Your Resource for Urban Reproductive Health
FERTILITY AND FAMILY PLANNING TRENDS IN URBAN
KENYA: A RESEARCH BRIEF
BACKGROUND
Rapid urbanization in Kenya is putting pressure on
infrastructure and eroding the quality of life.
Kenya’s urban population grew from about 600,000
in 1960 to over 9 million in 2010. About 32 percent
of all Kenyans live in urban areas, according to the
2009 national census.1 That proportion is projected
to grow to almost half by 2050.2 Urban planning
and infrastructure have not kept pace with this rapid
growth, leaving many urban residents without adequate
housing, sanitation, safe water, garbage collection or
other services. An estimated 55 percent of Kenya’s
urban population lives in slums.3
The Kenya Urban Reproductive Health Initiative
(known as Tupange) seeks to increase use of modern
contraceptives by the urban poor.
Kenya National Bureau of Statistics (KNBS), Kenya 2009 National Population and Housing Census Highlights (Nairobi: KNBS, 2010). Available:
http://www.knbs.or.ke/docs/KNBSBrochure.pdf
2
United Nations Department of Economic and Social Affairs, World Urbanization Prospects: The 2009 Revision (New York: United Nations, 2010).
Available: http://esa.un.org/unpd/wup/
3
UN-HABITAT, Global Urban Indicators database. Available: http://www.
unhabitat.org/stats/
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MLE Research Brief 3 - 2012
www.urbanreproductivehealth.org
To expand the knowledge base on urban reproductive
health and help Tupange design effective interventions
for Kenya, the Measurement, Learning & Evaluation
(MLE) Project undertook a secondary analysis of urban
data from the 1993, 1998, 2003 and 2008/09 rounds of
the Kenya Demographic and Health Survey (KDHS)
and the 2010 Kenya Service Provision Assessment
(KSPA).4 This is the first time such an analysis has
been done.
Data from urban survey respondents and health
facilities were recoded and reanalyzed to describe
levels and trends in key fertility, family planning
and reproductive health indicators. The analysis also
examined differentials by province, household wealth
and education. The wealth and education variables
reflect two different dimensions of poverty: material
well-being and knowledge.
2006 Felix Masi, Courtesy of Photoshare
Tupange’s objective is to raise the contraceptive
prevalence rate by 20 percentage points over five years
in five urban areas across Kenya. To achieve this goal,
Tupange is designing and implementing interventions
to:
• Improve the quality and accessibility of family
planning services for the urban poor;
• Generate demand for family planning through
community mobilization;
• Guarantee the availability of contraceptives;
• Partner with the private sector;
• Strengthen policies that support family planning use
among the urban poor; and
• Build capacity for sustainability.
A reanalysis of Demographic and Health Survey data
sheds light on fertility and family planning trends
among the urban poor.
In an urban slum in Nairobi, Kenya, a man washes plastic bags
collected from the trash to sell and reuse for human waste disposal.
Most urban slum dwellers do not have access to clean water or
sanitation services.
This research brief summarizes family planning and fertility data from the
MLE Project’s reanalysis of KDHS data. For the full paper, see Jean Christophe Fotso et al., “Levels, Trends, and Differentials in Family Planning and
Reproductive Health Indicators in Urban Kenya,” MLE Technical Working
Paper 2-2011 (December 2011). Available: http://www.urbanreproductivehealth.org/publications/levels-trends-and-differentials-family-planning-andreproductive-health-indicators-urba
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Key Findings
➤ Urban fertility rates have been slowly declining in Kenya; women had an average of 2.9
children in 2008/09 compared with 3.5 children in 1993.
➤ Gaps in fertility levels are increasing between the rich and poor and between the most and
least educated.
➤ Almost half of urban women use modern contraception, increasingly to postpone first births
and space subsequent births rather than to limit births.
➤ Education has a greater impact than household wealth on fertility rates, contraceptive use and
attitudes toward family size and family planning.
➤ Approval of contraceptive use and couple communication about family planning were
declining prior to 2003, the last year for which there are DHS data.
➤ Urban women’s exposure to family planning messages in the mass media is increasing,
although it remains lower among the poor.
➤ Poor urban women continue to rely primarily on the public sector for modern contraceptives.
➤ Fertility and family planning indicators show clear differences by province, but the pattern
changes from one indicator to another.
URBAN FERTILITY LEVELS
A large proportion of the urban population is young.
