Data Stories
Train Traditional Birth Attendants, Don’t Ban Them
Traditional birth attendants (TBAs) remain the main providers of delivery services, especially in rural and remote areas. Rather than banning them, governments should support them to reduce maternal and child mortality, and ensure that they get adequate training.

Throughout African history, traditional birth attendants (TBAs) have provided maternity care for women despite having no formal training.
Poverty, cultural practices, and a shortage of primary healthcare services are forcing women to seek the help of untrained traditional birth attendants, despite the serious risks involved.
Last year Kenya recorded a maternal death rate of about 362 per 100,000 live births and an under-five death rate of 52 per 1,000 live births, while in Tanzania, one in every 126 women die due to maternity complications. The story is the same in Uganda and Ghana as well. According to the World Health Organisation (WHO)’s figures for 2016 on maternal mortality, 560 women die per 100,000 births in Nigeria.
Despite these shocking figures, women, even learned ones, are still flocking to unskilled birth attendants’ homes to give birth, putting their lives at risk. Why is this so? Is it is because governments are failing them?
For some women, traditions prevent them from attending hospital. For others, long distances to medical facilities prevent them from reaching a health facility in time to give birth. Some are put off by health workers’ attitudes.
TBAs can provide them with all the care they need, both during and after pregnancy and childbirth, and there is no doubt they are a much-needed resource.
In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.
It is evident that pregnant women are not satisfied with the quality of care they are given at the hospitals. With the high number of women taking advantage of the free services, combined with the few health care workers to attend to them, some women are giving birth on their own even when they are in hospitals.
In 2013, Kenya had one of the highest maternal mortality rates in the world: 488 maternal deaths per 100,000 live births, according to the Ministry of Health.
In 2013, the Kenyan government introduced free maternal healthcare. The goal was to encourage more women to give birth in health facilities. However, according to data from the Kenya National Bureau of Statistics (KNBS) released this year, more women are still flocking to TBAs.
According to KNBS data for 2015/2016, the findings reveal that three out of ten children were delivered at home in 2018 in Kenya; this is an estimated 31.3 per cent improvement from 53.9 per cent recorded in 2005/06.
The survey showed that in rural areas the proportion of children born at home was 40.7 per cent compared to 13.3 per cent in urban areas.
“The county with the lowest proportion of children born at home was Kirinyaga, at 3.8 per cent, while Wajir, Mandera, Samburu and Marsabit had over 70 per cent of children born at home. Kirinyaga, Nyeri and Kisii counties recorded over 90 per cent of children born in a health facility,” KNBS stated.
The proportion of children delivered with the assistance of a traditional birth attendant in rural areas was 25.6 per cent compared to 7.8 per cent in urban areas. Wajir, Mandera and Samburu had over 60 per cent of the births assisted by a traditional birth attendant. Turkana County had the highest proportion of self-assisted births, at 34.5 per cent.
The low hospital births among pastoral communities may be partly linked to inadequate health facilities and personnel in the regions they live in. Families in pastoral counties also tend to be polygamous, which puts a strain on resources such as healthcare.
Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.
Statistics further show that more deliveries are now handled by trained medical personnel, which is a plus in attaining safer childbirths. However, women in rural areas still prefer to be attended by TBAs, friends, and relatives during delivery.
According to WHO, with the exception of sub-Saharan Africa, where most births in rural areas are conducted by TBAs, rates of births assisted by a medically trained attendant have shown impressive increases over the past 15 to 20 years, Current data indicate that 59 per cent of births in the developing world are assisted by a medically trained professional.
Nairobi, Kisii, Kiambu, Kirinyaga and Nyeri counties top in childbirths in hospitals, an indication of the success of the safety campaigns. These five counties are the only counties that recorded over 74 per cent of children born in hospitals.
Uganda banned TBAs) in 2010 but they have continued to practise. Eighty per cent of rural women prefer TBAs to skilled attendants, according to officials at the Ministry of Health; 10 per cent of them delivered with the assistance of TBAs.
With TBAs playing such an important role in maternal and newborn healthcare, especially in rural areas, should governments abolish them completely or look for ways of incorporating them into the system as referral agents to hospitals?
One midwife’s experience
The Telegraph, through an informal survey in Kisumu’s Nyalenda Estate in Kenya, established that some mothers delivering in hospitals still relied on traditional birth companions during pregnancy and after giving birth.
Pictures of newborn babies adorn the walls of Margret Owino’s house. They are a treasured decor in the improvised maternity ward in her two-roomed corrugated iron-walled house. Hundreds of women have trekked the dusty and curvy road to Ms Owino’s Kisumu home, judging from the many pictures.
It is at 6 am when we got to her house. Dressed in a blue nylon apron, she is busy attending to a pregnant woman. In a busy month, she delivers over 60 children, according to her well-kept records.
Her small house acts as a labour and delivery room. She is among traditional midwives who assist women at childbirth, mostly in areas that lack infrastructure and trained health personnel.
Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.
Ms Owino learned the midwife’s skills at a tender age. When she was 15 her late grandmother, who was a midwife, placed herbs in her right hand and some coins in the left — the traditional way of transferring the skills to her. This has since been her job. She is among Kenya’s 35 registered traditional birth attendants who work with hospitals to ensure safe deliveries.
She has had women who are bleeding profusely brought to her in the middle of the night. She does not attend to them but sends them immediately to the nearby hospital. Some clinics contact her to attend to mothers with breech births and at times they are brought to her “clinic”.
She also refers HIV-positive women to the hospital, but says she knows not all women disclose their status to her. She says it is a constant risk.
Her maternity services are similar to those in health facilities. She records clients’ details in a book and weighs infants on a weighing machine given to her as a token.
One of her clients said that harassment in public hospitals is one of the reasons they still troop to traditional birth attendants’ clinics.
Even though there are several health facilities in the area, some pregnant women prefer traditional birth attendants. They say they are more comfortable with them than obstetricians and trained midwives.
