Determinants of Maternal Overweight and Obesity in Malawi: A Multilevel Analysis of the 2024 Demographic and Health Survey

Background. Malawi continues to carry a heavy burden of childhood undernutrition, yet overweight and obesity among women of reproductive age have risen steadily over the past two decades and now threaten to compound, rather than replace, that burden. National evidence on who is most affected, and on how much of the variation sits between communities rather than between individuals, remains limited for the most recent survey round. This study estimated the prevalence of maternal overweight and obesity in Malawi and identified its individual-, household-, and community-level determinants using multilevel modelling. Methods. We analyzed data from the 2023–24 Malawi Demographic and Health Survey (2024 MDHS), restricted to 9,714 non-pregnant women aged 15–49 years with valid anthropometry. The outcome was overweight/obesity, defined as a body mass index (BMI) of 25.0 kg/m² or higher. Three sequential random-intercept logistic regression models were fitted, with women nested within primary sampling units: Model 1 contained individual-level factors, Model 2 added household characteristics, and Model 3 added community and regional variables. Between-cluster variation was summarized with the intraclass correlation coefficient (ICC), and models were compared using the Akaike information criterion (AIC). Results. The weighted prevalence of overweight/obesity was 24.0%, and 6.8% of women were obese. In the fully adjusted model, the odds of overweight/obesity rose with age (adjusted odds ratio [AOR] per year 1.24, 95% CI 1.18–1.30) with a significant negative quadratic term, and were higher among parous than nulliparous women, peaking at three to four births (AOR 1.71, 95% CI 1.32–2.21). A steep wealth gradient was evident: compared with the poorest quintile, the odds rose monotonically to an AOR of 3.73 (95% CI 3.00–4.63) in the richest quintile. Urban residence carried 33% higher odds (AOR 1.33, 95% CI 1.14–1.54). Relative to women with higher education, those with no formal education (AOR 0.49), primary education (AOR 0.57), or secondary education (AOR 0.66) were substantially less likely to be overweight or obese, and women in the Southern region had lower odds than those in the Northern region (AOR 0.82, 95% CI 0.71–0.95). Employment, media exposure, improved water, and improved sanitation were not associated with the outcome once household factors were included. The ICC fell from 0.10 in the null model to 0.03 in the full model, indicating that most geographic clustering was explained by the composition of communities. Conclusions. One in four Malawian women of reproductive age is now overweight or obese, and the condition is patterned far more by socioeconomic advantage than by deprivation. Prevention efforts in Malawi should extend beyond undernutrition to include double-duty actions that reach older, parous, urban, and better-off women, without losing sight of the poorer and rural groups among whom the prevalence is also non-trivial.