Inside Kenya’s deadliest counties for mothers

It is 2am. A sharp pain tears through your abdomen and jolts you awake. You are 17, pregnant for the first time, and your body already knows what your mind is not ready for. 

You are in labour.

You are not in Nairobi. You are not near any town. You are deep in a remote village where female genital mutilation is practised, and you have been cut. That scar now turns what should be the most natural thing in the world into something that could kill you. Complications are a certainty.

The nearest hospital with an operating theatre is 150 kilometres away. There is no ambulance coming, no emergency line to call, no helicopter circling overhead. There is your husband’s boda boda. Or there is nothing.

Also read: System and governance failure: Why Kenyan mothers are still dying in childbirth

So, you climb on. In the dark. In labour. And you hold on. Every bump on the road travels straight through you. Every kilometre feels like a negotiation between your body and whatever time you have left. The hospital is still hours away.

Would you survive?

This is not a story from a century ago. This is happening today, in Kenya, in 2026. It is the daily reality for millions of women in Samburu, Garissa, West Pokot, Tana River, and Homa Bay;  five counties where the health system has consistently failed its most vulnerable people.

In West Pokot County alone, two to three women die every week making this desperate journey. Some never make it out of their villages at all.

“Weekly, our county loses about two to three women,” says Nancy Chebet, West Pokot Sub-County Health director. She says it with the steadiness of someone who has delivered this statistic too many times to too many people who nodded and moved on.

The numbers are clinical. The reality behind them is not. Behind every one of those numbers is a girl like Sarah Mnangat. When she developed complications during labour, her local health centre had no doctor, no anaesthetist, no blood bank. Just a nurse who could not handle the emergency. She was bleeding, and there were no drugs to stop it. She did not have the means to make the 150km journey to the hospital that could have saved her. She bled to death.

On February 25,, Kenya launched the Her Health Project, “Systems that Work for Her,” in these five counties. To understand why it matters, you must first understand the geography of maternal death in Kenya’s most vulnerable counties.

West Pokot: one theatre, 160km away

The county has only one facility that can perform emergency obstetric caesarean sections: Kapenguria Referral Hospital. For a mother living 160 kilometres away, and many do, getting there when things go wrong is like running a marathon while bleeding to death.

“A mother has to be referred and travel for six hours to reach the hospital on time. Since they have to travel such long distances, many don’t make it,” says Chebet.

Kapenguria performs between 150 and 200 emergency caesarean sections every month. These are the lucky ones, the women who survived the journey. For every woman who reaches the operating theatre, another dies on the road, in a boat crossing a river, or at home, too far or too afraid to even try.

Only 36 per cent of women in West Pokot deliver with skilled attendance. Nearly two-thirds give birth at home, attended by traditional birth attendants, relatives, or nobody.

“Issues of access, ignorance, and cultural norms predispose our women to maternal risks,” Chebet says. “It’s not just that facilities are far. It’s that by the time a woman decides to seek help, by the time her family agrees to let her go, by the time they find transport, it’s already too late.”

The challenge in West Pokot is not only distance. It is the combination of distance, cultural norms around seeking care, and a referral system that places the entire burden of survival on the woman and her family. When the system offers only one facility for an entire county, the women who live farthest away are, by design, the least likely to survive

Tana River: crossing a river to reach a theatre

The county covers 38,000 square kilometres with a population of 320,000 people spread across vast, remote stretches of land.

“The population is sparsely distributed, and reaching everyone with health care services is an enormous challenge,” says Dr Oscar Ndegwa, director of Health Services.

The county has three Level 4 facilities, but only two offer emergency obstetric care: Hola and Gao. The third, Bura, has its operating theatre under renovation. Madogo Health Facility is still under construction, and its theatre is not yet functional. This means that some women must travel 150 kilometres to reach Hola, or cross into Garissa County because their own county cannot serve them.

“In case of an emergency, if movement is not done on time, we are talking about deaths. Or women delivering on the road, in boats, in places where no mother should give birth,” Dr Ndegwa says.

