Measuring Women’s Experiences with Maternity Services: Development of a Feedback Tool in Malawi

Measuring Women’s Experiences with Maternity Services: Development of a Feedback Tool in Malawi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Measuring Women’s Experiences with Maternity Services: Development of a Feedback Tool in Malawi Mtisunge Joshua Gondwe, Yamikani Chimwaza, Chifundo Kondoni, Leonard Mndala, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7643760/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Feedback from maternity service users is critical to improving the quality of care, yet existing tools often lack contextual relevance and fail to capture experiential aspects of care. This study aimed to co-develop a maternity-specific feedback tool by engaging service users and relevant stakeholders in identifying meaningful quality indicators using participatory methods. Methods A qualitative, consensus-driven design was employed across two multi-stakeholder workshops held in July 2024 and February 2025 in Malawi. Participants included service users (individuals who received maternity care), service providers (health professionals), policymakers, and community representatives. Participatory techniques, specifically the World Café (a structured conversational process that supports open and intimate discussion), gallery walks (an activity where participants review and provide feedback on visual displays), and group discussions, were employed to elicit and prioritize quality indicators and assess delivery modalities for the tool. Data from transcripts, notes, visual materials, and observations were analyzed thematically, with triangulation of visual (pictures, charts) and verbal data enhancing the depth of insights. Two structured rounds of stakeholder feedback were used to refine the tool iteratively. Results A total of 95% (N = 46) of the invited stakeholders participated in the co-design workshop, and 95% (N = 39) attended the validation workshop. The resulting tool includes 27 antenatal, 28 labour and delivery, and 32 postnatal indicators across seven domains: respectful and dignified care, communication and education, emotional support, timely and equitable access, continuity and coordination of care, quality of services received, and overall satisfaction. The tool will be piloted in two formats, paper-based and electronic. These findings demonstrate that the tool comprehensively captures user experiences and is considered contextually relevant by stakeholders. Conclusion The participatory co-design process yielded a maternity feedback tool that aligns with user priorities and is tailored to Malawi’s health system. The feedback tool systematically captures women’s experiences using indicators valued by stakeholders, enabling scalable quality improvement in maternal care. Maternity care Feedback tool Quality indicators Participatory research Maternal health Service user engagement Respectful care World Café Gallery Walk Low-resource settings Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction In 2020, there were an estimated 287,000 maternal deaths globally, with an MMR (maternal mortality ratio) of 223 per 100,000 live births ( 1 ). About 70% of these deaths happened in Sub-Saharan Africa ( 1 ). SDG 3 (Sustainable Development Goal 3) aims to lower global MMR to fewer than 70 per 100,000 by 2030, ensuring no country exceeds twice that average ( 2 ). However, this is unlikely without understanding the primary factors driving use and quality of maternity services. In Malawi, over 95% of pregnant women attend at least one antenatal care (ANC) visit and deliver in a facility ( 3 ). Despite this, Malawi’s MMR remains high at 381 per 100,000 live births, suggesting that quality, rather than access, is the key issue ( 1 ). Satisfaction with maternity services plays a critical role in shaping women’s health-seeking behaviors and their continued utilization of antenatal and other maternal health services ( 4 ). In Malawi, a study exploring women’s perspectives on quality of maternal healthcare revealed high levels of satisfaction with prenatal services, but widespread dissatisfaction with the care provided during the intrapartum and postpartum periods ( 5 ). Disrespect and abuse during childbirth are well-documented across many low- and middle-income countries (LMICs), contributing significantly to negative maternity experiences ( 6 ). Women’s satisfaction is therefore a crucial concern for healthcare providers, administrators, and policymakers aiming to improve the quality of care ( 7 ). However, assessing satisfaction requires the use of reliable and valid tools ( 7 , 8 ). Several instruments specific to maternity care have been developed, including the Patient Perception Score, the Pregnancy and Maternity Care Patients’ Experiences Questionnaire, the Childbirth Experience Questionnaire, the Childbirth Perception Scale, and the Maternal Satisfaction Scale for Caesarean Section ( 9 ). More general tools, such as the Patient Satisfaction Questionnaire (PSQ-III) and its short form (PSQ-18), are also commonly used ( 10 , 11 , 12 ). While these general tools are available in LMICs, their psychometric properties are limited, highlighting the need for further development that incorporates qualitative input ( 13 ). Client satisfaction data are most often gathered through in-person interviews ( 7 ). However, to ensure meaningful quality improvement, countries must invest in developing context-specific, valid, and reliable instruments that reflect the priorities and experiences of the populations they serve. Although user satisfaction is a key indicator of maternal health service quality, Malawi has limited data directly sourced from service users. Recognizing this gap, the Ministry of Health, through the Quality Management Directorate (QMD), has prioritized collecting user feedback and recently introduced standardized feedback assessment tools for use during client visits. However, these tools are general and not tailored to maternity services, currently constrained to face-to-face interviews with a limited scope of content. Developing maternity-specific feedback tools would offer more nuanced insights into the quality of maternal care, an area often perceived by users as inadequate. Importantly, such tools would also facilitate the systemic inclusion of service users’ voices in quality improvement initiatives. To address these gaps and contribute to the improvement of maternal health services, this paper aims to outline the development of a user feedback tool tailored specifically for maternity care. The following sections describe how the tool was designed to systematically monitor and improve the quality of maternal health services in Malawi, with a focus on its intended use by maternity service providers and healthcare quality evaluators. Methods Study design and setting This study employed a consensus-based, participatory approach to develop a contextually appropriate feedback tool for maternity services. This approach involves interactions with a group to collaborate and harness the knowledge of stakeholders (people who are affected by or involved in maternity care) ( 14 ). The methodology incorporated collaborative techniques, including gallery walks (sessions where participants review posted materials and give feedback as they walk around) and the World Café method (small, rotating group discussions to encourage sharing a broad range of perspectives), to ensure that the resulting tool reflected the priorities and lived experiences of both service users and healthcare providers. Two consensus workshops were conducted, engaging experts and key stakeholders in maternal and child health services in Malawi. The first workshop, focused on co-design, was held over one and a half days from July 2–3, 2024, in Dowa District, located in Malawi’s Central Region. The second workshop, aimed at validating the tool, took place over a similar duration from February 4 to 5, 2025, in Mangochi District, situated in the Southern Region. Both venues were strategically chosen to minimize external distractions and maintain active participant engagement. The use of consensus workshops, gallery walks, and the World Café method was particularly valuable in this context, as these approaches promote inclusive and participatory decision-making while integrating diverse stakeholder perspectives. Consensus workshops provide a structured space for interaction among service users, healthcare providers, and policymakers, facilitating the co-creation of feedback tools that are both contextually relevant and widely acceptable ( 15 ). Gallery walks, in which participants engage with visual displays of draft materials and provide feedback, encourage reflective input and help reduce hierarchical power imbalances often present in group discussions ( 16 ). The World Café method further supports inclusive dialogue through informal, small-group discussions that rotate participants across topics, ensuring a wide range of voices are heard, including those of traditionally marginalized or less vocal individuals ( 17 ). In the context of maternity care, where patient-provider relationships, cultural sensitivity, and service delivery quality are central, these participatory techniques ensure that the resulting tools are grounded in lived experiences and professional knowledge. This improves their usability, relevance, and potential impact on maternal healthcare quality improvement efforts ( 18 ). Selection of participants A purposive sampling approach was employed to recruit experts and stakeholders involved in maternal and child health services for participation in the consensus-building processes. Participants were drawn from a diverse range of institutions, including the Ministry of Health (MoH) and its implementing partners, international donor organizations, national and international non-governmental organizations (NGOs), research and training institutions, regulatory bodies, professional associations, maternal health service providers, service users, and community representatives. A total of 58 individuals were invited to the co-design workshop and 53 to the validation workshop (see Additional file 1). Engaging such a broad spectrum of stakeholders ensured that the feedback tool was contextually appropriate, functional, and broadly endorsed. This participatory approach strengthens the tool’s credibility, usability, and potential for successful adoption within Malawi’s health systems ( 19 , 20 , 21 ). An initial planning meeting was held with the Reproductive Health Directorate (RHD) and the Quality Management Directorate (QMD) of the MoH to minimize selection bias and ensure broad stakeholder participation. During this meeting, the research team, with support from the RHD and QMD, mapped ongoing maternal health programs and identified relevant partner organizations to target. In addition to purposive sampling, a snowball technique was employed to capture other key stakeholders active in maternal and child health initiatives. Some participants were also identified through previous collaboration with the research team. This multi-pronged strategy ensured the inclusion of key actors involved in policy development and program implementation across national, district, and primary healthcare levels. Rather than limiting participation to a small group of decision-makers, the process aimed to ensure inclusivity and transparency, enabling diverse perspectives to inform tool development. Considerable time was invested in the preparatory phase, which included consultations with RHD and QMD to identify stakeholders, gather relevant materials (e.g., draft satisfaction tools and visual designs), and develop a detailed workshop agenda (see Additional files 2 and 3). These preparatory steps helped to build a shared understanding of the project’s objectives and laid a strong foundation for collaborative decision-making. Additional preparations included selecting appropriate workshop materials and training facilitators. To ensure grassroots perspectives were captured, invitations were extended to community members, local organizations, and patient representatives. Stakeholders were initially contacted via email with an explanation of the meeting’s objectives and participant expectations; follow-up emails were sent if no response was received