Fertility rates in urban areas have declined in recent
years, but remain high in some provinces.
Over 34 percent of the urban population in Kenya is
less than 15 years old, while less than 2 percent is aged
65 or older. A disproportionately large share of women
ages 20 to 29 contributes to a growing number of
young children. A high ratio of dependents to workers
strains the ability of urban areas to meet residents’
essential needs, including health, education, food and
shelter.
Nationwide, urban women had an average of 2.9
children in 2008/09, compared with 3.5 children in
1993. However, urban women in Nyanza, Western and
North Eastern provinces have more than 4 children—
twice as many as women in Eastern and Rift Valley
provinces (Figure 1).
There is a widening gap between the rich and poor,
and the more and less educated.
Figure 1. TFR in urban areas, by province, 2008/09
The burden of high fertility and its associated health
risks falls more heavily on the poor and less educated.
From 1993 to 2008/09, fertility rates in urban areas
declined more among rich than among poor and
middle-income women (Figure 2).5 Over the same
period, fertility rates increased among women with
less education, while decreasing among women with
secondary or higher education. By 2008/09, the urban
2.8
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
North Eastern
3.9
3.1
1.6
4.3
2.2
4.3
4.5
2.9
All urban areas
0
1
2
3
TFR
MLE Research Brief 3 - 2012
www.urbanreproductivehealth.org
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5
The analysis divided the population into three equal groups (or tertiles)
by household wealth. All data on the urban poor describe the bottom tertile,
while data on the rich describe the top tertile.
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2
poor had 1.7 more children, on average, than the rich;
women with no education had 2.7 more children than
those with secondary or higher education.
Figure 2. Trend in urban TFR, by household wealth
Poor
Middle
MODERN CONTRACEPTIVE USE
Almost half of urban women now use modern
contraceptives, and the gap between rich and poor has
disappeared in recent years.
Rich
5
4
Overall, modern contraceptive use6 rose from 38 percent
of urban women in 1993 to 47 percent in 2008/09, with
the greatest gains occurring since 2003.
3
2
1
0
1993
1998
2003
2008/09
Early childbearing, especially among the poor and
less educated, increases health risks for some women.
Adolescent childbearing and short birth intervals
increase health risks for mothers and children. The
proportion of urban teenagers ages 15 to 19 who were
pregnant or mothers rose from 17 percent in 1993 to
22 percent in 2003, before declining to 19 percent in
2008/09. Teen pregnancy rates are especially high
among the poor and uneducated (Figure 3).
Figure 3. Percent of urban teenagers ages 15 to
19 who were pregnant or mothers, by wealth and
education, 2008/09
The gap between rich and poor has virtually disappeared
because of a recent decline in contraceptive use among
rich women, even as contraceptive use rose sharply
among poor women (Figure 4). Targeted efforts to
increase access to family planning among the poor may
have contributed to the trend.
Figure 4. Percent of urban women currently using
modern contraception, by household wealth
Poor
50
Percent
36
27
26
18
20
9
10
0
30
20
10
60
30
40
0
40
Poor
Middle
Rich
9
No
Primary Secondary
education
Short birth intervals (less than two years) preceded 20
percent of births in urban areas of Kenya in 2008/09,
down from 29 percent in 1993. Short birth intervals are
equally common among rich and poor women.
However, the proportion of urban women who
delivered a child after a short birth interval is 2.1 times
MLE Research Brief 3 - 2012
www.urbanreproductivehealth.org
Rich
60
70
50
Middle
70
Percent
TFR
higher among those with no education than among those
with secondary or higher education.
1993
1998
2003
2008/09
Differences in contraceptive use by education and
province remain large. The proportion of urban women
who use a modern method is 3.7 times greater among
those with secondary or higher education than among
those with no education. Less than one-third of women
in Nyanza and North Eastern provinces use modern
contraception, compared with more than half of women
in Central, Eastern and Rift Valley provinces (Figure 5).
In all four surveys, modern contraceptives included the following methods:
female and male sterilization, oral contraceptive pills, intrauterine devices
(IUDs), injectables, implants, male condoms, diaphragms, foam and jelly. Female condoms and emergency contraception were added to the list of modern
methods in the 2003 and 2008/09 surveys, and the Lactational Amenorrhea
Method (LAM) was added in the 2008/09 survey.
