Towards an understanding of regional disparities in social inequities in maternal health in Malawi.

BACKGROUND: Improving maternal health remains a major challenge facing Malawi because at 984 deaths per 100,000 live births, the maternal mortality ratio is among the highest in the world. Although the health status of women in child-bearing age groups is low in all the three regions of Malawi, there are marked regional differences in several health indicators. OBJECTIVE: To analyze the degree of socio-economic inequities in maternal health in Malawi both at regional and national levels. METHODS: Using data from a sample of 4,276 women from the Malawi Second Integrated Household Survey of 2004 who reported giving birth up to two years preceding the survey, deliveries attended by skilled health personnel and access to prenatal care services were used to analyze socio-economic inequities in maternal health. Household income, from which household socio-economic status was derived, was proxed by real annual household expenditure. Concentration indices were then calculated for the two indicators for the whole sample, as well as for each of the three regions of Malawi. The proportion of household income that is spent on health was also considered to ascertain whether the poor spend a larger proportion of their income on health than the non-poor. RESULTS: There is no evidence that the poor spend a higher proportion of their income on health than the non-poor. We found very high rates of utilization of antenatal care services with no income-related inequality in its utilization both at regional and national levels. There are socioeconomic inequalities in the deliveries by skilled health personnel. The pro-rich inequalities in the medically attended deliveries are highest in the central region followed by the north and lowest in the southern region, with traditional birth attendants still playing an important role in handling deliveries. CONCLUSIONS: The free government medical services appear to be effective in ensuring that the poor do not spend a higher proportion of their income on health than the non-poor. However, there is a wide mismatch between utilization of antenatal care services and skilled attendance at childbirth