within ten working days. Data collection Training of facilitators Facilitator training was conducted before both consensus workshops to ensure the effective delivery of participatory methods. Two training sessions were held in preparation for the co-design workshop, and one session was conducted ahead of the validation workshop. A total of seven facilitators (MJG, CK, AK, CB, NC, LK, and EC) were trained by an expert on how to effectively facilitate group discussions and implement participatory techniques, including gallery walks and the World Café method. The training focused on promoting inclusive engagement, managing group dynamics, and ensuring that all voices, particularly those of service users and community representatives, were meaningfully included in the consensus process. Co-design workshop A one-and-a-half-day co-design workshop was held on July 2–3, 2024, in Dowa district, Malawi, with the participation of 48 stakeholders (see Additional file 1). The objective of the workshop was to engage participants in structured, collaborative, and constructive dialogue to determine the key informational content areas for inclusion in a maternity-specific feedback tool and to identify the most appropriate tool formats for implementation. The workshop commenced with a series of presentations, as outlined in the agenda (see Additional File 2), which laid the groundwork for subsequent discussions. These presentations highlighted the importance of feedback mechanisms within the broader context of maternity care and quality improvement. Topics included the design and application of maternity-specific satisfaction tools, their contextual relevance, and insights from general patient satisfaction experiences at a Malawian hospital. Collectively, the sessions underscored the need for a dedicated maternity feedback tool and informed key considerations for its development. Following the presentations, participants were divided into small groups to discuss the types of information that should be captured in a maternity-specific feedback tool, as well as the preferred format for the tool. The workshop employed interactive participatory methods, including World Café discussions and gallery walks, to facilitate the exchange of ideas and consensus-building. Group outputs were consolidated to inform the next steps in the development of the tool. A visual summary of the co-design process is provided in Fig. 1 . Facilitators audio-recorded all group discussions after obtaining prior informed consent from participants. These recordings were later transcribed and analyzed to document the decision-making processes, identify consensus and areas of divergence, and capture participants’ perspectives and underlying rationale. Participant Grouping and Facilitated Structured Discussions Participants were purposely allocated into six diverse groups, each comprising an average of seven stakeholders, to ensure a broad representation of perspectives during the co-design workshop. The structured, facilitator-led discussion focused on identifying key elements of the maternity-specific feedback tool and determining appropriate methodologies for its administration. The group composition was intentionally diverse, comprising a variety of stakeholders, including healthcare providers, facility managers, policy-level representatives, district officers, data managers, and community representatives, such as women and individuals with disabilities (see Additional file 4). This inclusive approach to group formation was intended to ensure that the feedback tool would be relevant, equitable, and feasible for implementation across different levels of the health system. Bringing together individuals with diverse expertise and lived experiences enabled the integration of multiple viewpoints, fostering a holistic understanding of user needs and service delivery realities. Such diversity not only enhanced the quality and practicality of the tool’s design but also fostered shared ownership among stakeholders, critical for successful implementation and long-term sustainability. A detailed summary of group composition is provided in Additional File 4. Phase one: Group discussion In the first phase of group discussion, all six groups focused on identifying the key types of information or indicators to be included in the maternity-specific feedback tool. Discussions were structured to address the entire continuum of care across general service quality, antenatal care, labour and delivery, and the postnatal period. In addition to identifying relevant indicators, participants were asked to determine the most appropriate level of the health system (primary, secondary, or tertiary) at which each type of information should be collected or applied. To support interactive and organized engagement, each group used adhesive sticky notes to record their suggested indicators, which were then displayed on flip charts. This method enabled participants to organize their ideas visually, facilitated collaborative prioritization, and allowed for cross-group sharing during plenary sessions. The visual format also supported transparency and traceability of the discussions, laying a foundation for consensus in subsequent phases. World Café Sessions Following the initial group discussions on the content of the maternity-specific feedback tool and the appropriate levels of health system delivery, a World Café was employed to support further the participatory development and iterative refinement of the tool. This approach facilitated structured, small-group dialogue among a diverse mix of stakeholders as described in Additional file 4. Two rounds of 15-minute table discussions were conducted, with participants rotating between tables after each round. This rotation encouraged the cross-pollination of ideas and exposed participants to a broader range of perspectives. Each table was facilitated by a trained moderator who guided the discussions and summarized key points on flipcharts. Additionally, designated recorders captured verbatim comments to ensure a detailed and accurate account of stakeholder input. Following the World Café sessions, each group reconvened and presented its consolidated perspectives on what it considered to be the most appropriate content for inclusion in the maternity feedback tool. This collaborative and iterative approach helped to ensure that the tool reflected both consensus and diversity in stakeholder priorities. Phase two: Group discussions on delivery methods In the second phase of the group discussions, the first five groups (see Additional File 4) explored various modes of delivering the maternity-specific feedback tool, building on the insights gained in Phase 1. Each group was assigned a specific delivery format for in-depth examination: Group 1 focused on a paper-based version, Group 2 discussed an electronic-based version, Group 3 explored a mobile application, Group 4 examined an audio tool using Audio Computer-Assisted Self-Interviewing (ACASI), and Group 5 assessed the feasibility of a combined or hybrid approach. . Each group discussed several key considerations, including the appropriate length of the tool, potential advantages and disadvantages of the proposed format, adaptability across different facility levels, and the overall feasibility in terms of required resources, time requirements, and ease of administration. Flip charts were used to visually organize and display group inputs, while voice recorders captured the full discussions for later analysis and review. Group 6, composed of stakeholders with expertise in tool development, was tasked with conducting a critical evaluation of all five potential delivery methods. Their assessment focused on identifying the facilitators, barriers, and technical design requirements for each method. The inclusion of this expert group was instrumental in ensuring that the selected tool delivery approach would be contextually appropriate, user-friendly, and compatible with clinical practice. In addition to evaluating delivery formats, Group 6 also considered broader implementation issues (local workflows, resource availability, and staff capacity, enhancing its usability, adoption, and sustainability. These included stakeholder engagement, logistical requirements, pilot testing locations, ethical considerations, timing and frequency of tool administration, language and cultural appropriateness, data management, confidentiality, dissemination strategies, and mechanisms for routine data collection and analysis. Gallery Walk To further refine the proposed delivery methods for the maternity-specific feedback tool, a gallery walk was conducted. Draft versions of the five delivery formats were displayed around the room, allowing participants to freely circulate, review, and provide feedback through informal dialogue and written comments. This technique encouraged active engagement and critical reflection in a non-hierarchical setting, ensuring that all participants, regardless of role or status, could contribute their perspectives ( 16 ). All groups rotated through each station, reviewing the delivery options and offering feedback on feasibility, appropriateness, and potential implementation challenges. This participatory process enabled stakeholders to build on each other’s ideas and fostered a sense of collective ownership. Following the gallery walk, each group reconvened to present their reflections and recommendations, consolidating feedback into actionable suggestions. Selection of Tool Delivery Mode After the group presentations, participants were invited to vote on the delivery method(s) they considered most suitable for the Malawian context. This decision was informed by both the content to be included in the tool and the broader contextual and systemic factors discussed throughout the workshop. Each participant was given a sticky note and was asked to record their preferred delivery format(s), which they then placed on a flip chart displaying the five proposed delivery formats: paper-based, electronic, mobile application, audio (ACASI), and a combined approach. A total of 46 participants engaged in the voting process, submitting a total of 51 votes, as some stakeholders selected more than one delivery method. In addition to selecting a preferred format, participants were encouraged to provide input on language preferences for the tool, ensuring that communication would be accessible and culturally appropriate across different user groups. Data Analysis All data generated during the co-design process, including audio transcripts, written notes, visual materials (flip charts and sticky notes), and facilitator observations, were collected and organized for analysis. The research team began by immersing itself in the data to gain a comprehensive understanding of the content and context. Thematic coding was then applied to identify recurring patterns, concepts, and issues across the various participatory methods employed. Related codes were grouped to form overarching themes, capturing both the substantive content and process dimensions of the discussions. Visual artefacts from the gallery walk exercise were analyzed using content analysis to uncover recurring symbols, comments, or messages. These findings were triangulated with verbal data from group discussions and World Café sessions to deepen interpretive insights and validate emergent themes. This multi-method integration enabled a nuanced analysis that reflects the diverse perspectives and experiences of participants. Throughout the analytical process, special attention was paid to group interactions and power dynamics that may have influenced the data, ensuring that less dominant voices were not overlooked. Participant quotations and observations were incorporated to preserve authenticity and ground findings in the lived realities of stakeholders. The study team’s positionality actively influenced coding choices in notable ways. Deep embeddedness in the health research community functioned as both a strength and a potential source of bias, necessitating continuous reflexive practice. One reflexive step involved noting divergent interpretations during coding sessions. This process provided a platform to acknowledge and address subjective biases, thereby enhancing the rigor of grounded theory. The final themes captured areas of consensus, divergence, and