‘‘The midwives harass us, calling us names while we are often left in the hands of inexperienced trainees. The midwife can detect when a woman has the strength to push the baby or not, or if the baby is in the right position,” she says.
She says community midwives pamper and take care of women during and after delivery. She says this helps them give birth with dignity. That is why a lot of women come back to her when they are having another baby
Initially, the government was threatening the TBAs while others were being harassed and their tools were being confiscated. However, this has since changed; they are now being registered and undergo training to ensure safe deliveries.
The Ugandan government has also lifted the ban on TBAs and the focus now is training them. As a result, there has been a shift towards skilled birth attendants capable of averting and managing childbirth complications.
Ms Owino only attends to women who know their HIV status. She ensures that HIV positive clients have antiretroviral (ARVs) drugs given by a doctor, which she gives to the child immediately after tying the umbilical cord.
Benefits of supporting and training TBAs
Rather than educate against the use of TBAs, the United Nations Population Fund (UNFPA) believes that working with them is the best solution. It did a a study on the benefits of supporting and training TBAs across the world. The study was done in the Upper East Region in Ghana, and tracked antenatal visits and deliveries conducted by trained TBAs from 1990 to 1993.
“Antenatal visits increased from 20,000 to 180,000. Deliveries reported by TBAs increased from less than 10,000 to 50,000. Nationally, the percentage of TBA deliveries as a percentage of supervised deliveries increased from 16.4 percent to 22.2 percent between 1992 and 1993. Policymakers and program managers state that TBAs have contributed to: improve prenatal care, increase contraceptive acceptance rate, and decrease neonatal tetanus admissions”.
“The role of traditional birth attendants in the provision of healthcare in resource-poor countries is still important because of the current inadequacy of human resources for health. In developing countries for years to come, TBAs will remain the main providers of child deliveries in rural areas,” it states.
Dr Elizabeth Ogaja, a health analyst, says that midwives are an integral part of the healthcare system, adding that the reduction of maternal and newborn mortality in developing countries requires rigorous efforts that involve governments and non-governmental organisations in identifying TBAs who are known by the community to be experts.
“Recruitment and training of TBAs using adult learning techniques is important. The programmes should focus on basic primary healthcare, especially on symptoms of risky cases that need to be referred to formal health services and on hygiene to prevent mother and child from infections,” she says.
“Creation of dialogue, trustworthiness, patient, tolerance, willingness to collaborate, transparent and familiarity during training are key when working with TBAs as partners in health care and when sharing experiences,” says Dr Ogaja.
Training, she says, should be followed up by frequent meetings to share feedback and problems TBAs experience.
“We have realised that they are very important. Mothers trust them and we want to integrate them as much as we can. We advise that they bring pregnant mothers to hospitals so that we can take it from there,” she says.
Dr Lawrence Koteng’, the Homa Bay health executive, acknowledges the role played by traditional midwives but encourages expectant women to deliver in health facilities.
He says the county health department is training community health workers to discourage unsafe home deliveries.
“We do not support expectant women to deliver at home or anywhere except at health facilities where there are experts who can help whenever there is a complication,” says Dr Koteng’.
However, Allan Mayi, the deputy project director at Elizabeth Glaser Paediatric Aids Foundation, says the birth attendants should not attend to expectant mothers because they lack the skills needed to offer safe deliveries.
The organisation encourages women to deliver in hospitals and even offers incentives to birth attendants to take them to health facilities.
“Most mother-to-child HIV transmissions are recorded at midwives’ homes,” says Mr Mayi.
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Data Stories
Sex Education: Are We Doing Enough?

Comprehensive Sexual education in Kenya has been a topic of concern in recent years. The question of whether youth in Kenya are equipped with comprehensive sexual education has been raised by many stakeholders in the education sector. Responding to a recent article published by Nation Africa, the United Nations Population Fund (UNFPA) Director Technical Division Julitta Onabanjo said Kenya has withdrawn from the Eastern and Southern Africa (ESA) ministerial commitment to comprehensive sexuality education.

Ministerial Commitment to Sex Education.
This comes after the Kenya Demographic and Health Survey (KDHS) 2022 revealed in January that almost half of Kenyan adolescents aged 15-17 years do not know how to protect themselves from HIV/AIDS. Moreover, the percentage of girls and young women aged 15–19 years who have ever been pregnant is highest in Samburu (50%), West Pokot (36%), Marsabit (29%), Narok (28%), Meru (24%), Homa Bay (23%), Migori (23%), Kajiado (22%), Siaya (21%), and Baringo (20%), and lowest in Nyeri and Nyandarua (5% each).
Jane* (not her real name) is among the 41.6% of teenage girls aged between 15 -19 years who are sexually active and are not using any contraceptive according to the KDHS 2022. According to KNBS, only 11% of sexually active teenagers in Kenya are using contraceptives to prevent unintended pregnancies.
Source: KNBS
Jane falls under the other 89% who do not use birth control but are sexually active. These teenagers lack basic information on their sexual and reproductive health. Jane, 17, who requested anonymity to speak freely, told The Elephant that she regrets her first sexual encounter, which happened in the dormitory with a boy in her school. She did it because of peer pressure.
“My friends were talking about it and how good it feels, so I wanted to fit in,” she disclosed.
Jane, however, said that she is not well-informed about safe sex and protecting herself against unintended pregnancy, HIV/AIDS and other sexually transmitted infections.
The little she knows has been gleaned from brief conversations with her mother, Sarah Nekesa, a single mother living in an informal settlement, who has on occasion mentioned that there is a right time to have sex. Jane’s mother has also advised her to use protection if she can’t wait for the “right time.”
Moreover, Jane’s mother has also told her that if she has a boyfriend, they should be tested (for HIV) before engaging in sex. However, her mother discourages her from using contraceptives at her age, which she says is too young. As far as her mother who is staunch Christian is concerned, there is only one way that Jane can protect herself from getting infected or even pregnant—abstain from sex. What she does not know is that, apart from the incident in school, Jane has been engaging in transactional sex for several years. “I started sleeping with men who would give me money to buy pads and other essentials which my mother could not afford to give me,” Jane says.
