Toward consensus: a Delphi study on the core principles and indicators of respectful maternity care

The core principles and key indicators of Respectful Maternity Care (RMC), particularly in low-income settings, are under-researched. Validated core principles and indicators are crucial for measuring RMC, especially in contexts where workforce shortages, infrastructure gaps, and sociocultural factors impact the care. Thus, this study aimed to identify and validate the core principles and indicators of RMC in resource-limited settings.

A three-round Delphi study was conducted. Maternity care professionals (midwives, educators, researchers, and obstetricians) based in Ethiopia (n = 33) were recruited via email through professional networks. Original peer-reviewed research published in English-language journals between 2010 and 2024 was reviewed and used to generate 75 initial indicators, which were securely uploaded to Qualtrics^® for digital distribution. The indicators were evaluated on a four-point Likert scale for importance, relevance, and clarity. Responses were analysed and reported back to the participants for round two. After analysing the second-round results, the final version was shared with the participants for the third round. The third round did not generate any new information or ideas. Participants were also invited to provide feedback and suggest additional core principles and indicators that they considered missing.

In the first round, 75 indicators were assessed. The Item-level Content Validity Indexes ranged from 0.66 to 1.00 for importance and relevance, and 0.90 to 1.00 for clarity. The Scale-level Content Validity Index was 0.94 for importance and relevance and 0.98 for clarity. Three indicators were eliminated in round one; 12 were merged, and three remained unchanged. Two new indicators were added to the items. Thirteen core principles of RMC were proposed, and ten were accepted. Sixty indicators aligned with the ten core principles of RMC were finalised for round two. After round two, 11 indicators were removed, leading to a final list of 49 indicators. The third round generated no further revisions to the questionnaire.

The ten core principles and forty-nine indicators validated in this study provide a robust blueprint for the consistent implementation and monitoring of RMC. This validated framework also provides a timely, evidence-based response to the WHO's call for the most valid and responsive RMC indicators in clinical settings. Future research should assess the core principles and indicators' validity and reliability across diverse contexts.