innovation, directly informing subsequent refinements to the feedback tool. The analysis process was iterative and spanned approximately two months, from July to September 2024. The findings were contextualized within the existing literature and relevant theoretical frameworks to enhance their credibility and relevance for future applications. Prototyping Following the finalization of the tool’s content, the study team collaborated with a designer from the Malawi Liverpool Wellcome Programme Data Department to develop visual and functional prototypes for the selected delivery methods. This phase involved an iterative, user-centered design process, in which preliminary versions of the tool were created and then shared with stakeholders for structured review and feedback. Stakeholders were invited to assess both the design and content of the prototypes, offering input on usability, clarity, and contextual appropriateness. Feedback was systematically collected and relayed to the designer to guide revisions, ensuring that the tool evolved in alignment with user needs, the health system, and contextual realities. Two structured rounds of stakeholder feedback were conducted over three months, from September to November 2024. Each round allowed for the refinement and progressive validation of the prototypes, with specific attention paid to functionality, design coherence, and ease of use. This iterative process strengthened the tool’s relevance, enhanced its usability in real-world settings, and increased its acceptability among intended users. Ultimately, the prototyping phase ensured that the final tool was both fit for purpose and grounded in the lived experiences of its end users. Validation Workshop A one-and-a-half-day validation workshop was conducted on February 4–5, 2025, in Mangochi District, Malawi, with the participation of 39 stakeholders. The purpose of the workshop was to collaboratively review and validate the contents and delivery methods of the maternity-specific feedback tool developed during the co-design session. To ensure a balance between continuity and fresh perspectives, approximately half of the participants had also participated in the earlier co-design workshop, while the remaining half were newly engaged stakeholders. This approach preserved the contextual understanding and design rationale of the original contributors while introducing independent, unbiased feedback and fresh insights from new participants. The diverse composition enhanced the credibility, inclusiveness, and overall robustness of the validation process. The workshop began with a presentation summarizing the tool’s content and delivery formats, with a recap of the co-design process (see Additional File 5). This helped orient participants, establish a shared understanding of previous decisions, and clarify the objectives of the validation meeting. Participants were then divided into six groups to assess the tool’s content, language, and delivery modalities for contextual relevance, usability, and appropriateness. Most groups were composed of stakeholders with mixed professional backgrounds, while Group 6 was intentionally formed with community women to gather direct user feedback. Groups engaged in hands-on use of both the paper-based and electronic formats of the tool, assessing usability, practicality, and appropriateness from an end-user perspective. Group discussions Each group was tasked with reviewing each section of the feedback tool across both delivery modalities and in the two languages provided. Discussions focused on assessing the clarity, relevance, and appropriateness of the content and language, following the questionnaire guide (see Additional File 6) to facilitate the conversation and prompt discussion points. Participants were encouraged to suggest any necessary adjustments and describe the rationale for their recommended changes. Group discussions were audio-recorded, with informed consent obtained from all participants prior to the recording. These recordings were later transcribed for analysis to capture decision-making processes, points of consensus and divergence, and participants’ reasoning. Gallery walks Following the group discussions, a gallery walk exercise was conducted. Each group reviewed and responded to suggestions made by other groups, either agreeing or disagreeing and providing justifications for their positions. Groups rotated through all stations, reviewed each tool version, and proposed modifications, ultimately presenting their reflections and final recommendations to the larger group. Data Analysis After the workshop, the study team synthesized the data collected from group discussions, gallery walk feedback, and facilitator observations. A thematic analysis was conducted to identify recurring suggestions, areas of disagreement, and innovative ideas. These insights directly informed the subsequent revisions of the feedback tool. The analysis and tool refinement process were completed over one month in February 2025. Stakeholder Engagement and Iterative Tool Refinement During March and April 2025, the study team, in collaboration with the designer, conducted two structured rounds of follow-up engagement with all stakeholders who participated in the validation workshop. These sessions focused on reviewing the revised content and design of the maternity-specific feedback tool. Based on the feedback received, the tool was finalized and prepared for pilot testing in May 2025. The results of this pilot phase will be presented in a separate publication. Ethical approval Ethical approval for this study was obtained from the Kamuzu University of Health Sciences Research Ethics Committee (P.07/23-0167) and the University of Liverpool Ethics Committee (UoL13920). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and relevant institutional guidelines. Participation in this study was entirely voluntary, with written informed consent (see Additional file 7) obtained from all stakeholders. Anonymity and confidentiality were maintained throughout the process by ensuring that all data collected was non-identifiable. Results Distribution of participants A total of 58 stakeholders were invited to the co-design workshop, and 53 to the validation workshop. Of these, 83% (n = 48) attended the co-design workshop, and 74% (n = 39) participated in the validation workshop (see Additional file 1). Among the co-design workshop participants, 96% (n = 46) actively engaged in all group discussions and interactive rotations (see Additional file 4). Similarly, 95% (n = 37) of the validation workshop participants participated in all group activities (see Additional file 5). The median number of stakeholders per group was eight for the co-design workshop and six for the validation workshop (see Additional files 4 and 5). Participants represented a broad range of stakeholder categories, including officials from the Ministry of Health and various government departments, training institutions, professional associations and organizations, community and patient representatives, clinical service providers, local non-governmental organisations (NGOs), organizations representing people with disabilities, key donors and international partners, and research institutions (see Additional file 1). Co-design Workshop Phase One: Group Discussion During the first phase of the co-design workshop, all six groups focused on identifying key indicators for inclusion in a maternity-specific feedback tool. Discussions were structured to capture client feedback across the entire continuum of maternal care, covering general health system issues, antenatal care, labour and delivery, and the postnatal period. Each group documented their outputs using sticky notes and flip charts, which facilitated collaborative brainstorming and visual organisation of ideas. These materials enabled participants to cluster related themes and build consensus around core content elements to be included in the tool (see Figure 2). Common themes consistently emerged across all six groups and were subsequently synthesised into key components reflecting recognised domains of maternity care quality. These components included: Respectful and dignified care; Effective communication and information sharing; Emotional support and companionship; Accessibility and timeliness of services; Continuity and coordination of care; Provision of care and services received; and Overall client satisfaction (see Table 1 for a summary of these domains and associated indicators). In selecting these indicators, we prioritized feasibility and psychometrics to ensure content validity. The decision to include 27 antenatal, 28 labor and delivery, and 32 postnatal indicators was based on their comprehensive coverage of critical aspects of each care phase while balancing the practicality of implementation. These numbers reflect an optimal trade-off between depth of insight and manageability for health workers. Within the domain of respectful and dignified care, participants emphasized the importance of assessing client experiences related to privacy, informed consent, respectful treatment by healthcare workers, provider attitudes, and the inclusiveness of care for persons with disabilities. The presence or absence of a chosen companion during care was also highlighted as a key indicator. For effective communication and information sharing, suggested indicators included the quality of provider-client rapport, clarity and relevance of information shared, and the type of health education delivered at each stage of the maternity care continuum. In the domain of emotional support and companionship, stakeholders recommended incorporating questions about the presence of a companion during care and the availability of follow-up emotional or psychosocial support, especially in contexts involving loss or high-risk experiences. Regarding accessibility and timeliness, feedback centred on waiting times between services, the number and timeliness of antenatal contacts, and the physical environment of the health facility, including cleanliness, infrastructure condition, and comfort within facilities. Within continuity and coordination of care, participants highlighted the need to assess follow-up services, availability and function of bereavement care (where applicable), the presence and visibility of the ombudsman or complaints office, and consistency in obtaining informed consent throughout care. In the provision of care and services category, participants recommended evaluating the range and quality of services received across antenatal, intrapartum, and postnatal care. They also proposed indicators on whether any informal payments were requested, and how clients perceived the quality of the services provided. Lastly, for client satisfaction, participants recommended that the tool should capture both overall satisfaction levels and more detailed reflections on specific aspects of care. This would enable facilities and policymakers to identify areas of excellence and those that require targeted improvement. A comprehensive summary of the proposed tool content, mapped across the maternity care continuum, is provided in Additional file 8. Table 1. Summary of indicators to include in the Maternity-specific Feedback Tool Component Feedback Elements 1. Respectful and Dignified Care · Respect and rights (RMC) · Privacy and confidentiality · Informed consent · HCW attitude · Disability-friendly services · Bereavement care (if applicable) · Companionship 2. Effective Communication and Information · Establishing a rapport · Communication · Health education · Information giving 3. Emotional Support and Companionship · Companionship · Follow-up care (as emotional support) 4. Accessibility and Timeliness of Care · Waiting time · Number of visits · Sanitation and environment · Disability-friendly services 5. Continuity and Coordination of Care · Follow-up care · Bereavement care (if applicable) · Ombudsman office · Consent 6. Provision of Care and Services Received · Services received · Areas of care · Payment 7. Client Satisfaction · Satisfaction · Areas of improvement Participants also contributed insights on the most appropriate level of the health system (primary, secondary, or tertiary) at which each feedback indicator would be most applicable (see Figure 2). This mapping exercise enhanced alignment between