rural areas have an average of 3.9 children, compared to 2.8 in urban areas. Women with no formal education average 5.3 children, while those with education beyond secondary school average 2.8. Women in the poorest households average 5.3 children, against 2.7 in the wealthiest, a gap that mirrors, almost exactly, the distance between Mandera and Nairobi. 

The high-fertility belt: 1 in 10 women of reproductive age is pregnant at any given time in Mandera 

Mandera’s total fertility rate of 7.7 is accompanied by a current pregnancy rate of 10.5 per cent, meaning roughly one in ten women of reproductive age is pregnant at any given moment. The ten highest-fertility counties form a near-contiguous belt across Kenya’s arid and semi-arid lands, including West Pokot at 6.9, Wajir at 6.8, Marsabit at 6.3, Turkana at 6.0, Samburu at 5.8, Tana River at 5.7, Garissa at 5.3, Narok at 4.9, and Lamu at 4.6. 

West Pokot records the single highest current pregnancy rate in the country at 13.2 per cent, meaning more than one in eight women of reproductive age in that county is pregnant at any given time. Wajir records the highest mean children ever born of any county at 7.8, suggesting that completed fertility there exceeds even Mandera’s. 

In Wajir and Mandera, absolute poverty levels are estimated at between 85 and 89 per cent, and the modern contraceptive prevalence rate is less than 3 per cent. A 2021 study published in Global Public Health, conducted through interviews with healthcare providers and community leaders in both counties, identified four overlapping barriers: a cultural and religious preference for large families; tension between spouses over contraceptive decision-making; fears and misconceptions about side effects; and physical distance from functioning health facilities. In nomadic and semi-nomadic pastoralist communities, seasonal movement patterns further complicate continuity of care, making even injectable contraceptives difficult to sustain consistently. 

Health insurance coverage in Mandera stands at just 6 per cent, compared to 46 per cent in Nairobi City. A woman in Mandera giving birth to her seventh child is doing so not only with the physical risks associated with high parity, but with a fraction of the institutional support available elsewhere in the country. 

The low-fertility counties: Nyeri, Uasin Gishu, Nandi, Kisii, Mombasa, Kiambu, Machakos 

Kenya’s ten lowest-fertility counties are predominantly urban or peri-urban, concentrated in the central highlands, southern Rift Valley, and coastal regions. They include Nyeri at 3.1, Uasin Gishu at 3.1, Nandi at 3.0, Kisii at 3.0, Mombasa at 2.9, Kiambu at 2.9, Machakos at 2.8, Kirinyaga at 2.8, Nyamira at 2.7, and Nairobi City at 2.6. The decline in fertility across these areas has been linked to higher educational attainment, household wealth, and urban residence. 

Nairobi City’s total fertility rate of 2.6, approaching but not yet at the replacement rate of 2.1, is consistent with fertility trends in middle-income urban centres across East Africa. Its mean children ever born of 3.1, however, indicates that completed fertility among older women in the capital remains above replacement. 

Notably, several low-fertility counties are not strictly urban. Kisii and Nyamira in Nyanza, and Nandi in the Rift Valley, have achieved total fertility rates below 3.0 despite being predominantly rural. This suggests that community-level health infrastructure, educational investment, and prevailing cultural attitudes towards family size can drive fertility decline independent of urbanisation alone. Among married women, 84 per cent of those with primary school education and 94 per cent of those with secondary education reported not wanting more children, a figure that illustrates how powerfully education reshapes reproductive preference. 

The adolescent pregnancy crisis: High-burden counties in arid, remote and poorer regions 

The proportion of adolescents who have begun childbearing ranges from 50 per cent in Samburu to just 5 per cent in Nyeri and Nyandarua. Nationally, teenage pregnancy rates have declined from 18 per cent in 2014 to 15.7 per cent in 2022, but high-burden counties in arid, remote, and poorer regions continue to record extreme levels, driven by poverty, low education, early marriage, female genital mutilation, and weak health systems. 

Data gaps and underreporting, particularly in marginalised areas, further obscure the true scale. Despite policy efforts and rising contraceptive use, progress has not reached the most vulnerable. Kenya’s target of reducing teenage pregnancy to 10 per cent by 2025 is unlikely to be achieved. 

The survey’s county-level data makes one thing impossible to ignore: national progress is real, but it is not evenly shared. And for the women living furthest from it, the distance is not measured in statistics. It is measured in lives. 

Sources: KDHS 2022 (KNBS)/WHO/MoH/UNFPA/Peer-reviewed research 

Data analytics & visualisation: Stanley Njihia  

Text: Yvonne Kawira