“I could never talk to my mother about sex. I only did what I saw other friends my age do. After sex, I would take the morning-after pill (P2) to avoid pregnancy. The pills had some side effects. I experienced stomach pain and blood in the urine so I had to stop such activities. I didn’t use any protection, it is a relief I’m in good health,” Jane narrated.
A 2015 study by Guttmacher in three counties, namely Nairobi, Mombasa and Homa Bay found that most students in Forms 2 and 3 (96%) had received some sex education by the time they completed primary school, but the information received at this level is basic and does not include information on safe sex. Messages conveyed are often conservative and focused on abstinence. For instance, six in 10 teachers strongly emphasised that sex is dangerous and immoral and two-thirds strongly emphasised that abortion is immoral. Students said that the lessons focus on reproductive physiology and HIV prevention, and only 2% said they learnt all topics that constitute a comprehensive curriculum (including values and interpersonal skills, gender and sexual and reproductive health rights, contraception and unintended pregnancy).
Many curricula fail to provide adequate information about modern contraception – particularly, but not limited to, emergency contraception and female condoms – or HIV prevention through PrEP and PEP.
The inadequacy of education of children in practical matters of contraception and intercourse is often based on the belief that this information will encourage promiscuity, yet most students (93%) say sex education would be useful or very useful to their personal lives.
Yet abstinence-only programmes are still delivered in many countries despite robust evidence that this approach is ineffective. An increasing number of teen pregnancies in Kenya indicates that abstinence-only programmes are not effective. According to guidelines on sexuality education authored by six UN bodies (UNESCO, UNAIDS, UNFPA, UNICEF, UN Women and WHO), abstinence-only programmes are more likely to contain incomplete or inaccurate information regarding topics such as sexual intercourse, homosexuality, masturbation, abortion, gender roles and expectations, condoms and HIV.
The fact that Jane is sexually active but unaware of safe sex shows the risks that adolescents, especially girls who bear the brunt of teenage pregnancy, HIV infections and sexual and gender-based violence, face in the absence of comprehensive education about healthy sexuality.
A study conducted in Western Kenya in 2018 estimated that among 2.8 million girls aged 15-19 years, 24% (665,000) were sexually active and did not want a child, but were not using a modern contraceptive method. This age group accounted for 86% of all unintended pregnancies in the country.
Some of these girls are survivors of gender-based violence, including child marriage. United Nations Population Fund (UNFPA) estimates that Kenya’s child marriage prevalence rate is 23%. Child marriage is a driver of low education attainment, in turn limiting the employment and life options of girls. On the flip side, low education attainment also drives child marriage, fueling a vicious cycle.
These girls are further exposed to sexually transmitted infections. A study conducted in 2011 in the Rift Valley and Coast regions among HIV-positive adolescents aged 15-19 years found that about half had ever been tested and only a quarter of them knew their HIV status. Moreover, among sexually active HIV-positive adolescents, only a quarter reported using condoms at their first sexual intercourse. The study further found that two-thirds of HIV-positive girls had already begun childbearing or were pregnant, while 27% of boys had impregnated someone. In addition, 75% of pregnancies among HIV-positive girls were reported as unintended.
To equip young people with the information and skills needed for healthy sexuality in adulthood and to protect themselves from the risks that come with a lack of accurate and comprehensive information, UNESCO recommends that information on the cognitive, emotional, physical and social aspects of sexuality be included in the school curriculum. According to UNESCO, comprehensive sexuality education aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to: realise their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and, understand and ensure the protection of their rights throughout their lives.
Further, the Constitution of Kenya guarantees the right to the highest attainable standard of healthcare, including reproductive health, and the Health Act provides for an overarching legal framework for health. The law clearly supports Kenya’s commitments to the regional push for rights-based CSE in 2013, which includes several key goals. The ESA commitment calls for scaling up access to and quality of comprehensive sexuality education, increasing access to youth-friendly sexual and reproductive health services, eliminating all HIV infections, reducing early and unintended pregnancies, and eliminating gender-based violence and child marriage. These commitments are now on hold following Kenya’s withdrawal.
Comprehensive sex education has been opposed by various campaigners, such as the Commission for Education of the Kenya Conference of Catholic Bishops (KCCB) headed by Bishop Paul Njiru Kariuki. One of their campaigns titled Stop CSE said that the curriculum “is one of the greatest assaults on the health and innocence of children.”
The opposition to CSE, however, ignores clear evidence that CSE has a positive impact on sexual and reproductive health, notably contributing to a reduction in sexually transmitted infections, HIV and unintended pregnancy. CSE also improves knowledge and self-esteem, changes attitudes and gender social norms, and builds self-efficacy.
Purity Ngina, the evidence manager at Zizi Afrique Foundation, who recently completed a two-year survey of 17,000 teenagers aged 13-17 years in Kilifi County, said the survey revealed that only 16% have awareness of sexual and reproductive health.
“Many young boys think they can’t interact with girls because it is wrong and they will impregnate them. Lack of guidance and misinformation highly contributes to young people engaging in risky behaviours,” she said, adding that teenagers need to be trained to build decision-making and problem-solving skills, so they can make healthy decisions concerning their sexuality.
Ms Ngina added that the dissonance between what children are taught in church or at home and scientific information only leaves them confused.
“We hope that someone will use the Bible to train them on good morals and how our bodies change, but there is incongruence between science topics and what the adolescents are taught in church or by their parents at home,” she said.
Given the benefits of CSE on sexual and reproductive health, especially in reducing STIs, HIV and unintended pregnancy, it is vital for adolescents to receive proper education during this period of significant growth and development, filled with vulnerabilities. A good education presents a unique opportunity to foster better health outcomes as adolescents’ experiences likely shape their health behaviour throughout their lives. A 2020 study found that CSE programmes are highly effective, cost-effective and may even be cost-saving, especially if they are intra-curricular, nationally rolled out and jointly delivered with youth-friendly services.