participant-generated feedback and established maternal health quality frameworks, reinforcing the contextual relevance and coherence of the tool’s design. While most indicators were considered applicable across all levels of care, some issues were identified as level-specific. For instance, referral pathways, the availability of specialist care, and surgical interventions, such as caesarean sections, were deemed more relevant for assessment at secondary and tertiary facilities (Figure 2). This differentiation ensured that the feedback tool would remain adaptable and meaningful across varying facility contexts. World Café During the World Café session (see Figure 3), participants engaged in two rounds of focused dialogue, with each discussion table addressing a specific aspect of the feedback tool’s structure and content. The key thematic areas included clarity and simplicity of language, relevance of questions to women’s lived experiences, and comprehensiveness of the proposed feedback domains. Participants offered concrete, user-centred suggestions to enhance the tool’s usability, cultural appropriateness, and ability to elicit meaningful responses. All contributions were carefully documented and later analysed. These insights directly informed subsequent revisions to the tool, contributing to a more refined, accessible, and contextually grounded feedback instrument. Phase Two: Group discussion During the co-design workshop, Groups 1-5 were each assigned one of five delivery methods for the maternity-specific feedback tool (paper-based, electronic, mobile application, audio-based (ACASI), and combined approaches). Discussions highlighted the distinct strengths, limitations, and feasibility of each method across healthcare settings in Malawi. A summary of the group discussions is presented in Additional File 8. Group 1: Paper-based tools Paper-based tools were considered cost-effective, easy to use, and well-suited for environments with limited digital infrastructure. They do not require internet connectivity and support structured data collection that can minimise omissions. Participants noted that these tools are feasible for basic feedback mechanisms, such as suggestion boxes and exit interviews, but require substantial investment in human and material resources, supervision, and storage when implemented at scale or in more complex formats (e.g., community scorecards or verbal autopsies). Challenges included the need for secure physical storage, vulnerability to data loss during disasters, and manual data management, which can delay analysis and compromise accuracy. Implementing these tools is feasible across all levels of healthcare and is usually overseen by hospital ombudsmen or human resources officers, taking around 30 minutes to complete. Group 2: Electronic Tools Electronic tools were found to streamline data collection through efficient storage, rapid access to information, and minimal spatial requirements. Their feasibility was considered high with moderate resource input. Limitations included the exclusion of illiterate clients, high maintenance and operational costs, risks of equipment theft, and the need for trained personnel. Electronic feedback mechanisms are suitable for all facility levels and can be self-administered, preferably under the guidance of a neutral party such as an ombudsman. Group 3: Mobile applications Mobile platforms, including SMS, WhatsApp, Facebook, voice calls, and CommCare, were valued for their flexibility, portability, and real-time data access. Their self-administration potential and short feedback duration (10–15 minutes) were also seen as advantages. However, challenges include network instability, high data costs, and limited interaction (e.g., lack of real-time clarification or probing). Moreover, some platforms, like CommCare, are not entirely self-administered and require staff support. Group 4: Audio Tools (ACASI) ACASI tools were highlighted for their suitability for clients with visual impairments and for ensuring standardised delivery across sites. They reduce printing costs and improve data accuracy through automated input. Despite their potential, these tools are resource-intensive, requiring technical infrastructure, trained staff, and financial support. Limitations include inaccessibility to clients with hearing impairments, limited flexibility for probing questions, and reliance on stable power sources. Implementation across all levels of care is possible, with tools typically requiring 15–20 minutes to complete. Group 5: Combined Approaches The combined approach integrates paper, electronic, mobile, and audio tools to enhance system resilience and data reliability, ensuring continuity and accommodating variations in infrastructure. It offers flexibility and inclusivity, especially in contexts with intermittent electricity or diverse user needs. However, the approach demands significant logistical coordination, financial investment, and training. Preparatory steps would require planning for community sensitization, tool integration with existing systems (e.g., DHIS2), and health worker capacity building. Feasibility was considered moderate to high, contingent on facility context, and administration would typically be managed by personnel from the Ombudsman’s office. The tool duration may range from 10 to 20 minutes. Group 6: Comparative evaluation by experts The technical experts in Group 6 critically assessed all five tool types and contributed additional practical recommendations (see Additional file 8). Paper-based forms were valued for simplicity and broad familiarity among most health personnel, as well as the ease of producing translated or disability-friendly versions (e.g., Braille). However, scalability, manual data handling, and potential timeliness of data analysis were noted as limitations. Electronic tools offer real-time integration with existing platforms, such as HMIS, and facilitate efficient analysis. However, they face barriers including internet connectivity issues, power supply limitations, cybersecurity concerns, and the need for technical expertise. Mobile applications improve flexibility and portability, but digital literacy and data privacy concerns must be addressed. Audio tools (ACASI) mitigate literacy barriers, but require technical support, stable electricity, and carry similar cost burdens. The combined approach was acknowledged for its resilience, but was described as resource-intensive, inheriting the implementation challenges of each format. Cross-cutting themes and practical implementation considerations Several cross-cutting themes and practical implementation considerations emerged across all stakeholder groups as essential to the successful rollout and integration of the maternity feedback tool within Malawi’s health system. These include the need for robust community awareness and client sensitisation, sustained stakeholder engagement, targeted capacity building for implementers, and comprehensive sustainability planning, including resource mobilisation. Key enablers for implementation identified across all tool types include translation into local languages, assurance of confidentiality and data protection, fostering client and community acceptance, and securing sufficient logistical and financial support for piloting and scale-up across diverse regions. Building on this, Group 6 provided specific, actionable recommendations to guide effective implementation. These include upholding privacy, confidentiality, and informed consent throughout data collection; ensuring representative sampling by conducting interviews across weekdays, weekends, and public holidays; and selecting pilot districts based on resource availability, facility workload, and regional diversity. Group 6 further recommended assigning dedicated, trained data collectors to minimise disruption to routine care, translating the tool into all widely spoken local languages, and implementing secure data management protocols, such as storing data in locked cabinets within restricted-access areas. To build trust and ensure ethical compliance, clients and stakeholders must be reassured that their information will be handled with the highest standards of privacy and integrity. Finally, convening a dissemination meeting to share pilot findings and planning for potential adaptation of the tool for use in community-based and outreach settings was identified as a key strategy for supporting future scale-up. Detailed insights from Group 6 are provided in Additional File 8. Prototyping, Gallery Walk, and Selection of Tool delivery mode Following three months of collaboration with the tool designer and two structured rounds of stakeholder feedback, the content of the maternity feedback tool was finalised and compiled into a paper-based format. The tool was systematically organised into three distinct modules, each addressing a specific stage of the maternity care continuum: antenatal care, labour and delivery, and postnatal care. This modular structure was designed to support focused, context-specific, and comprehensive data collection that aligns with each phase of the maternal health service delivery. To support further refinement and stakeholder consensus, a gallery exercise was conducted. This interactive process allowed all participant groups to rotate through stations where the components of the feedback tool were visually presented and analysed. Participants engaged with each tool module, reviewed the findings from other groups, and contributed additional suggestions (see Table 2). The exercise fostered deeper reflection, encouraged collaborative input, and served as a preparatory step for the subsequent voting process on preferred delivery modalities. Following the gallery walk and group presentations, stakeholders participated in a voting exercise to select the most appropriate feedback tool modality for pilot implementation (Figure 4). A total of 51 votes were cast, yielding the results shown in Table 3. While the electronic tool received the highest number of individual votes, participants reached a consensus to pilot both the paper-based and electronic modalities. The paper-based tool was selected for its accessibility and ease of use across all levels of the health system, particularly in low-resource settings. The electronic version was favoured for its potential to facilitate real-time data collection, analysis, and management. This dual-modality approach was endorsed as a practical and inclusive strategy for the pilot phase, ensuring both feasibility and future scalability of the feedback system. The maternity feedback tool was finalised into three modular forms: antenatal, labour and delivery, and postnatal care, each designed to capture clients’ experiences across the continuum of care. Each form collected facility-level information and included 24–25 questions covering reception, rapport-building, service provision, communication quality, respectful care, informal payments, disability inclusion, and overall satisfaction. The antenatal form focused on services received during clinic visits; the labour form addressed delivery processes and immediate postpartum care; and the postnatal form assessed care provided to both mother and newborn at 48 hours, 7 days, and 6 weeks. All forms were developed in English and translated into Chichewa and were prepared in both paper-based and electronic formats for validation. Validation Workshop During the validation workshop, participants reviewed the maternity feedback tool in both paper-based and electronic formats, assessing clarity, language, design, and usability. Through group discussions and a gallery walk exercise (Figure 5), they evaluated each section (antenatal, labour and delivery, and postnatal care), providing consensus-based recommendations for refinement. Key revisions included simplifying medical language, expanding demographic details (e.g., age, education, disability), and rephrasing questions on respectful care, communication, satisfaction, and payments. Additional updates addressed labour-specific content (e.g., vaginal exams, delivery provider), postnatal needs (e.g., infant loss support, HIV exposure, kangaroo care), and accessibility considerations. A summary of the modifications is provided in Table 2, with more detailed modifications summarised in Additional File 9. Feedback from all five