Geospatial Analysis of Antenatal Care Utilization and Obstetric Fistula in Malawi: Bridging Maternal Health Disparities

Background : Antenatal care (ANC) is a cornerstone of maternal health and enables the early identification and prevention of complications. Despite global recommendations for at least four ANC visits, coverage in Malawi remains suboptimal, exacerbating maternal health disparities. Obstetric fistula, a severe and preventable childbirth injury, disproportionately affects women in underserved areas. This study leverages geospatial analysis to explore the relationship between ANC utilization, healthcare access, and fistula prevalence in Malawi, providing data-driven insights to inform interventions. Methods : A population-based cross-sectional study was conducted using data from the 2015–16 Malawi Demographic and Health Survey (DHS), district-level population projections, and geocoded health facility datasets. Geographic information systems (GIS) were used to map ANC utilization, health facility density, and fistula prevalence. Spatial autocorrelation, hotspot analyses, and regression modeling were used to identify patterns and relationships between ANC attendance, facility accessibility, and maternal health outcomes. Results: The national prevalence of obstetric fistula was estimated to be 0.6%, with regional variations (0.7% in the northern and southern regions and 0.4% in the central region). An estimated 1,091 and 829 women with obstetric fistulas were reported in high-risk districts, including the Mangochi and Lilongwe Rural districts, respectively. GIS mapping highlighted significant geographic disparities in healthcare access, particularly in rural districts such as Mangochi, which has only 6.7 health facilities per 10,000 WRA, compared to urban centers such as Lilongwe city (12.8 facilities per 10,000 WRA). ANC coverage was suboptimal, with only 51% of women attending four or more ANC visits during their pregnancy. A strong negative correlation was found between ANC coverage and obstetric fistula incidence (r = -0.68, p < 0.01), indicating that districts with higher ANC coverage had lower rates of fistula. Barriers such as distance to health facilities (56% of women reported distance as a barrier) and financial constraints (53%) were significantly associated with higher fistula incidence (r = 0.53, p < 0.05 and r = 0.68, p < 0.01, respectively). Conclusion : Geographic disparities in maternal healthcare access are a key driver of obstetric fistula incidence in Malawi. This study underscores the urgent need for equitable healthcare interventions in Malawi, particularly in rural areas. Expanding healthcare infrastructure, deploying mobile clinics, and addressing socioeconomic and cultural barriers are critical to improving ANC coverage and reducing fistula prevalence. While these findings are based on the most recent DHS data available (2015–16), the upcoming 2024–25 DHS presents a vital opportunity to assess progress and refine strategies. Future analyses incorporating updated data will be instrumental in monitoring and addressing persistent maternal health disparities.