Rich women record five times more C-sections as Kenya's rate hits 20%

A woman's financial status is increasingly reflected in how she gives birth in Kenya, with new health figures revealing a striking difference in access to Caesarean section deliveries between wealthy and low-income households, even as the national rate continues to climb.

The proportion of births delivered through Caesarean section has more than quadrupled over the past two decades, rising from four per cent in 2003 to 20.3 per cent in 2026, according to the latest Kenya Demographic and Health Survey (KDHS).

The report, released by the Kenya National Bureau of Statistics (KNBS) in October, shows that the national rate has increased from 17 per cent in 2022, placing Kenya above the World Health Organisation's (WHO) recommended range of 10 to 15 per cent.

However, behind the rising national figures lies a significant disparity in access to surgical deliveries, with women from the wealthiest households recording rates more than five times those of mothers from the poorest families.

The survey indicates that 41 per cent of births among women in the richest wealth category were through Caesarean section, compared with just eight per cent among those in the lowest income group.

Geographical location also determines the likelihood of undergoing the procedure, with urban women recording a rate of 29 per cent against 13 per cent in rural areas.

Education presents another clear divide. Women who had studied beyond secondary school recorded a C-section rate of 35.2 per cent, almost three times the 12.4 per cent reported among those with primary education.

Differences are equally visible across healthcare providers, with private for-profit hospitals reporting the highest proportion of surgical births at 33.1 per cent. Faith-based facilities followed at 29.2 per cent, while public hospitals recorded 18.2 per cent.

At county level, Embu topped the national rankings, with 43 per cent of births delivered through surgery. Kiambu followed at 38.6 per cent, Kirinyaga at 37.5 per cent, Nyeri at 36.9 per cent and Murang'a at 35.6 per cent.

The figures further show that a mother's age and the number of children she has previously delivered are linked to the likelihood of undergoing a Caesarean section.

First-time mothers had a rate of 23.9 per cent, compared with 7.2 per cent among women delivering their sixth child or later. Mothers aged 35 and above recorded 24.8 per cent, while those below 20 years had a rate of 11.5 per cent.

Attendance at antenatal clinics was also associated with higher rates of surgical deliveries. Women who made at least four antenatal visits recorded 22.2 per cent, compared with 1.7 per cent among those who did not attend any visits.

The survey, however, does not indicate how many of the operations were medically required, arranged beforehand or conducted in response to emergencies.

Dr Dennis Miskellah, an obstetrician-gynaecologist and deputy secretary-general of the Kenya Medical Practitioners, Pharmacists and Dentists Union, says the growing number of Caesarean deliveries is partly linked to more women accessing hospital maternity services.

He explains that delivering in health facilities gives medical teams an opportunity to detect complications and provide treatment, including surgery where necessary.

The latest survey shows that facility-based deliveries have increased to 91.1 per cent, up from 88.1 per cent in 2022.

Miskellah also points to improved access to healthcare, insurance coverage and increased awareness among women about their reproductive rights as other factors behind the rising numbers.

"Some women do ask for the operation, and it is not always wrong to agree. Sometimes even a woman just asking for it is an indication, because there is something called patient autonomy," he says.

Nevertheless, he raises concerns about the influence of legal pressure on medical decisions, saying some doctors may recommend surgical deliveries because they fear being taken to court if complications occur during natural childbirth.

He also recognises that financial considerations could play a role, as some practitioners may be encouraged to recommend Caesarean sections because the procedures attract higher charges than normal deliveries.

The doctor also challenges the use of a standard international threshold to judge the country's performance, arguing that the focus should remain on preventing deaths and complications among mothers and newborns.

Dr Edward Serem, head of the Ministry of Health's Division of Reproductive, Maternal, Newborn, Child and Adolescent Health, links the increase to the expansion of health infrastructure and improvements in the training of medical workers.

He says the availability of better-equipped hospitals and skilled personnel has improved the ability of health workers to identify complications affecting mothers and unborn babies and intervene before their conditions deteriorate.

These include cases of foetal distress, prolonged labour and complications involving scars from previous Caesarean section operations.

Serem says the Ministry of Health is carrying out additional analysis to determine the medical circumstances behind the rising number of surgical births, including the reasons doctors recommend the procedures.

He also warns against applying international benchmarks without considering differences in patients' medical conditions and the healthcare needs of individual countries.

"Clinical decisions are made based on the immediate needs of the mother and newborn at that specific moment," he says.

The WHO maintains that Caesarean section rates of about 10 per cent can help reduce maternal and newborn deaths, but increasing the proportion beyond that level has not been shown to provide further benefits. On the other hand, rates below five per cent could point to gaps in access to emergency surgical care.