groups is summarized in Additional 10. Stakeholders’ engagement and iterative tool refinement The tool underwent adjustments based on recommendations provided during the validation workshop, where the study team and designer implemented changes and conducted two structured rounds of feedback with all stakeholders who participated in the validation meeting over two months. The final antenatal form had 27 indicators, 28 for labour and delivery, and 32 for the postnatal form (Table 2). The tool is now ready for piloting, and sample outputs for the forms are shown in Figure 6 below. The forms are available in both paper-based and electronic versions, which will be administered as a survey during the piloting phase. Table 2. Summary of maternity feedback tool structure, content, and revisions Module Number of questions Focus areas Key features Key revisions from Validation workshop (Group Discussions & Gallery Walk) Antenatal Care (ANC) Feedback Form 24 questions - Facility details (name, level, ownership, SLA status, location) - Client reception and orientation - Services received (history, exam, labs, drugs/vaccines, health education) - Waiting times and respectful care - Mistreatment or abuse - Communication and provider interaction - Informal payments - Expectation fulfilment, disability inclusiveness, accessibility challenges, and satisfaction - Focused on both initial and follow-up ANC visits - Emphasis on respectful maternity care, service quality, and access barriers - Rephrased form title and simplified medical terms - Expanded demographic section (age, education, disability) - Reworded questions on rapport, abuse, communication, expectations, and satisfaction - Disability items repositioned - Added prompt for explanation of payments Labour & Delivery Feedback Form 24 questions - Facility and reception details - Orientation to the labour ward - Delivery process and procedures - Informed consent and provider identity - Services for mother and newborn - Respectful care, mistreatment - Communication, provider interaction - Informal payments - Expectations met, disability inclusion, access issues, and overall satisfaction - Mirrors ANC structure - Additional focus on informed consent, delivery experience, and immediate newborn care - Updates mirrored ANC form revisions - Revised questions on vaginal exams, contractions, and companionship - Added demographics on the baby’s condition - New items: time of delivery, baby’s sex - Reworded questions on payments and satisfaction Postnatal Care (PNC) Feedback Form 25 questions - Facility and ward orientation - Services within PNC timeline (48 hrs., 7 days, 6 weeks) - Maternal and newborn care received - Client involvement and information received - Waiting times, respectful care - Mistreatment, communication quality - Informal payments, accessibility - Expectation fulfilment, disability inclusion, satisfaction, and improvement suggestions - Tracks care across the WHO-recommended postnatal timeline - Assesses continuity of care and client engagement - Incorporated changes from ANC and labour forms - Added: date and mode of delivery, care for mother vs baby, mental health support for infant loss - New questions on nursery admission, HIV exposure, and kangaroo care - Standardized language and payment-related items Table 3. Voting exercise results Tool modality Number of votes Electronic-based tool 16 Paper-based tool 13 Mobile application 12 Audio (ACASI) tool 8 Combined approach 2 Discussion This study aimed to co-develop a maternity-specific feedback tool that is contextually grounded and reflective of stakeholder priorities by employing participatory approaches. By engaging a broad spectrum of maternity care stakeholders, including service users, healthcare providers, policymakers, and community representatives, the process ensured the inclusion of diverse perspectives, cultural sensitivity, and the prioritization of lived experience. Methods such as group discussions, gallery walks, and World Café sessions were employed to facilitate meaningful dialogue, collective reflection, and the co-construction of quality indicators aligned with people-centered care and the WHO framework for quality maternal and newborn health services (16, 23). This discussion highlights two key dimensions of the study: (1) the methodological strengths and challenges of participatory approaches in health tool design, and (2) the practical and policy relevance of the emergent quality indicators for strengthening maternity care. Methodological strengths and challenges of participatory approaches The participatory methods used in this study proved highly effective in generating rich, contextually relevant insights and fostering shared ownership of the final tool. The iterative, dialogic design promoted reciprocal learning between service users and providers, supporting the co-production of knowledge in a manner consistent with the principles of community-based participatory research (24,25). Group discussions facilitated the integration of multiple viewpoints, ranging from personal experiences of care to system-level constraints, resulting in a feedback tool that reflects both user priorities and operational realities. Participants noted the value of including indicators related to respectful communication, emotional support during childbirth, and decision-making autonomy, domains often underrepresented in conventional metrics. Such insights underscore the importance of grounding feedback tools in the lived experiences of users to ensure their salience and utility in driving quality improvement (26,27). Inclusivity was further enhanced by the involvement of a diverse range of stakeholders, including healthcare workers, facility managers, district health officials, researchers, representatives from disability organizations, and local community leaders. This broad participation fostered legitimacy and promoted the future acceptability and integration of the tool into routine health systems (25,28). Engaging underrepresented groups, especially community and disability stakeholders, was essential in ensuring the tool addressed equity and access dimensions often neglected in traditional tool development. The World Café approach emerged as a potent participatory method. By enabling rotating small-group conversations in a relaxed setting, it supported open dialogue, idea refinement, and the surfacing of shared priorities. Its informal structure helped reduce hierarchical barriers, creating space for all participants to contribute equitably (29,30). Similarly, the gallery walk technique promoted collaborative learning through visual and interactive engagement. It facilitated the iterative refinement of indicators and ensured clarity and consensus around their interpretation, particularly among participants who were less comfortable with verbal discussions (31,32). Notably, the participatory process itself acted as a capacity-building mechanism. Stakeholders reported increased awareness of care standards, rights, and responsibilities, suggesting that the development process may have benefits beyond the tool itself, by fostering accountability and shared understanding of quality benchmarks (22,33). Nonetheless, participatory approaches are not without challenges. Balancing diverse perspectives, particularly between users and providers, required deliberate facilitation to avoid dominance by any one group. Facilitator training was therefore integral, ensuring inclusive, respectful, and equitable engagement. Managing power asymmetries was especially critical when integrating experiential insights from users with system-level constraints described by providers and policy actors. Additionally, these methods are resource-intensive. They require significant time, logistical coordination, and skilled facilitation, factors that may hinder scalability in resource-limited settings (34,35). However, our early collaboration with the Ministry of Health, particularly through the Reproductive Health Directorate (RHD) and Quality Management Directorate (QMD), helped to navigate these constraints. Engagement with institutional actors familiar with the health system streamlined coordination and strengthened the relevance of stakeholder input. Compared to more conventional, often top-down methods such as structured interviews or surveys, our approach enabled richer interactions and reflections. Participatory methods facilitated real-time co-creation and mutual learning, elements often absent in more extractive forms of consultation (36,37). This enhanced the contextual relevance and credibility of the tool, improving its likelihood of uptake and sustained use in routine maternal care systems. Emerging themes and quality indicators The quality indicators generated through this participatory process reflect key dimensions of maternity care that are consistently highlighted in the global literature and LMIC contexts (15, 38, 39). These included respectful and dignified treatment, clear and compassionate communication, emotional support, timely and equitable access to services, continuity and coordination of care, technical quality of care, and overall client satisfaction. Such themes align closely with global evidence on what women value most during maternity care [15,38–40] and correspond with the WHO Quality of Care framework, which emphasizes both clinical effectiveness and the experience of care as integral to service quality (16). Notably, the participatory process enabled the prioritization of relational and experiential elements of care, such as autonomy, trust, and respectful interactions, that are often underrepresented in conventional performance metrics. The inclusion of these elements was facilitated by the participatory methods employed, which created a space for service users to articulate nuanced expectations and experiences. By doing so, the tool localizes global standards, thereby enhancing cultural and contextual relevance and ultimately improving its potential for acceptability and sustained use in routine care settings. Policy and practice implications These findings offer practical insights for health systems seeking to institutionalize people-centred quality improvement processes. By embedding user perspectives into the development of quality indicators, the feedback tool supports enhanced accountability, responsiveness, and continuous learning within maternity care services. Involving maternity staff in the design process further promoted buy-in and fostered a shared understanding between users and providers, contributing to trust and collaborative problem-solving. This participatory approach offers a scalable model for other LMICs advancing national maternal health and universal health coverage agendas. As countries operationalize their quality-of-care strategies, integrating such feedback mechanisms into existing health management and information systems can enhance their sustainability and effectiveness (22,41). At a policy level, the tool provides a locally validated, low-cost mechanism for routinely capturing client feedback to inform quality assurance processes. Its alignment with both national and international quality frameworks increase its potential for integration and scale. Strengths and Limitations A key strength of this study lies in its inclusive and methodologically diverse participatory design, which involved a wide range of stakeholders and drew on multiple interactive methods to generate and refine indicators. The use of group discussions, gallery walks, and World Café approaches facilitated the co-production of relevant, user-informed indicators grounded in lived experience and aligned with established quality frameworks. However, several limitations must be acknowledged. First, although the sample was diverse, it may not have fully captured the perspectives of sub-groups such as adolescents or women who experienced severe obstetric complications or adverse outcomes, potentially limiting the generalizability of some indicators. To address this in future studies, we plan to incorporate tailored sampling strategies designed to involve these hard-to-reach populations, such as outreach through community groups that support adolescents and women with complications. Additionally, we acknowledge that despite efforts to mitigate power dynamics, the presence of healthcare professionals and