More than 40 per cent of deliveries in Tana River still occur at home. This means that out of every 10 children born in this county, four enter the world without skilled medical attendance.

Many rural facilities are staffed by just one or two nurses, people Dr Ndegwa calls “the bedrock of service delivery.” But that bedrock is fragile. “If a nurse goes on leave or for training, the hospital has to close, and mothers must seek services elsewhere,” he says. That elsewhere can be 50km away, 10 times the recommended five-kilometre distance.

Part of Tana River’s communities are also migratory, especially during droughts. 

“So you cannot keep a good eye on the situation of mothers,” Dr Ndegwa explains. 

Death here is often unrecorded. In Muslim communities where burials happen quickly, a woman can die before the health system even knows she was in labour. “If you lose a mother and she is Muslim, by the time we know about it, she’s already been buried, and everything has moved on. We are trying to use community health promoters to monitor what’s happening, but we are always playing catch-up,” he says.

Samburu: one in every two girls is pregnant

Walk through Samburu streets today and randomly sample the adolescent girls you encounter. One in every two is either pregnant or has already given birth.

“The pregnancy means the girl will not be able to achieve her full potential. She drops out of school. Her economic opportunities vanish. Often, she faces complications during childbirth because her body isn’t fully developed. The cycle of poverty continues,” says Dr Patrick Amoth, director-general of Medical Services.

This statistic, he says, is so staggering it bears repeating. In Samburu County, 50 per cent of adolescent girls are either pregnant or have already given birth.

Also read: From zero to 27 deaths: Makueni grapples with maternal health crisis

The teenage pregnancy crisis is compounded by vast distances between health facilities, deeply entrenched cultural practices including early marriage, and a healthcare system that treats adolescent sexual and reproductive health as an afterthought. Young girls in Samburu face a triple threat: pregnancy too early, facilities too far, and cultural barriers too high.

Garissa: the young men know, the young women don’t

Here, 91 per cent of adolescent and young men have comprehensive knowledge about HIV — how it is transmitted, prevented, and treated. Among adolescent and young women in the same county, that figure is just 17 per cent, according to data from the International Centre for Research on Women, 2026.

Same county, same communities. A gap of 74 percentage points.

“This points to entrenched gendered inequities in access to information and services,” says Dr Mohamed Sheikh, director general of the National Council for Population and Development (NCPD).

For Dr Sheikh, this is not academic. He once served as the district medical officer in Ijara, bordering Tana River, as the only doctor for miles.

“My experience in that area has always remained in my mind. I witnessed first-hand women of reproductive age struggling to access reproductive services,” he says.

Then, he describes a scene that sounds like it belongs to a different era.

“Ijara had no theatre, no anaesthetist. Whenever there was a maternal emergency, I would transport the mother from Mashinani hospital to the riverbank of Tana River, take a boat with the bleeding mother, cross the river, then board a waiting ambulance on the other side and drive her to the theatre. After we were done, we took her back the same way,” he recalls.

A bleeding woman, a boat, a river and an ambulance waiting on the other side. That was the referral system.

“This is why when we talk about maternal deaths, I would not say it is issues to do with accountability, because at times hospitals lack basic things,” Dr Sheikh says.

For him, the Her Health Project carries personal weight. 

“Northern Kenya, like the other target counties, faces challenges of distance, stigma, and cultural norms that shape daily lives. Many women and girls arrive at facilities late, mostly when complications have already set in. What I witnessed didn’t just inform my clinical judgment but changed my conviction that systems must be responsive and accessible. Healthcare must meet the girl where she is, without stigma, without delay, and without compromising her dignity.”

Homa Bay: dying without ever knowing their status

The county’s challenge is different in nature but no less serious.

In 2023, adolescent and young women aged 15 to 24 accounted for approximately 31 per cent of the 13,009 new adult HIV infections recorded in Kenya, according to the Kenya 

Demographic Health Survey 2022. Among adolescents aged 10 to 19, an estimated 2,083 new HIV infections and about 1,351 Aids-related deaths occurred that same year.