This was evident in the results of a pilot study of more than 6,000 students who received sex education. The 2014 study noted a demonstrable increase in HIV knowledge, contraception and condom use among the sexually active, and a reduction in risky sexual behaviour among students. Students who received sex education also reported delayed sexual initiation compared to those who did not.
Evidence of the benefits of CSE is clear, but what will it take for it to work in a country like Kenya?
Ibrahim Okumu, a secondary school teacher says that, for one, the focus should not be on abstinence-only and that education policies that are overreliant on abstinence-only education should be reviewed.
“We are trying to tell our students to abstain but this is becoming more difficult,” he said in a YouTube video on video published by Citizen TV.
According to human rights advocate Wangui Gitahi, Kenya should also renew its official commitment to ESA, and implement its promise to expand comprehensive rights-based sexuality education.
There is also a push for CSE to be a stand-alone subject and not integrated into other subjects as is the case currently. Research from four low and middle-income countries including Kenya, published in PLOS pointed to the drawbacks of an integrated approach. For instance, teachers trained in their primary subject areas are rarely taught how to integrate CSE and might easily skip over topics they consider controversial with the excuse that they do not have adequate knowledge to cover them. Moreover, integration can diminish the importance of CSE in the curriculum as it gets diluted and doesn’t wield the weight of a standalone subject for both teachers and students.
Implementing CSE also requires resources, and the lack of dedicated funding for CSE from governments has posed a challenge. Historically, funding for CSE has been piecemeal, mainly from external sources, and tied to specific projects. Moreover, there is a lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development.
Easther Mwema a youth activist from Zimbabew who runs a sexual and reproductive health data collection centre recommends that youth should be included as stakeholders in the discussions on comprehensive sex education.
“Growing up, there were lots of situations that made me feel very unsafe as a female. But I was never asked what I would like to do about them, or what I could do to protect myself. All policies related to sexual education and rights are made by adults. That’s not right. I think youth should be in the room when decisions are being made about their bodies,” she said in an interview with Hivos.
Why CSE works in some countries and not others
As Kenya faces roadblocks in CSE implementation, South Africa’s Department of Basic Education DBE expanded the Comprehensive Sexuality Education curriculum in the Life Orientation subject.
South Africa’s HIV incidence rates are highest among adolescent girls and young women (AGYW), accounting for an estimated 29% of all new infections in 2018. HIV prevalence among girls aged 15–19 years was 5.8%, and 4.7% among boys in 2017. Birth rates have decreased moderately from 78 births per 1000 in 1996 to 65 births per 1000 in 2016 among the 15–19 age group. However, these birth rates remain high with data revealing that the majority of girls who become pregnant while attending school often do not return after childbirth, and in instances where girls do return to school, they face challenges balancing school and childcare.
In response, the SA Department of Basic Education (DBE) developed the HIV, STI, and TB policy, which included the call to educate girls and boys about sexuality and sexual behaviour in an effort to reduce both unintended pregnancy and HIV rates. One of the key interventions pronounced in this policy is the provision of comprehensive sexuality education (CSE). The aim of CSE, as specified by the DBE, is to build and shape learners’ understanding of concepts, content, values, and attitudes around sexuality and sexual behaviour.
Since 2015, the DBE has developed and piloted Scripted Lesson Plans (SLPs) across five provinces (KwaZulu-Natal, Free State, Gauteng, Mpumalanga, and Western Cape) to strengthen the teaching of CSE in schools. These support materials aid educators and improve the effectiveness of CSE lessons. This formed part of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) initiative, which aimed to reduce HIV infection among young women. The delivery of CSE using SLPs forms part of the DREAMS package of “layered” evidence-based HIV prevention interventions targeting biological, behavioural, and structural factors to reduce the vulnerability of girls and young women to HIV with the aim of reducing HIV incidence by 40% among adolescent girls and young women over a two-year period (2016–2018).
According to Hivos.org sex education increases the level of sexual responsibility among adolescents, as they gain essential knowledge and skills that will benefit them in adulthood. Currently, because of inadequate sex education, many adolescents and teenagers are uninformed. The myths and misconceptions about sex prevail among them.
In countries like the Netherlands where children learn about relationships from as young as four years old, the results are impeccable. The Netherlands has one of the lowest teenage pregnancies, abortion, and sexually transmitted diseases (STDs) rates in Europe.
A study by the All India Educational and Vocation Guidance Institute found that between 42% to 52% of young students in India feel that they do not have adequate knowledge about sex. In a recent survey conducted by India Today, a leading news magazine, in 11 Indian cities revealed that almost half of all young people interviewed didn’t know enough to protect themselves from HIV/AIDS.
Due to this, it is submitted that India is obliged to provide comprehensive sexuality education in all public and private schools in India and that the denial of such education to children, adolescents and young people generally and the banning of the Adolescence Education Programme (AEP) by state governments specifically is a violation of India’s commitments under international law. Arguments on culture, morality or federalism are invalid in this context. Further, the provision of age-appropriate comprehensive education on sexuality and HIV/AIDS can also have important consequences in dealing with child abuse and in reducing the spread of HIV/AIDS.
In many African countries CSE, gender sensitisation and human rights education are not supported due to lack of political will. The 2003 Maputo Protocol initiated by members of the African Union encourages member states to integrate gender sensitisation and human rights education at all levels of education; it has not been ratified by two-thirds of the African member states. Implementation of CSE is donor-driven with oversight given to both Education and Health Ministries, creating funding and accountability problems.
Without information on sexual and reproductive health and gender equality, young people face a heightened risk of contracting HIV or experiencing unintended pregnancy, which might not only limit their future prospects but also put their lives at risk. Complications during pregnancy and delivery are one of the leading causes of death among adolescents globally. Research has established that CSE can improve sexual and reproductive health knowledge, and be effective in reducing risky sexual behaviour. Studies in sub-Saharan Africa have to an extent affirmed these results, indicating that changes in adolescents' sexual behaviour after exposure to these programmes are modest, but achievable, while positive improvements in adolescents' attitudes and knowledge were consistently produced.