policymakers in mixed-group discussions may have inhibited some service users from providing critical feedback. Third, this study does not evaluate the tool’s implementation, fidelity, or long-term impact within health facilities. These are important areas for future research. Recommendations for future research and practice Based on these findings, several recommendations can guide future research and implementation. Firstly, the feedback tool should be piloted in diverse settings, including rural primary facilities, urban centers, and referral hospitals, to assess its usability, acceptability, and responsiveness. This piloting is currently underway and will be reported in a subsequent publication. Secondly, future studies should examine how the routine use of the tool influences provider behavior, patient satisfaction, and maternal health outcomes over time. Thirdly, training facility-level staff in data interpretation and the application of feedback for action planning will be essential to operationalize the tool effectively. Lastly, policymakers should consider embedding such feedback tools into national monitoring and quality assurance frameworks to institutionalize user-centered metrics in maternal health systems. Conclusion This study demonstrates the feasibility and added value of using participatory approaches to co-develop a maternity-specific feedback tool that reflects the shared priorities of service users, healthcare providers, policymakers, and community stakeholders. The resulting indicators address both technical and experiential aspects of care, providing a practical, contextually grounded mechanism for improving maternity service delivery. The co-design process itself strengthened stakeholder ownership, fostered mutual understanding, and promoted trust; elements critical for sustaining quality improvement efforts. As global health systems continue to prioritize respectful, equitable, and responsive maternity care, participatory development of feedback tools should be recognized not only as a methodological innovation but also as a strategic imperative for policy and practice. We invite policymakers and clinicians to reflect on their roles in sustaining these participatory feedback mechanisms by reflecting on their contributions to shared stewardship and ensuring the integration of feedback into ongoing improvements. This challenge is an opportunity to energize action and commitment toward these goals. Abbreviations ACASI Audio Computer-Assisted Self-Interviewing ANC Antenatal Care DHIS2 District Health Information Software HMIS Health Management Information System LMICs Low- and Middle-Income Countries NGOs Non-Governmental Organizations PSQ-18 Patient Satisfaction Questionnaire (18-item) QMD Quality Management Directorate RHD Reproductive Health Directorate. RMC:Respectful Maternity Care Declarations Ethics approval and consent to participate. Research ethics approval was sent to the College of Medicine Research Ethics Committee (P.07/23-0167) and the University of Liverpool Ethics Committee (13920). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and relevant institutional guidelines. Participation in this study was entirely voluntary, and anonymity was ensured using non-identifiable data. Written informed consent was obtained from all stakeholders. Consent for publication Participants gave written informed consent for their personal details to be published in this study. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Competing Interests The authors declare no competing interests. Funding This research was funded by the NIHR (NIHR 134781: Improving the quality of maternal healthcare in Africa), utilizing UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Authors’ Contribution ALNM, DL, and EC conceptualized the project. ALNM, MJG, and CK supervised the project. DL and ALNM acquired funding and took responsibility for the manuscript. MJG, CK, LM, AK, BM, CB, LG, LK, EC, EC, and ALNM planned the project, developed methods, and discussion guides. MJG, CK, AK, LM, CB, EC, LK, and ALNM facilitated the discussions. MJG, CK, AK, and CB transcribed the data. MJG, CK, AK, and ALNM developed the analysis plan. MJG performed formal data analysis. MJG drafted the manuscript, and YC, CK, LM, AK, BM, CB, LG, LK, EC, EC, DL, and ALNM critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. Acknowledgements We want to thank everyone involved in the co-design and validation workshop for their valuable contributions. We also thank the Ministry of Health Directorates (RHD and QMD) for their participation and coordination. Special thanks to Sonia Whyte and Nancy Medley from the University of Liverpool for helping to proofread the manuscript. References World Health Organization. Trends in maternal mortality 2000–2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]., Geneva; 2023 [cited 2025 April 29]. Available from: https//www.who.int/publications/i/item/9789240068759 Osborn D, Cutter A, Ullah F. Universal sustainable development goals. Understanding the transformational challenge for developed countries. 2015;2(1):1–25. National Statistical Office. Malawi Demographic and Health Survey 2024 Key Indicators Report. Zomba, 2024 Dec. 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Additional Declarations No competing interests reported. Supplementary Files Additionalfile1Listofinvitedstakeholders.docx Additionalfile2AgendaforCoDesignMeeting.pdf Additionalfile3Agendaforthevalidationworkshop.pdf Additionalfile4Groupcompositionofstakeholdersattendedcodesignworkshop.docx Additionalfile5Groupcompositionvalidationworkshop.docx Additionalfile6QuestionnaireguideDEVELOPINGAMATERNITYSPECIFICFEEDBACKTOOL.docx Additionalfile7InformedconsentandPILsafemotherhoodapproval.pdf Additionalfile8Summaryoftoolcontentfromallgroupsduringcodesign.docx Additionalfile9proposedchangestofeedbacktoolduringvalidatio.docx Additionalfile10Summaryoffivegroupsontypesoftool.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Dec, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviews received at journal 05 Nov, 2025 Reviews received at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 23 Oct, 2025 Editor invited by journal 02 Oct, 2025 Submission checks completed at journal 01 Oct, 2025 First submitted to journal 30 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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15:24:47","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":8322724,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile7InformedconsentandPILsafemotherhoodapproval.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7643760/v1/b171f11da6ddc3b92dde04e7.pdf"},{"id":95527022,"identity":"29e48726-76ea-4772-a692-211f85134760","added_by":"auto","created_at":"2025-11-10 10:09:08","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":35080,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile8Summaryoftoolcontentfromallgroupsduringcodesign.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643760/v1/4cfcdbf980f004b392ca07ae.docx"},{"id":95444472,"identity":"fdb723e6-bba8-4268-a6e5-637181d0713b","added_by":"auto","created_at":"2025-11-08 15:24:48","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":16933,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile9proposedchangestofeedbacktoolduringvalidatio.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643760/v1/9f8ed3fac7ab04a02ea61068.docx"},{"id":95444469,"identity":"4c58df45-a479-4975-9fb9-2d0bf67c9feb","added_by":"auto","created_at":"2025-11-08 15:24:48","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":26162,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile10Summaryoffivegroupsontypesoftool.docx","url":"https://assets-eu.researchsquare.com/files/rs-7643760/v1/818fd08e1c2a5929dc4b04ea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Measuring Women’s Experiences with Maternity Services: Development of a Feedback Tool in Malawi","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2020, there were an estimated 287,000 maternal deaths globally, with an MMR (maternal mortality ratio) of 223 per 100,000 live births (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). About 70% of these deaths happened in Sub-Saharan Africa (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). SDG 3 (Sustainable Development Goal 3) aims to lower global MMR to fewer than 70 per 100,000 by 2030, ensuring no country exceeds twice that average (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, this is unlikely without understanding the primary factors driving use and quality of maternity services. In Malawi, over 95% of pregnant women attend at least one antenatal care (ANC) visit and deliver in a facility (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite this, Malawi\u0026rsquo;s MMR remains high at 381 per 100,000 live births, suggesting that quality, rather than access, is the key issue (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSatisfaction with maternity services plays a critical role in shaping women\u0026rsquo;s health-seeking behaviors and their continued utilization of antenatal and other maternal health services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In Malawi, a study exploring women\u0026rsquo;s perspectives on quality of maternal healthcare revealed high levels of satisfaction with prenatal services, but widespread dissatisfaction with the care provided during the intrapartum and postpartum periods (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Disrespect and abuse during childbirth are well-documented across many low- and middle-income countries (LMICs), contributing significantly to negative maternity experiences (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWomen\u0026rsquo;s satisfaction is therefore a crucial concern for healthcare providers, administrators, and policymakers aiming to improve the quality of care (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, assessing satisfaction requires the use of reliable and valid tools (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Several instruments specific to maternity care have been developed, including the Patient Perception Score, the Pregnancy and Maternity Care Patients\u0026rsquo; Experiences Questionnaire, the Childbirth Experience Questionnaire, the Childbirth Perception Scale, and the Maternal Satisfaction Scale for Caesarean Section (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). More general tools, such as the Patient Satisfaction Questionnaire (PSQ-III) and its short form (PSQ-18), are also commonly used (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). While these general tools are available in LMICs, their psychometric properties are limited, highlighting the need for further development that incorporates qualitative input (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Client satisfaction data are most often gathered through in-person interviews (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, to ensure meaningful quality improvement, countries must invest in developing context-specific, valid, and reliable instruments that reflect the priorities and experiences of the populations they serve.\u003c/p\u003e\u003cp\u003eAlthough user satisfaction is a key indicator of maternal health service quality, Malawi has limited data directly sourced from service users. Recognizing this gap, the Ministry of Health, through the Quality Management Directorate (QMD), has prioritized collecting user feedback and recently introduced standardized feedback assessment tools for use during client visits. However, these tools are general and not tailored to maternity services, currently constrained to face-to-face interviews with a limited scope of content. Developing maternity-specific feedback tools would offer more nuanced insights into the quality of maternal care, an area often perceived by users as inadequate. Importantly, such tools would also facilitate the systemic inclusion of service users\u0026rsquo; voices in quality improvement initiatives.\u003c/p\u003e\u003cp\u003e To address these gaps and contribute to the improvement of maternal health services, this paper aims to outline the development of a user feedback tool tailored specifically for maternity care. The following sections describe how the tool was designed to systematically monitor and improve the quality of maternal health services in Malawi, with a focus on its intended use by maternity service providers and healthcare quality evaluators.