Background <p>Malawi has made significant strides in maternal and reproductive health, yet the underlying drivers of these shifts remain insufficiently understood. This study examines changes in modern contraceptive use, skilled birth attendance, and fertility between 2015 and 16 and 2024, with a focus on socioeconomic inequalities and underlying mechanisms.</p> Methods <p>A secondary analysis was conducted of the 2015–16 and 2024 Malawi Demographic and Health Surveys (MDHS), using harmonized Individual Recode (IR) and Births Recode (KR) datasets. Modern contraceptive use and fertility were analysed using the pooled IR sample (<i>N</i> = 46,149 women aged 15–49 years); skilled birth attendance was analysed using the pooled KR sample, restricted to each woman’s most recent birth in the recall period covered by the delivery-assistance module (five years for 2015–16; three years for 2024, owing to a shorter module reference period in that survey round), yielding <i>N</i> = 20,554. Survey-weighted logistic regression models were used to estimate associations for modern contraceptive use and skilled birth attendance, while fertility (children ever born) was modeled using Poisson regression. Interaction terms were included to assess changes in socioeconomic gradients over time. A Blinder–Oaxaca decomposition was applied to modern contraceptive use to distinguish compositional (endowment) and coefficient effects.</p> Results <p>Modern contraceptive use increased from 45.0% (95% CI: 44.1–46.0) in 2015–16 to 53.1% (95% CI: 51.9–54.2) in 2024. Skilled birth attendance also increased, from 90.5% (95% CI: 89.6–91.4) in 2015–16 to 96.2% (95% CI: 95.5–96.9) in 2024, broadly consistent with the rise reported in the official 2024 MDHS report. Fertility also declined, with women in 2024 having lower expected numbers of children ever born (IRR = 0.87, 95% CI: 0.84–0.91). Adjusted models showed higher odds of modern contraceptive use in 2024 (OR = 1.51, 95% CI: 1.27–1.79); the adjusted odds of skilled birth attendance were higher in 2024 than in 2015–16, though the effect did not reach conventional statistical significance (OR = 1.63, 95% CI: 0.94–2.85, <i>p</i> = 0.083). Decomposition results indicate that the increase in contraceptive use was driven almost entirely by coefficient effects, with no statistically significant contribution from compositional (endowment) changes.</p> Conclusion <p>Reproductive health trends in Malawi between 2015 and 16 and 2024 show largely positive patterns, with rising contraceptive use, declining fertility, and a descriptive rise in skilled birth attendance that was not statistically significant after adjustment; persistent socioeconomic gradients in skilled birth attendance, particularly by education and wealth, indicate that gains have not been evenly distributed. Strengthening maternal health services while sustaining gains in family planning should remain a key policy priority.</p>