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This story has been produced with the support of The Africa Women Journalism Project (AWJP)
Data Stories
Declining Birth Rates No Cause for Alarm
The declining fertility and birth rate could yield a dividend for Kenya, particularly if investments are made in the education and skills of the working-age population.

After decades of efforts to reduce the fertility rate, Kenyan women are having fewer children, from eight children per woman in the 1970s to three in 2022.
According to Yohannes Dibaba Wadoa, a research scientist at APHRC specialised in sexual and reproductive health rights, the decline in fertility and birth rates is driven by socio-economic changes such as changing marriage and family formation patterns, increased use of contraception and access to healthcare, improved child survival, and women’s education and their increased involvement in modern society. Improved income and employment opportunities for both women and men have also led to the desire for fewer children.
“Women’s role has changed. They are perceived as equal to men and engage in productive employment rather than being segregated into childbearing and rearing roles,” said Wadoa, adding that improved healthcare and desire for fewer children lead to increased use of contraceptives. For instance, the percentage of married women who use contraceptives in Kenya increased from 33 per cent in 1993 to 63 per cent in 2022, according to data from the Demographic and Health Surveys.
Financial concerns could also be a factor, going by the concerns raised by respondents to an informal survey by the Africa Women Journalism Project (AWJP) shared on social media platforms. Many of the 39 respondents said they had delayed childbearing or restricted the number of children they had due to financial instability.
One respondent aged between 20 and 24 years said she wanted to have four children in future after working on financial stability to provide a happy life for her children. Yet another (in the 25-29 years age group) said she wanted to have two children and was laying an economic foundation for their future.
“I’m a student. Having a child at this point in my life will make me vulnerable and expose me to financial constraints,” she said, adding that society restricts what she should be doing at a certain age.
One man in his thirties (30-34 years) also cited financial stability, saying that he planned to have four children if his fortunes changed and if he could provide a better future for them; coming from a poor family, he had worked hard in school to break the cycle of poverty, but unemployment stands in the way of creating a better life for himself and subsequently keeps him from starting a family.
“I have been unemployed for 10 years since I graduated, so starting a family is a challenge. I also come from a history of poverty. I worked so hard in school to live a better life, but it’s like I am in a vicious cycle of poverty.”
At 27.357 births per 1000 people, the current birth rate is a 1.2 per cent decline from 2022, a trend that has provoked conversations about what that means for the Kenyan population. Globally, the UNFPA’s State of the World Population Report 2023 revealed widespread “population anxieties” that have governments adopting policies to raise, lower or maintain fertility rates. In countries with lower fertility rates, there have been concerns about the ageing population and the anticipated consequences such as an additional strain on social security services, with fewer workers expected to fund the increasing pension and healthcare needs of a greying population.
He had worked hard in school to break the cycle of poverty, but unemployment stands in the way of creating a better life for himself and subsequently keeps him from starting a family.
Some of these sentiments were expressed by respondents of the AWJP’s informal survey, with 13 per cent of the respondents expressing worry or concern about Kenya’s declining birth rate. However, the majority – Nearly half (49 per cent) of the 39 respondents – expressed positive sentiment towards Kenya’s declining birth rates, while a third (28 per cent) said it doesn’t matter. Most of the respondents (27) were female and 44 per cent were happy with the decline, while 57 per cent of the seven men who responded were content with the declining birth rates.
Most of the respondents who expressed positive sentiment about the declining birth rate were in the 25-29 years age group and had never been married, while those aged 35 years and above expressed concern about the declining birth rate, citing economic concerns, career, breakdown of values and change in priorities.
While most of the respondents did not have children, many of those who did had one or two and a good number said they did not plan to have more.
Since adopting its first family planning policy in 1967, Kenya’s goal has been to increase the use of contraceptives and reduce the fertility rate, which according to the latest National Family Planning Guidelines for Service Providers (6th edition) plays a key role in the achievement of national and international goals such as the Sustainable Development Goals (SDGs). A lower population through women having fewer children is expected to lead to development by reaping from the demographic dividend – having more people of working age to enhance productivity and drive economic growth.
Subsequently, the updated guidelines published in 2019 recommended more investments to accelerate rapid fertility decline. However, the current government reduced the allocation towards procurement of family planning and reproductive health commodities from KSh1.2 billion (2022-2023 financial year) to KSh1 billion for the 2023-2024 financial year, a deficit of 200 million.
Since adopting its first family planning policy in 1967, Kenya’s goal has been to increase the use of contraceptives and reduce the fertility rate.
Even as investments that would lead to a decline in fertility and yield a demographic dividend reduce, the guidelines note that “the demographic dividend is not automatic or guaranteed – it is earned through economic reforms that create jobs, investments in human capital and efficient governance”.
The declining fertility and birth rate could yield a dividend for Kenya, says Wadoa. “Birth rate is one of the key drivers for population growth or decline along with mortality (death) and migration. A falling birth rate brings about a decline in the rate at which the population changes from time to time. In Kenya, the rate of population growth declined from about 3.5 per cent in 1980 to about two per cent in 2020 due to declines in the birth rate. During the same time, the average number of children per woman declined from 7 children to 3.4 children. This has various implications for women, children, families and societies at large,” he says.
For one, fewer and well-spaced pregnancies are beneficial for the health and survival of the mother and the newborn. The converse is true: With too many births, closely spaced births and births at an older age, women may lack the strength and health to withstand the complications of pregnancy.
Secondly, as observed in national policies, a falling fertility rate means a lesser child dependency burden at the household and societal level, which reduces expenses on food, education and health services. Fewer children mean families can spend more on food and invest more in education and health services instead of struggling to meet the needs of many children.
A falling birth rate benefits a country’s development, particularly if investments are made in the education and skills of the working-age population (labour force). This demographic dividend will be larger the faster the birth rate falls.
“For women, a declining birth rate offers them the opportunity to engage in economic and social activities instead of spending their most productive years on childbearing and rearing,” Wadoa said.