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3
Figure 5. Percent of urban women currently using
modern contraception, by province, 2008/09
49
55
38
60
30
54
44
Figure 7. Ideal number of children for urban
women and men, by household wealth and
education, 2008/09
20
47
All urban areas
0
10
20
30
40
50
60
70
Percent
Urban women increasingly use
contraceptive methods
to postpone the first birth and space subsequent births.
From 1993 to 2008/09, the percentage of married
urban women who wait until they have three or more
children before using contraception fell by half. Women
increasingly adopted contraception when they had
just one or two children or even before they had any
children (Figure 6).
Figure 6. Percent distribution of currently married
urban women by parity at first contraceptive use
No children
1-2 children
3+ children
70
60
Percent
50
40
30
20
12
Men
10.7
10
8
6
4
3.5
4.2
5.3
3.1 3.3
2.8 3.3
Middle
Rich
3.4 3.8
2.8 3.3
2
0
Poor
No Primary Secondary
education
The proportion of urban births considered mistimed
dropped from 32 percent in 1993 to 17 percent in
2008/09. About 12 percent of births were unwanted
in both 1993 and 2008/09. The proportion of women
who report that recent births were unwanted or
mistimed is 1.9 times higher among the poor than
the rich, suggesting a greater unmet need for family
planning among the urban poor.
A large majority of women and men approve of
using contraceptive methods.
10
0
Women
Number of children
Nairobi
Central
Coast
Eastern
Nyanza
Rift Valley
Western
North Eastern
Men want larger families than women, regardless
of household wealth and education (Figure 7).
Poor urban women and men want 0.7 and 0.9 more
children, respectively, than rich women and men.
Urban women and men with no education want 2.5
and 7.4 more children, respectively, than those with
secondary or higher education.
1993
1998
2003
2008/09
ATTITUDES TOWARD FERTILITY AND
FAMILY PLANNING
Desired family size has declined in recent years but
remains higher than two decades ago, especially for
men and women with no education.
Desired family size increased in urban Kenya through
the 1990s, before starting to decline after 2003.
However, desired family size was still higher in
2008/09 than in the early 1990s. For example, women
in 2008/09 preferred to have, on average, 3.1 children,
compared with 3.4 children in 2003 and 2.9 children in
1993.
MLE Research Brief 3 - 2012
www.urbanreproductivehealth.org
Disapproval of family planning can act as a barrier
to contraceptive use. Although the 2008/09 KDHS
did not ask respondents whether they approved of
contraceptive use, data are available from earlier
surveys. Approval levels fell from 92 percent in 1993
to 88 percent in 2003 among urban women, and from
90 percent in 1993 to 82 percent in 2003 among urban
men. The proportion of women who approved of
couples using contraceptive methods in 2003 was 1.6
times higher among those with secondary education
than among those with no education; the proportion
was 3 times higher among men with secondary
education than men with no education (Figure 8).
Differentials were relatively small by household
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wealth and province, except for North Eastern province
where approval levels were extremely low.
Figure 9. Percent of urban women obtaining
modern contraceptives from the private sector, by
province
Figure 8. Percent of urban women and men who
approve of contraceptive use, by household wealth
and education, 2003
Percent
Women
100
90
80
70
60
50
40
30
20
10
0
85
90
79
1993
90 88
86
78
95
77
37
Nairobi
Central
Coast
Eastern
Nyanza
Men
88
50
47
50
43 50
47
14
27
Rift Valley
Western
North Eastern*
58
30
2008/09
31
32
50
21
40
All urban areas
0
10
20
30
55
58
45
40
50
60
70
Percent
Poor
Middle
Rich
* No data are available for North Eastern province in 1993.
No
Primary Secondary
education
Many urban women, especially the uneducated, do
not intend to use contraceptives in the future.
Among urban women who are not currently using
a contraceptive method, the proportion who do not
intend to use contraception in the future rose from
33 percent in 1993 to 38 percent in 2008/09. The
proportion of urban women who say they do not intend
to use contraception in the future is 1.3 times higher
among rich than poor women. The proportion is 1.8
times higher among women with no education than
those with secondary education.
SOURCE OF CONTRACEPTIVES
Poor urban women largely rely on the public sector
for modern contraceptives.
Private-sector sources are more important for middleincome and rich women; only about one-quarter of the
urban poor rely on the private sector for contraceptives
(Figure 10). The proportion of urban women who
obtain contraceptives from the private sector is about
three times higher among those with at least primary
education than among those with no education.
