Co-development of a contextually relevant maternity service user feedback tool in Malawi using participatory...

Improving the quality of maternity care requires systematic incorporation of women's experiences into quality improvement processes. Although several instruments exist to measure maternity care experiences, few have been developed for routine feedback within low-resource health systems, and existing tools used in Malawi are generic and do not adequately capture maternity-specific experiences. This study aimed to co-develop and establish stakeholder-informed content validity for a context-specific maternity service user feedback tool for routine quality improvement in Malawi.

We conducted a qualitative participatory consensus study involving two multi-stakeholder workshops held in Malawi between July 2024 and February 2025. Stakeholders included maternity service users, healthcare providers, policymakers, programme implementers, researchers, and community representatives. The tool was developed through a structured pathway comprising preparatory stakeholder engagement, co-design, prototype development, iterative refinement, and validation. World Café discussions, group discussions, gallery walks, structured voting, and thematic analysis were used to identify, prioritise, and refine feedback domains, indicators, and delivery modalities.

A total of 48 stakeholders participated in the co-design workshop and 39 participated in the validation workshop. Through iterative stakeholder consensus, approximately 300 recommendations were synthesised into 35 descriptive categories and subsequently refined into seven priority domains: respectful and dignified care; communication and health education; emotional support; timely and equitable access; continuity and coordination of care; quality of services received; and overall satisfaction. These domains informed the development of a maternity service user feedback tool comprising 27 antenatal care, 28 labour and delivery, and 32 postnatal care indicators organised into three modular questionnaires. Stakeholders recommended piloting both paper-based and electronic versions to support feasible implementation within routine maternity quality improvement systems.

This study developed a stakeholder-informed maternity service user feedback tool tailored to the Malawian health system. The findings establish the tool's contextual relevance and stakeholder-informed content validity while providing a foundation for future evaluation of feasibility, reliability, construct validity, and implementation within routine maternity quality improvement programmes.