A falling birth rate benefits a country’s development, particularly if investments are made in the education and skills of the working-age population.
Wadoa, however, warned of a relentless lowering of the birth rate which he said might create momentum for future population decline. He explained that a low birth rate reduces the population, not at all ages, but among the young, which leads to a smaller workforce and an older population and this has negative implications for economic productivity and per capita income growth.
Falling fertility rates could also lead to population declines in the long term (such as those in European countries), population ageing and a shortage of labour. Nevertheless, countries like Kenya will not experience such demographic challenges in the near future, even though the decline in fertility rates in Africa and in other low- and middle-income countries of the world is the result of years of population policies and programmes that focused on reducing fertility rates.
Kenya, for instance, launched a family planning programme in 1967 to reduce the fertility rate, which stood at eight children per woman in the 1970s. Over the years, the fertility rate has fallen to the current 3.4 in 2022.
For several years, especially before the International Conference on Population and Development (ICPD) that was held in Cairo in 1994, the discussion around population growth centred on the implications of rapid population growth for socio-economic development and environmental sustainability.
It was believed that rapid population growth in Low and Middle-Income Countries (LMICs) contributes to poverty, environmental degradation and conflicts, while the slow population growth in the developed world is leading to a shortage of labour force, population ageing, and social crisis in the long term.
Several Low and Middle-income countries (LMICs) have employed various strategies including educational campaigns, increased availability and affordability of contraceptives, improvements in healthcare infrastructure, and empowering women to make informed decisions about their reproductive health and use modern methods of contraception to bring down fertility rates and reduce population growth.
Policies adopted to manage population growth differ from country to country. For example, while Kenya adopted policies that promoted family planning programmes and created awareness of the various methods available, China adopted a one-child policy in 1979 which restricted couples from having more than one child. This was enforced by a variety of methods, including financial incentives for compliance, promotion of contraceptives, and while not endorsed by the government, compulsory sterilisations and forced abortions were part of the policy.
China’s one-child policy remained in place until January 2016 when it was amended to allow couples to have two children. But even after the policy was amended, couples still hesitate to have a second child for reasons such as concerns about their ability to afford another child, availability of childcare, and worries about how having another child would affect their careers, especially for mothers. Furthermore, decades of messaging and policies devoted to limiting family size to just one child succeeded in ingraining the viewpoint that having one child was preferable.
With the ICPD, the debate shifted from a demographic target (of reducing the fertility rate to 2.6 children per woman by 2030) to ensuring the upholding of people’s reproductive rights. This is the message Wadoa says should take centre stage, and something the UNFPA’s recent report titled Billion Lives, Infinite Possibilities: The Case for Rights and Choices, highlighted, noting that efforts to influence fertility rates can erode women’s rights.
Decades of messaging and policies devoted to limiting family size to just one child succeeded in ingraining the viewpoint that having one child was preferable.
This is often evident in discussions about declining fertility and birth rates, which often incorporate anti-feminist, nationalistic and misogynistic views, with women being viewed as baby-making machines. Their choice on whether to have or when to have children is often criticised as them abandoning the primary role of their existence.
According to Wadoa, the focus of population programmes should be ensuring the reproductive health and the rights of women, girls and men by providing access to sexual and reproductive health information and services. This recognises that people have the right to give birth to the number of children they want, when they want.
Moreover, the ICPD made it clear that women and couples have the fundamental right to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights. Thus, discussion about population growth should consider reproductive rights rather than demographic targets that aim to reduce or increase birth rates.
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This article was produced as part of the Aftershocks Data Fellowship (22-23) with support from the Africa Women’s Journalism Project (AWJP) in partnership with The ONE Campaign and the International Center for Journalists (ICFJ).
Data Stories
Are GMOs the Answer to Kenya’s Food Insecurity?
The path to alleviating food insecurity is layered with complex challenges and GMOs are not a one-size-fits-all solution.

On November 8th 2012, the Kenyan government banned the importation of food crops and animal feeds produced through biotechnology innovations and open cultivation of genetically modified crops.
Almost ten years later, in October 2022, the government revoked the ban on genetically modified crops, in part to deal with the drought that was ravaging the country causing widespread hunger and high food prices. While lifting the ban, President William Ruto cited the need to adapt to climate change and reduce reliance on rain-fed agriculture.
“We are adopting emerging and new alternatives to farming that will ensure early maturity and more production of food to cushion millions of Kenyans from perennial famine,” President Ruto said when revoking the ban.
There have been mixed reactions to the decision, with those opposed concerned about the potentially harmful effects on health, the environment and small farms, while supporters say lifting the ban will improve food security.
President Ruto gave assurances that the Kenya National Biosafety Authority, the body established to exercise general supervision and control over the transfer, handling and use of genetically modified organisms (GMOs), had developed guidelines for their introduction into the country’s food chain.
This was immediately refuted by the coordinator of the Biosafety Association of Kenya Ann Maina, who said there was no sufficient evidence that GMOs would combat food insecurity or provide farmers with socio-economic benefits. Ms Maina said the Authority did not have the capacity to regulate GMOs as it had limited personnel and financial resources to properly undertake its mandate.
Instead of allowing GMOs, Ms Maina urged the government to increase its research funding for organisations such as the Kenya Agriculture and Livestock Research Organisation to develop local innovations and technologies that can spur agricultural growth.
Food security as a concept emerged in the mid-1970s during the global food crisis. At the time, the discussion focused primarily on food supply problems—availability and, to some extent, the price stability of food commodities—at the international and national level. Over time, the definition has evolved to be more inclusive and comprehensive by acknowledging the complexities linked to technology and policy issues and other emerging factors such as climate change and the COVID-19 pandemic.
“Food security is when all people, at all times, have access to sufficient, safe and nutritious food that they prefer/are likely to enjoy and access. It connotes that the food is physically within reach, socially acceptable within the space they are in and they have the financial means to purchase it at all times,” says Antonina Mutoro, an associate research scientist in nutrition and food systems at the African Population and Health Research Center.