Figure 10. Percent of urban women obtaining
modern contraceptives from the private sector, by
household wealth
Poor
The percentage of women who obtain contraceptives
from the private sector has changed little since 1993.
MLE Research Brief 3 - 2012
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Rich
80
70
60
Percent
The private sector has the potential to increase
coverage of reproductive health services, especially for
women who cannot or choose not to access government
services. The proportion of urban women in Kenya
who obtain modern contraceptives from the private
sector, including mission facilities, private hospitals/
clinics and pharmacies, rose from 40 percent in 1993
to 45 percent in 2008/09. Private-sector sources
have increased in importance in just three provinces:
Nairobi, Eastern and Nyanza (Figure 9).
Middle
50
40
30
20
10
0
1993
1998
2003
2008/09
5
Long-acting contraceptive methods are less widely
available than short-acting methods.
According to the 2010 KSPA, 76 percent of urban
health facilities offer at least one short-acting
contraceptive method, but only 55 percent offer
a long-acting method. Government or municipal
facilities are the most likely, and facilities operated
by faith-based groups the least likely, to offer
contraceptives. Both short- and long-acting methods
are most widely available in Nyanza province (Figure
11).
Progestin-only injectables, male condoms and
combined oral contraceptive pills are the most widely
available methods, in stock at about two-thirds
of urban health facilities, followed by progestinonly pills, in stock at about half of facilities. More
facilities stock IUDs than implants (39 percent and
28 percent, respectively), while 40 percent stock
emergency contraceptive pills.
Figure 11. Types of contraceptives in stock at
urban health facilities, by province, 2010
Nairobi
Central
Coast
Eastern
Nyanza
68
52
Rift Valley
Western
61
28
28
All urban areas
55
0
20
40
Women’s exposure to family planning messages in
the media has increased since 1998 (Figure 12). In
2008/09, a larger proportion of women than men
recalled hearing or seeing family planning messages
on radio and television; the proportion of women who
recalled seeing these messages in newspapers was
almost as large as the proportion of men. Around one
in six women and men have no exposure to family
planning messages in any of these media.
60
24
North Eastern
91
74
74
Women have greater exposure to family planning
messages in the mass media than men.
Figure 12. Percent of urban women and men who
recall hearing or seeing family planning messages
in the mass media during the past month
Any long-acting method
56
Radio is the most common media source of family
planning messages for urban women and men,
regardless of sex, age, education, household wealth
and province, followed by television and newspapers
(see Figure 12 for data by sex). The impact of those
messages depends on their content and execution, but
that information is not available from DHS surveys.
60
1998
87
90
83
79
97
Percent
Any short-acting method
At least two-thirds of urban households in every
province own a radio, but television ownership is
concentrated in Nairobi.
76
80
100
Percent
MASS MEDIA EXPOSURE
Radio is the most common media source of family
planning messages.
The mass media are a powerful way to convey
family planning messages to the public and can help
change social norms and facilitate behavior change.
Radio ownership increased from 68 percent of
urban households in 1993 to 82 percent in 2008/09.
Television ownership expanded even more rapidly
over the same period, from 22 percent to 57 percent.
MLE Research Brief 3 - 2012
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100
90
80
70
60
50
40
30
20
10
0
78
38
Radio
73 72
64
63
2008/09
46
55
TV Newspapers
Women
54
Radio
60
69
56
TV Newspapers
Men
Exposure to mass media increases with wealth and
education.
Higher proportions of rich and middle-income
urban women than poor women have heard or seen
family planning messages on radio, television and
newspapers (Figure 13). In 2008/09, the proportion
of poor women who recalled hearing family planning
messages on the radio was about twice as large as
the proportion who recalled seeing family planning
messages either on television or in the newspaper.
Exposure to family planning messages in all three
mass media also increases with education.
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Figure 13. Percent of urban women who recall
hearing or seeing family planning messages in the
mass media, by household wealth, 2008/09
Poor
Percent
100
90
80
70
60
50
40
30
20
10
0
Middle
82 82
Rich
78
69
68
68
Figure 14. Percent of married urban women who
discussed family planning with their spouse in the
past year, by household wealth
58
41
34
discussing family planning with their husbands
was 1.8 times higher among those with primary
education than among those with no education. There
is little difference in couple communication between
provinces, except for North Eastern province, where
only 5 percent of women reported discussing family
planning with their husbands in 2003.
