Socioeconomic inequality in the completion of the continuum of care for maternal, newborn, and child health in Malawi
Background Despite improvements in maternal, newborn, and child health (MNCH) service coverage in Malawi, completion of the continuum of care (CoC) remains low and unequally distributed across socioeconomic groups. This study quantified socioeconomic inequality in MNCH CoC completion and its determinants. Methods We analyzed pooled data from the 2010, 2015–16, and 2024 Malawi Demographic and Health Surveys, including 18,741 women with a live birth; analytic samples were 15,552 women for maternal CoC and 7,625 children aged 12–23 months for full CoC. Wealth-related inequality was assessed using Erreygers concentration indices. Multivariable and multilevel logistic regression identified determinants of CoC completion, while Wagstaff, Oaxaca–Blinder, Fairlie, and inequality-of-opportunity decompositions identified inequality contributors. Results Full CoC completion rose from 1.4% (2010) to 6.8% (2024); maternal CoC rose from 4.9% to 17.4%. Women completed an average of 8.3 of 11 interventions. Pro-rich inequality persisted for maternal CoC (Erreygers index = 0.036, p < 0.001); inequality in full CoC was smaller and not statistically significant (0.004, p = 0.497). Women's education, particularly higher education, was the strongest and most consistent predictor of completion (adjusted OR: 3.42 maternal, 3.45 full CoC, pooled). Contributors varied by method: education, wealth, and rural residence dominated the Wagstaff decomposition, while education, age, and parity contributed more consistently in the Oaxaca–Blinder and Fairlie decompositions. Circumstance variables reproduced the entirety of observed maternal CoC inequality, falling to 78.7% when wealth was excluded. Conclusions Although MNCH CoC coverage improved substantially in Malawi, socioeconomic inequalities persisted, particularly for maternal CoC, and were closely linked to structural circumstances. Policies improving geographic access, expanding girls’ and women's education, and addressing structural barriers may support more equitable progress toward Sustainable Development Goal 3.