Food insecurity is a recurring issue, with 3.2 million Kenyans in the arid and semi-arid regions (24 per cent of the population) facing high levels of acute food insecurity as of September 2022. The numbers were projected to increase to 4.4 million (29 per cent of the population) by October last year according to the Integrated Food Security Phase Classification. With 80 per cent of the country considered to be arid and semi-arid lands (ASAL) and dominated by smallholder farmers, there is even less arable land for the expansion of crop production.
Land fragmentation
The percentage of total land use for agriculture has remained constant since 2013 at 27.6 million hectares, which is 48.6 per cent of the country’s total land area, yet the population continues to increase at 2 per cent annually.
The total land area used for agriculture is further subdivided, with 77 per cent used for permanent meadows and pastures, 21 per cent arable land used for crop production and 1.9 per cent used for perennial crops like coffee and tea.
A report released in October 2021 by the National Land Commission on the effects of land fragmentation and food security in 13 counties in Kenya—with secondary data from KNBS—indicated that the number of smallholder farmers with less than five hectares increased by 55 per cent in 2015/2016. The study established that this was happening mostly in areas of high agricultural production.
The average decline of farm sizes is not only a serious threat to farm productivity and food security but also to natural ecosystems such as forests as it is one of the main causes of encroachment. The division of land into smaller units that are too small to be viable is not conducive to optimal economic production as the smaller portions cannot be used for the same purpose as before the subdivision.
Status of food security in Kenya
Kenya was ranked 94 out of 121 countries In the 2022 Global Hunger Index. The scores are calculated based on a formula that combines four indicators used to measure progress toward the Sustainable Development Goals: undernourishment, child stunting, child wasting and child mortality.
Undernourishment or hunger focuses on the general population while the other indicators relate to children, who are particularly vulnerable. At a score of 23.5, Kenya’s hunger levels are considered “serious”. A score of 9.9 and below is recommended.
Further, Kenya was ranked 82 out of 113 countries in the 2022 Global Food Security Index, which measures four indicators—affordability, availability, quality and safety, and sustainability and adaptation. Affordability measures the ability of consumers to buy food, their vulnerability to price shocks and policies to support consumers when price shocks occur. Availability measures agricultural production and on-farm capabilities, the risk of supply disruption, and national capacity to disseminate food research to expand agricultural output. The quality and safety indicator measures the variety and nutritional quality of the average diet, as well as the safety of food, while the sustainability and adaptation indicator assesses a country’s exposure to impacts of climate change, its susceptibility to natural resource risks and how the country is adapting to these risks.
Kenya had an overall food security score of 53 per cent, which is the weighted average of the scores on the four indicators – affordability (41.7 per cent), availability (52.5 per cent), quality and safety (68.8 per cent) and sustainability and adaptation (52.6 per cent).
Of the four indicators, Kenya scored the lowest and below average on affordability, yet the ability to buy food is often overlooked as a factor in food security. Instead, hunger is often perceived through the lens of stark images in places like Turkana, Moyale and Wajir where large herds of livestock die and where people are perennially dependent on food aid.
As food costs continue to rise Kenyans have been cutting back on meals. “We have been forced to adjust to just two meals a day and sometimes one meal a day. We occasionally have fruits with meals and even further substitute some food items as we cannot afford them,” said Rose Mbaru, a Nairobi resident who told The Elephant that the cost of living has affected her family’s meal plans over the years.
Antonina Mutoro refers to this as a coping mechanism indicative of a household being food insecure, a situation that is commonplace in many Kenyan households.
Food security and affordability
In February, Kenyans spent 13.3 per cent more on food and non-alcoholic beverages, an increase of 1.2 per cent from January, with food prices being noted as a key driver of inflation amid a 9.2 per cent total average increase in the prices of goods and services. As of 16 March 2023, 10.8 million people were not consuming enough food.
Affordability is a key contributor to food insecurity; 17 per cent of the population lives on less than US$1.90 (Sh250) per day which translates to 8.9 million Kenyans living in extreme poverty. With the escalating food prices, people are using coping strategies like skipping meals and consuming cheaper and nutritionally inadequate food.
In countries where GMOs are permitted, food prices are lower by about 12.5 per cent. Proponents of genetically modified foods thus promote them as a chance to sustainably feed the growing population even as the country grapples with the worst drought ever.
While affordable food is a good thing, Felistus Mwala of Route to Food argued that the hunger situation should not be used as an opportunity to introduce GMOs. She said that the introduction of GMOs violates Kenyans’ right to food by infringing on the concept of acceptable quality.
A survey by Route to Food carried out last year assessed Kenyans’ perception of GMOs by looking at the level of awareness, willingness to consume and grow GMOs, and access to information on GMOs. It indicated that 57 per cent of Kenyans were not willing to consume GMOs, while 43 per cent were willing. It is disquieting to note that Kenyans who have more exposure to food insecurity, with less knowledge of GMOs, are more receptive to GMOs. Their willingness reflects their vulnerability rather than choice and free will.
Effect of drought
With the sixth failed rainy season in Kenya and high dependence on rain-fed agriculture, agricultural production has been severely affected, contributing to high food prices. GMOs are drought-resistant and studies have shown that genetically modified crops need up to 25 per cent less water to produce a regular yield.
Maize which is the staple food for Kenyans grows in areas with an annual rainfall of 600 to 1200 mm that is well distributed throughout the growing season. With irrigation, it can also be grown in the ASAL regions where annual rainfall does not exceed 100 mm. Therefore, even with the 25 per cent water reduction, GMO farming would still need to be heavily supplemented by irrigation.
Irrigation rates have been growing in Kenya but are not close to matching existing needs with irrigated fields occupying only two per cent of Kenya’s total area under agricultural production. More than 95 per cent of Kenya’s agricultural output is produced in rain-fed farming systems, yet only 17 per cent of the country’s arable land is deemed suitable for rain-fed agriculture. The remaining 83 per cent requires irrigation for optimal crop growth due to inadequate and infrequent rainfall.