Yet HIV testing among adolescents remains dangerously low. Only 25 per cent of young women and 12.5 per cent of young men aged 15 to 19 reported being tested for HIV in the 12 months before the survey done by the International Centre for Research on Women. In Homa Bay, this translates to girls becoming infected, progressing to Aids, and dying without ever knowing their status.

“These are girls who are very active in the social space. Maybe we as policymakers are the ones failing because we need to reconfigure how we deliver information to them so we can reach them in their places of comfort,” says Dr Amoth.

HIV is not the only concern. In 2023, about 252,660 adolescent girls aged 10 to 19 presented for their first antenatal clinic visit nationally, representing 17 per cent of all ANC attendees. Adolescents and young people are now among the highest-risk population groups in the country.

What the numbers say

According to the Maternal and Perinatal Death Surveillance and Response report by the Ministry of Health, Tana River leads the five counties with a maternal mortality ratio of 265 per 100,000 live births. Garissa follows at 247 per 100,000, then Samburu at 84 per 100,000, Homa Bay at 70 per 100,000, and West Pokot at 62 per 100,000.

“The national average masks the regional disparities and inequities which have persisted since independence. We have, as a ministry, mapped 26 counties with 60 per cent of the burden of maternal mortality,” says Dr Amoth. 

These five are among those 26. More than 1.36 million female adolescents live in them.

“We are not creating parallel structures. We are making the government’s health system work better for adolescent girls. This launch comes at a critical time when we are having a national discourse on maternal and new-born health. We have improved neonatal health more than maternal health,” says Dr Amoth.

The numbers bear this out.

“When you look at the 2022 Kenya Demographic Health Survey, seven out of 10 children under one year live to see their first birthday. Six out of 10 children born in Kenya live to see their fifth birthday. Eight out of 10 new-born babies live to see their first month. But we are losing the mothers. And we cannot celebrate babies surviving when mothers are dying,” Dr Amoth says.

A project built to last

The Her Health Project, formally titled Advancing Equitable Access to Quality Sexual, Reproductive, and Maternal Health Services among Adolescent Girls and Young Women, is funded by Co-Impact and anchored within existing government structures at the Ministry of Health. Partners include the Centre for Reproductive Rights, the Reproductive Health Network Kenya, and the National Council for Population and Development.

The five target counties were selected because they record maternal mortality ratios above Kenya’s 2030 national goal, alarmingly high teenage pregnancy rates, and significant unmet need for family planning services. With over 1.36 million female adolescents in these counties, the project will improve service delivery, build health worker capacity, and strengthen data systems so that the government can make evidence-based decisions that reach the girls who need care most.

Unlike short-term programmes that end when donor funding dries up, the Her Health Project is designed to work within and strengthen existing government structures. When the project ends, the systems it has built are meant to keep functioning.

Nelly Munyasia, executive director of one of the partner organisations, describes what the project represents. 

“We are shifting the question from ‘why did she fail?’ to ‘why did the system fail her?’ and then setting out to fix it. Today, we choose differently. We are choosing to ensure every girl has access to accurate information. That every health facility becomes a place of dignity, not judgment. That distance, cost, and stigma no longer stand between a girl and the care she deserves.”

She adds: “This is not a parallel system. Not donor-driven vertical programmes that disappear when funding dries up. But government-led, county-owned, community-rooted systems that are resilient, accountable, and built to last.”

For Ms Chebet in West Pokot, decentralisation is where the solution starts. “This new initiative will strengthen the referral system. It’s time to decentralise these services because the women need it.”

Dr Ndegwa in Tana River is focused on where the people are. “We want medical doctors going out to identify high-risk pregnancies in rural facilities where we don’t have specialists. It’s about making context-specific solutions. We are ready to work with the team.” 

“The decisions we make will mean more women, more mothers, more children survive. And we can do it,” says Dr Amoth.

Dr Sheikh, the man who once ferried a bleeding woman across River Tana in the middle of the night to reach an operating table, has the last word.

“Every girl in Kenya needs a system that works for her, addressing her needs without compromising who she is and where she’s coming from.”

[email protected]