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003e This study employed a consensus-based, participatory approach to develop a contextually appropriate feedback tool for maternity services. This approach involves interactions with a group to collaborate and harness the knowledge of stakeholders (people who are affected by or involved in maternity care) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The methodology incorporated collaborative techniques, including gallery walks (sessions where participants review posted materials and give feedback as they walk around) and the World Café method (small, rotating group discussions to encourage sharing a broad range of perspectives), to ensure that the resulting tool reflected the priorities and lived experiences of both service users and healthcare providers. Two consensus workshops were conducted, engaging experts and key stakeholders in maternal and child health services in Malawi. The first workshop, focused on co-design, was held over one and a half days from July 2–3, 2024, in Dowa District, located in Malawi’s Central Region. The second workshop, aimed at validating the tool, took place over a similar duration from February 4 to 5, 2025, in Mangochi District, situated in the Southern Region. Both venues were strategically chosen to minimize external distractions and maintain active participant engagement.\u003c/p\u003e\u003cp\u003eThe use of consensus workshops, gallery walks, and the World Café method was particularly valuable in this context, as these approaches promote inclusive and participatory decision-making while integrating diverse stakeholder perspectives.\u003c/p\u003e\u003cp\u003eConsensus workshops provide a structured space for interaction among service users, healthcare providers, and policymakers, facilitating the co-creation of feedback tools that are both contextually relevant and widely acceptable (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Gallery walks, in which participants engage with visual displays of draft materials and provide feedback, encourage reflective input and help reduce hierarchical power imbalances often present in group discussions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The World Café method further supports inclusive dialogue through informal, small-group discussions that rotate participants across topics, ensuring a wide range of voices are heard, including those of traditionally marginalized or less vocal individuals (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In the context of maternity care, where patient-provider relationships, cultural sensitivity, and service delivery quality are central, these participatory techniques ensure that the resulting tools are grounded in lived experiences and professional knowledge. This improves their usability, relevance, and potential impact on maternal healthcare quality improvement efforts (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSelection of participants\u003c/h3\u003e\n\u003cp\u003e A purposive sampling approach was employed to recruit experts and stakeholders involved in maternal and child health services for participation in the consensus-building processes. Participants were drawn from a diverse range of institutions, including the Ministry of Health (MoH) and its implementing partners, international donor organizations, national and international non-governmental organizations (NGOs), research and training institutions, regulatory bodies, professional associations, maternal health service providers, service users, and community representatives. A total of 58 individuals were invited to the co-design workshop and 53 to the validation workshop (see Additional file 1). Engaging such a broad spectrum of stakeholders ensured that the feedback tool was contextually appropriate, functional, and broadly endorsed. This participatory approach strengthens the tool’s credibility, usability, and potential for successful adoption within Malawi’s health systems (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn initial planning meeting was held with the Reproductive Health Directorate (RHD) and the Quality Management Directorate (QMD) of the MoH to minimize selection bias and ensure broad stakeholder participation. During this meeting, the research team, with support from the RHD and QMD, mapped ongoing maternal health programs and identified relevant partner organizations to target. In addition to purposive sampling, a snowball technique was employed to capture other key stakeholders active in maternal and child health initiatives. Some participants were also identified through previous collaboration with the research team. This multi-pronged strategy ensured the inclusion of key actors involved in policy development and program implementation across national, district, and primary healthcare levels.\u003c/p\u003e\u003cp\u003eRather than limiting participation to a small group of decision-makers, the process aimed to ensure inclusivity and transparency, enabling diverse perspectives to inform tool development. Considerable time was invested in the preparatory phase, which included consultations with RHD and QMD to identify stakeholders, gather relevant materials (e.g., draft satisfaction tools and visual designs), and develop a detailed workshop agenda (see Additional files 2 and 3). These preparatory steps helped to build a shared understanding of the project’s objectives and laid a strong foundation for collaborative decision-making. Additional preparations included selecting appropriate workshop materials and training facilitators. To ensure grassroots perspectives were captured, invitations were extended to community members, local organizations, and patient representatives. Stakeholders were initially contacted via email with an explanation of the meeting’s objectives and participant expectations; follow-up emails were sent if no response was received within ten working days.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eTraining of facilitators\u003c/h2\u003e\u003cp\u003eFacilitator training was conducted before both consensus workshops to ensure the effective delivery of participatory methods. Two training sessions were held in preparation for the co-design workshop, and one session was conducted ahead of the validation workshop. A total of seven facilitators (MJG, CK, AK, CB, NC, LK, and EC) were trained by an expert on how to effectively facilitate group discussions and implement participatory techniques, including gallery walks and the World Café method. The training focused on promoting inclusive engagement, managing group dynamics, and ensuring that all voices, particularly those of service users and community representatives, were meaningfully included in the consensus process.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCo-design workshop\u003c/h3\u003e\n\u003cp\u003eA one-and-a-half-day co-design workshop was held on July 2–3, 2024, in Dowa district, Malawi, with the participation of 48 stakeholders (see Additional file 1). The objective of the workshop was to engage participants in structured, collaborative, and constructive dialogue to determine the key informational content areas for inclusion in a maternity-specific feedback tool and to identify the most appropriate tool formats for implementation.\u003c/p\u003e\u003cp\u003eThe workshop commenced with a series of presentations, as outlined in the agenda (see Additional File 2), which laid the groundwork for subsequent discussions. These presentations highlighted the importance of feedback mechanisms within the broader context of maternity care and quality improvement. Topics included the design and application of maternity-specific satisfaction tools, their contextual relevance, and insights from general patient satisfaction experiences at a Malawian hospital. Collectively, the sessions underscored the need for a dedicated maternity feedback tool and informed key considerations for its development.\u003c/p\u003e\u003cp\u003eFollowing the presentations, participants were divided into small groups to discuss the types of information that should be captured in a maternity-specific feedback tool, as well as the preferred format for the tool. The workshop employed interactive participatory methods, including World Café discussions and gallery walks, to facilitate the exchange of ideas and consensus-building. Group outputs were consolidated to inform the next steps in the development of the tool. A visual summary of the co-design process is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eFacilitators audio-recorded all group discussions after obtaining prior informed consent from participants. These recordings were later transcribed and analyzed to document the decision-making processes, identify consensus and areas of divergence, and capture participants’ perspectives and underlying rationale.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipant Grouping and Facilitated Structured Discussions\u003c/h2\u003e\u003cp\u003eParticipants were purposely allocated into six diverse groups, each comprising an average of seven stakeholders, to ensure a broad representation of perspectives during the co-design workshop. The structured, facilitator-led discussion focused on identifying key elements of the maternity-specific feedback tool and determining appropriate methodologies for its administration. The group composition was intentionally diverse, comprising a variety of stakeholders, including healthcare providers, facility managers, policy-level representatives, district officers, data managers, and community representatives, such as women and individuals with disabilities (see Additional file 4).\u003c/p\u003e\u003cp\u003eThis inclusive approach to group formation was intended to ensure that the feedback tool would be relevant, equitable, and feasible for implementation across different levels of the health system. Bringing together individuals with diverse expertise and lived experiences enabled the integration of multiple viewpoints, fostering a holistic understanding of user needs and service delivery realities. Such diversity not only enhanced the quality and practicality of the tool’s design but also fostered shared ownership among stakeholders, critical for successful implementation and long-term sustainability. A detailed summary of group composition is provided in Additional File 4.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePhase one: Group discussion\u003c/h3\u003e\n\u003cp\u003eIn the first phase of group discussion, all six groups focused on identifying the key types of information or indicators to be included in the maternity-specific feedback tool. Discussions were structured to address the entire continuum of care across general service quality, antenatal care, labour and delivery, and the postnatal period. In addition to identifying relevant indicators, participants were asked to determine the most appropriate level of the health system (primary, secondary, or tertiary) at which each type of information should be collected or applied.\u003c/p\u003e\u003cp\u003eTo support interactive and organized engagement, each group used adhesive sticky notes to record their suggested indicators, which were then displayed on flip charts. This method enabled participants to organize their ideas visually, facilitated collaborative prioritization, and allowed for cross-group sharing during plenary sessions. The visual format also supported transparency and traceability of the discussions, laying a foundation for consensus in subsequent phases.\u003c/p\u003e\n\u003ch3\u003eWorld Café Sessions\u003c/h3\u003e\n\u003cp\u003eFollowing the initial group discussions on the content of the maternity-specific feedback tool and the appropriate levels of health system delivery, a World Café was employed to support further the participatory development and iterative refinement of the tool. This approach facilitated structured, small-group dialogue among a diverse mix of stakeholders as described in Additional file 4.