Overreliance on maize
Coupled with the COVID-19 pandemic, which not only affected food production and the cost of inputs but also disrupted supply chains, Kenya is experiencing one of the worst droughts in the last four decades, which has affected maize production. Moreover, the Russian war in Ukraine has affected the supply of grains and key inputs like fertilisers. All these events have resulted in the rise in the cost of production of maize to about KSh4,000 for a 90kg bag; a two-kilogramme packet of flour is retailing at KSh200.
“Over-reliance on maize, a staple food, is a key contributor to food insecurity. This means we are missing out on a variety of foods like millet and sorghum which are relatively nutritious. We have to diversify our dietary habits,” says Ms Mutoro.
“The introduction of GM maize is not solving the issue of overreliance but worsening it and taking away with it the opportunity of Kenyans exploring different foods with the same nutritional value that are less costly and require less water to produce,” adds Ms Mutoro.
Food loss and waste
Food loss and wastage also contribute to food insecurity. In Kenya, KSh72 billion is lost annually through food waste and post-harvest losses at different stages of the value chain according to a report by the Food and Agriculture Organisation and the United States Agency for International Development. The report estimates that post-harvest losses can reach up to 20 per cent for cereals, 30 per cent for dairy and fish and 40 per cent for fruits and vegetables.
While food loss and food waste are sometimes used interchangeably, they are not the same thing. Food loss is the decrease in quantity or quality resulting from the decisions and actions of food suppliers in the chain—for example, food that is discarded or incinerated along the supply chain, excluding the retail level, and does not re-enter at any productive level as either feed or seed. Food waste refers to a decrease in quantity or quality as a result of the decisions and actions of food service providers, retailers and consumers.
The gaps in our food system that contribute to food loss and wastage are farm management constraints, and market supply and policy-related constraints. Limited cold chain storage at the production level leads to produce going bad. Moreover, farmers’ limited awareness of timing of the entire crop production process, from planting to harvest, results in produce flooding the market.
On policy-related constraints, there are limited policies and strategies for the export of value-added produce and a poor regulatory environment and low government support for the food system supply chain.
Training on value addition through pre-cooking and biofortification may reduce the amount of harvested fresh produce going to waste and also put more money in farmers’ pockets. Farmers also need better access to post-harvest handling equipment like solar dryers for cereals like maize, pulses, and rice to ensure proper drying of produce and food safety by reducing aflatoxin levels. They also need cold chain management of vegetables and fruits from farms to packaging areas to lower spoilage by reducing dehydration. Supporting these technologies for local manufacturing would increase access and make them more affordable to small-scale farmers.
Moreover, diversification of the market for export so that grade 2 produce can be packaged and sold to the domestic market, as opposed to what is rejected being rendered as waste, would enhance the local supply of food. Improving road networks in rural areas for better rural-urban linkages to ease the transportation of farm produce to the end market would also serve as an intervention against food loss.
“With improved transport systems across the country for efficient food distribution, excess food in one region can reach regions with insufficient supply,” explained Ms Mutoro.
All these interventions require adequate allocations to the agriculture budget. While Kenya committed to increasing budgetary allocation to the sector to at least 10 per cent by ratifying the Maputo Protocol, the 2022/2023 budget allocated a meagre 1.39 per cent, making it difficult to invest in food storage systems and other off-farm activities.
Resilience through agroecology
According to Felistus Mwala of Route to Food, a key cog missing in the efforts to address food insecurity in the face of climate change is agroecology.
“Agroecology is an approach to farming and food systems that builds resilience against climate change and market shocks while empowering big and small producers. The concept and principles of agroecology extend beyond food production and off-the-farm, to whole food distribution and consumption. Farmers work with nature and use environmentally-friendly processes. They use what is locally available and low inputs. It not only promotes intergenerational equity but supports income and sustainable development,” said Ms Mwala.
Food security as a right
After all is said and done, all these interventions and the food security discussion must be underpinned by a focus on the constitutional right to food, according to Njeri Karanu, Senior Program Officer at Rural Outreach Africa and secretariat to the Right to Food Coalition.
“The constitution is explicit on the right to food in Article 43(1) c. In addition, we have many policies and laws that talk about food, but we have not moved the needle in the realisation of the right to food,” said Ms Karanu.
The high burden of malnutrition and routine hunger in Kenya is not only a threat to the achievement of national goals as well as the Sustainable Development Goals but is also an indication of inadequate realisation of human rights.
However, while Article 43(1) c is an important milestone and the basis for the realisation of the right to food, it is not sufficient in itself as it does not provide an elaborate framework to actualise this right. Therefore, the Right to Food Coalition—a partnership of 40 civil society organisations made up of researchers, academia, policy think tanks, consumer groups, and legal and media organisations—is developing a legal framework with binding obligations to realise this right.
The proposed Right to Food Bill will outline policies and accountability and redress mechanisms, and the resources needed to address challenges faced by Kenyans in accessing healthy food. It will use a systems lens to address issues cutting across sectors and groups, including access to water, land and tenure rights, inadequate safety nets, and poverty, among others. Although the right to food is achieved progressively, there should be a baseline to ensure there is no regression.
“The right-to-food bill will be developed in a participatory process by civil society and government, taking into account the needs of all Kenyans from all walks of life. A human rights approach to solving the problem of hunger and malnutrition is transformative. It addresses the inequities in the food system, promotes meaningful citizen participation, and establishes accountability mechanisms. It takes a long time, but it holds the promise to deliver long-term solutions,” says Ms Karanu.
The path to alleviating food insecurity is layered with complex challenges and GMOs are not a one-size-fits-all solution. “A rights-based multifaceted approach that looks at the underlying structural causes of food insecurity and focuses on sustainability is best,” concludes Ms Mwala.
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This article was produced as part of the Aftershocks Data Fellowship (22-23) with support from the Africa Women’s Journalism Project (AWJP) in partnership with The ONE Campaign and the International Center for Journalists (ICFJ).
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