Background: Despite the tremendous efforts to achieve universal health coverage and reduce maternal mortality ratio (MMR) in Malawi, progress has been trivial. This study examined the determinants of different maternal healthcare services; investigated the existence of socioeconomic inequalities in utilization of services and analyzed the trends thereof; and verified if Andersen's behavioral model of healthcare utilization could be invoked on the results of decomposition in order to characterize the existing inequalities as "inequities."
Methods: Using a total sample of 34120 women aged 15-49 drawn from three rounds of Malawi Demographic and Health Survey (MDHS) of 2004, 2010 and 2015-16, we analyzed utilization of three maternal healthcare services namely: (i) antenatal care (ANC) visits; (ii) skilled provider assisted (SPA) delivery; and (iii) facility-based delivery. Andersen's
behavioral model of healthcare utilization was employed to systematically select the covariates, and Logistic Regression was used to model the respective association of the various predictors with different maternal healthcare services. Furthermore, concentration curves (CC) and indices were used to analyze socioeconomic inequalities in the utilization of services.
Results: Empirical findings show that predisposing, enabling, and need factors have different effects on the utilization of each of the three maternal healthcare services under scrutiny. However, enabling factors (particularly education level and wealth status) have been found to
be the primary determinants of healthcare utilization. Furthermore, evidence strongly points to the presence of pro-rich utilization of all the three services. While analysis of the inequalities indicates a downward trend, the poor-rich gap in the utilization of at least four ANC services remains high. Also, decomposition analysis shows that enabling factors are the largest contributors to economic-related inequalities in utilizing each of the three services.
Recommendations: Our findings point to the need to improve education access and quality; and household incomes, as well as bridging financial barriers to maternal healthcare through the introduction of a national maternal health insurance scheme.

CHAPTER 1 1
INTRODUCTION 1
1.1 BACKGROUND 1
1.2 MALAWI’S MATERNAL MORTALITY RATIO 2
1.3 MATERNAL HEALTH CARE 3
CHAPTER 2 5
METHODS 5
2.1 THEORETICAL APPROACH 5
2.2 DATA AND SOURCES 8
2.3 DEFINING OUTCOME VARIABLE 9
2.4 EXPLANATORY VARIABLES 10
2.5 STUDY OBJECTIVES 11
2.6 ANALYTICAL APPROACH 11
2.6.1 Determinants of maternal healthcare utilization 11
2.6.2 Socioeconomic inequalities in maternal healthcare utilization 12
CHAPTER 3 15
EMPIRICAL RESULTS 15
3.1 GENERAL CHARACTERISTICS OF THE STUDY SAMPLE 15
3.2 BIVARIATE ANALYSES 17
3.2.1 Proportion of women by background characteristics, controlling for ANC Visits 17
3.2.2 Proportion of women by background characteristics, controlling for SPA delivery 18
3.2.3 Proportion of women by background characteristics, controlling for delivery place 19
3.3 MULTIVARIATE LOGISTIC REGRESSION ANALYSIS 21
3.3.1 ANC Utilization 21
3.3.1.1 Predisposing characteristics 21
3.3.1.2 Enabling factors 21
3.3.1.3 Need factors 22
3.3.2 Skilled Provider Assisted Delivery 22
3.3.2.1 Predisposing characteristics 22
3.3.2.2 Enabling factors 23
3.3.2.3 Need factors 26
3.3.3 Place of Delivery 26
3.3.3.1 Predisposing characteristics 26
3.3.3.2 Enabling factors 27
3.3.3.3 Need factors 27
3.4 MATERNAL HEALTHCARE UTILIZATION BY ENABLING FACTORS 28
3.5 SOCIOECONOMIC INEQUALITIES IN MATERNAL HEALTHCARE UTILIZATION 29
3.5.1 Trends in Socioeconomic Inequalities in Maternal Healthcare Utilization 29
3.5.2 Decomposition of Socioeconomic Inequalities in Maternal Healthcare Utilization 30
CHAPTER 4 33
DISCUSSIONS AND CONCLUSION 33
4.1 DISCUSSIONS 33
4.1.1 Predisposing characteristics 34
4.1.2 Enabling factors 35
4.1.3 Need factors 35
4.2 SOCIOECONOMIC INEQUALITIES 36
4.3 CONCLUSION 37
4.4 POLICY RECOMMENDATIONS 37
4.5 STUDY STRENGTHS AND LIMITATIONS 38
REFERENCES 39
APPENDIX 42

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