30
13 13
Radio
Television
Newspapers None of these
Poor
Middle
Rich
100
Many poor and uneducated urban women are not
exposed to family planning messages in the mass
media.
In urban areas, 30 percent of poor women and 47
percent of women without education did not recall
hearing, seeing or reading family planning messages in
any of the mass media. Many women in North Eastern
(67 percent) and Eastern provinces (35 percent) also
reported no media exposure.
Percent
80
60
40
20
0
1993
1998
2003
COUPLE COMMUNICATION
About two-thirds of urban couples have discussed
family planning.
2007 Sean Hawkey, Courtesy of Photoshare
Couple communication about family planning is an
important step on the path to adopting a contraceptive
method. In urban areas, the proportion of married
women who had discussed family planning with their
husbands in the past year rose from 69 percent in 1993
to 79 percent in 1998, but then declined to 66 percent
in 2003, the last year for which there are DHS data.
Equal proportions of poor and rich women discuss
family planning with their husbands.
Couple communication declined in every income
group from 1998 to 2003, but more so among the
rich than the poor, almost erasing the gap between
them (Figure 14). The gap between the most and least
educated is much larger and has persisted over time.
In 2003, the proportion of urban women who reported
MLE Research Brief 3 - 2012
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A woman and her child in Kibera, the largest urban slum in
Nairobi, Kenya.
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HIGHLIGHTS
Fertility levels have been declining slowly in
urban Kenya, but remain high among the poor
and uneducated. A large proportion of the urban
population is young, which fuels high fertility rates.
Teen pregnancies and short birth intervals contribute to
higher fertility among the uneducated and, to a lesser
extent, the poor. A larger proportion of poor women
than rich women reports unwanted or mistimed births,
suggesting a greater unmet need for family planning.
Fertility levels and contraceptive use vary more by
education than household wealth. Differences in
fertility levels between the most and least educated
urban women have grown faster and wider than
differences between the rich and poor. As for
contraceptive use, the gap between rich and poor has
almost disappeared in recent years, while differences
by education remain large. Among uneducated women,
only one in seven uses a modern contraceptive and half
of the rest do not intend to use contraception in future.
Nearly half of urban women use modern
contraceptives, increasingly to space rather than limit
births. Use of modern contraceptives has been rising
slowly in Kenya, and women have become more likely
to adopt a method when they have only one or two
children for spacing purposes. There is also growing
interest among wealthy and more educated women in
using contraception to postpone first births.
Men may pose an obstacle to family planning in
urban areas. Compared with women, urban men—
especially uneducated men—want larger families, are
less likely to approve of using contraception and are
less likely to be exposed to family planning messages
in the mass media. Discussion of family planning by
spouses also declined through 2003, although almost
two-thirds of couples reported discussing the topic.
Poor urban women largely rely on the public sector
for modern contraceptives. Only three provinces
have seen an increase in the proportion of women
who obtain modern contraceptives from the private
sector. Most urban women—especially poor women—
continue to rely on the public sector for contraceptive
supplies.
Women’s exposure to family planning messages in
the mass media is growing. Women are increasingly
likely to hear or see family planning messages in all
three mass media: radio, television and newspapers.
However, radio remains the best way to reach the urban
poor.
Provincial differences in fertility and family planning
indicators are complex. Fertility levels and most
family planning attitudes and practices show clear
differences by province, but the pattern changes from
one indicator to another. Eastern and Rift Valley
provinces are notable for a combination of low fertility
and high contraceptive use.
Attitudes toward fertility and family size have
changed markedly among the uneducated. Over
the past two decades, desired family size has jumped
and approval of contraception has plummeted among
women and men with no education, leading to wide
differences by education. Attitudes have changed far
less among the poor, and differences by household
wealth are relatively small.
For more information about urban reproductive health, please visit www.urbanreproductivehealth.org.
This fact sheet was made possible by support from the Bill & Melinda Gates Foundation under terms of the Measurement,
Learning & Evaluation (MLE) Project for the Urban Reproductive Health Initiative. The MLE Project is implemented by the Carolina
Population Center at the University of North Carolina at Chapel Hill, in partnership with the African Population and Health
Research Center and the International Center for Research on Women. The authors’ views expressed in this publication do not
necessarily reflect the views of the donor.
MLE Research Brief 3 - 2012
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