\u003c/p\u003e\u003cp\u003eTwo rounds of 15-minute table discussions were conducted, with participants rotating between tables after each round. This rotation encouraged the cross-pollination of ideas and exposed participants to a broader range of perspectives. Each table was facilitated by a trained moderator who guided the discussions and summarized key points on flipcharts. Additionally, designated recorders captured verbatim comments to ensure a detailed and accurate account of stakeholder input.\u003c/p\u003e\u003cp\u003eFollowing the World Café sessions, each group reconvened and presented its consolidated perspectives on what it considered to be the most appropriate content for inclusion in the maternity feedback tool. This collaborative and iterative approach helped to ensure that the tool reflected both consensus and diversity in stakeholder priorities.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePhase two: Group discussions on delivery methods\u003c/h2\u003e\u003cp\u003eIn the second phase of the group discussions, the first five groups (see Additional File 4) explored various modes of delivering the maternity-specific feedback tool, building on the insights gained in Phase 1. Each group was assigned a specific delivery format for in-depth examination: Group 1 focused on a paper-based version, Group 2 discussed an electronic-based version, Group 3 explored a mobile application, Group 4 examined an audio tool using Audio Computer-Assisted Self-Interviewing (ACASI), and Group 5 assessed the feasibility of a combined or hybrid approach.\u003c/p\u003e\u003cp\u003e.\u003c/p\u003e\u003cp\u003eEach group discussed several key considerations, including the appropriate length of the tool, potential advantages and disadvantages of the proposed format, adaptability across different facility levels, and the overall feasibility in terms of required resources, time requirements, and ease of administration. Flip charts were used to visually organize and display group inputs, while voice recorders captured the full discussions for later analysis and review.\u003c/p\u003e\u003cp\u003eGroup 6, composed of stakeholders with expertise in tool development, was tasked with conducting a critical evaluation of all five potential delivery methods. Their assessment focused on identifying the facilitators, barriers, and technical design requirements for each method. The inclusion of this expert group was instrumental in ensuring that the selected tool delivery approach would be contextually appropriate, user-friendly, and compatible with clinical practice. In addition to evaluating delivery formats, Group 6 also considered broader implementation issues (local workflows, resource availability, and staff capacity, enhancing its usability, adoption, and sustainability. These included stakeholder engagement, logistical requirements, pilot testing locations, ethical considerations, timing and frequency of tool administration, language and cultural appropriateness, data management, confidentiality, dissemination strategies, and mechanisms for routine data collection and analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eGallery Walk\u003c/h2\u003e\u003cp\u003eTo further refine the proposed delivery methods for the maternity-specific feedback tool, a gallery walk was conducted. Draft versions of the five delivery formats were displayed around the room, allowing participants to freely circulate, review, and provide feedback through informal dialogue and written comments. This technique encouraged active engagement and critical reflection in a non-hierarchical setting, ensuring that all participants, regardless of role or status, could contribute their perspectives (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). All groups rotated through each station, reviewing the delivery options and offering feedback on feasibility, appropriateness, and potential implementation challenges. This participatory process enabled stakeholders to build on each other’s ideas and fostered a sense of collective ownership. Following the gallery walk, each group reconvened to present their reflections and recommendations, consolidating feedback into actionable suggestions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSelection of Tool Delivery Mode\u003c/h2\u003e\u003cp\u003eAfter the group presentations, participants were invited to vote on the delivery method(s) they considered most suitable for the Malawian context. This decision was informed by both the content to be included in the tool and the broader contextual and systemic factors discussed throughout the workshop. Each participant was given a sticky note and was asked to record their preferred delivery format(s), which they then placed on a flip chart displaying the five proposed delivery formats: paper-based, electronic, mobile application, audio (ACASI), and a combined approach.\u003c/p\u003e\u003cp\u003eA total of 46 participants engaged in the voting process, submitting a total of 51 votes, as some stakeholders selected more than one delivery method. In addition to selecting a preferred format, participants were encouraged to provide input on language preferences for the tool, ensuring that communication would be accessible and culturally appropriate across different user groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAll data generated during the co-design process, including audio transcripts, written notes, visual materials (flip charts and sticky notes), and facilitator observations, were collected and organized for analysis. The research team began by immersing itself in the data to gain a comprehensive understanding of the content and context. Thematic coding was then applied to identify recurring patterns, concepts, and issues across the various participatory methods employed. Related codes were grouped to form overarching themes, capturing both the substantive content and process dimensions of the discussions.\u003c/p\u003e\u003cp\u003eVisual artefacts from the gallery walk exercise were analyzed using content analysis to uncover recurring symbols, comments, or messages. These findings were triangulated with verbal data from group discussions and World Café sessions to deepen interpretive insights and validate emergent themes. This multi-method integration enabled a nuanced analysis that reflects the diverse perspectives and experiences of participants.\u003c/p\u003e\u003cp\u003eThroughout the analytical process, special attention was paid to group interactions and power dynamics that may have influenced the data, ensuring that less dominant voices were not overlooked. Participant quotations and observations were incorporated to preserve authenticity and ground findings in the lived realities of stakeholders. The study team’s positionality actively influenced coding choices in notable ways. Deep embeddedness in the health research community functioned as both a strength and a potential source of bias, necessitating continuous reflexive practice. One reflexive step involved noting divergent interpretations during coding sessions. This process provided a platform to acknowledge and address subjective biases, thereby enhancing the rigor of grounded theory. The final themes captured areas of consensus, divergence, and innovation, directly informing subsequent refinements to the feedback tool. The analysis process was iterative and spanned approximately two months, from July to September 2024. The findings were contextualized within the existing literature and relevant theoretical frameworks to enhance their credibility and relevance for future applications.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePrototyping\u003c/h2\u003e\u003cp\u003eFollowing the finalization of the tool’s content, the study team collaborated with a designer from the Malawi Liverpool Wellcome Programme Data Department to develop visual and functional prototypes for the selected delivery methods. This phase involved an iterative, user-centered design process, in which preliminary versions of the tool were created and then shared with stakeholders for structured review and feedback.\u003c/p\u003e\u003cp\u003eStakeholders were invited to assess both the design and content of the prototypes, offering input on usability, clarity, and contextual appropriateness. Feedback was systematically collected and relayed to the designer to guide revisions, ensuring that the tool evolved in alignment with user needs, the health system, and contextual realities.\u003c/p\u003e\u003cp\u003eTwo structured rounds of stakeholder feedback were conducted over three months, from September to November 2024. Each round allowed for the refinement and progressive validation of the prototypes, with specific attention paid to functionality, design coherence, and ease of use. This iterative process strengthened the tool’s relevance, enhanced its usability in real-world settings, and increased its acceptability among intended users. Ultimately, the prototyping phase ensured that the final tool was both fit for purpose and grounded in the lived experiences of its end users.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eValidation Workshop\u003c/h2\u003e\u003cp\u003eA one-and-a-half-day validation workshop was conducted on February 4–5, 2025, in Mangochi District, Malawi, with the participation of 39 stakeholders. The purpose of the workshop was to collaboratively review and validate the contents and delivery methods of the maternity-specific feedback tool developed during the co-design session. To ensure a balance between continuity and fresh perspectives, approximately half of the participants had also participated in the earlier co-design workshop, while the remaining half were newly engaged stakeholders. This approach preserved the contextual understanding and design rationale of the original contributors while introducing independent, unbiased feedback and fresh insights from new participants. The diverse composition enhanced the credibility, inclusiveness, and overall robustness of the validation process.\u003c/p\u003e\u003cp\u003eThe workshop began with a presentation summarizing the tool’s content and delivery formats, with a recap of the co-design process (see Additional File 5). This helped orient participants, establish a shared understanding of previous decisions, and clarify the objectives of the validation meeting.\u003c/p\u003e\u003cp\u003eParticipants were then divided into six groups to assess the tool’s content, language, and delivery modalities for contextual relevance, usability, and appropriateness. Most groups were composed of stakeholders with mixed professional backgrounds, while Group 6 was intentionally formed with community women to gather direct user feedback. Groups engaged in hands-on use of both the paper-based and electronic formats of the tool, assessing usability, practicality, and appropriateness from an end-user perspective.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eGroup discussions\u003c/h2\u003e\u003cp\u003eEach group was tasked with reviewing each section of the feedback tool across both delivery modalities and in the two languages provided. Discussions focused on assessing the clarity, relevance, and appropriateness of the content and language, following the questionnaire guide (see Additional File 6) to facilitate the conversation and prompt discussion points. Participants were encouraged to suggest any necessary adjustments and describe the rationale for their recommended changes. Group discussions were audio-recorded, with informed consent obtained from all participants prior to the recording. These recordings were later transcribed for analysis to capture decision-making processes, points of consensus and divergence, and participants’ reasoning.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eGallery walks\u003c/h2\u003e\u003cp\u003eFollowing the group discussions, a gallery walk exercise was conducted. Each group reviewed and responded to suggestions made by other groups, either agreeing or disagreeing and providing justifications for their positions. Groups rotated through all stations, reviewed each tool version, and proposed modifications, ultimately presenting their reflections and final recommendations to the larger group.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAfter the workshop, the study team synthesized the data collected from group discussions, gallery walk feedback, and facilitator observations. A thematic analysis was conducted to identify recurring suggestions, areas of disagreement, and innovative ideas. These insights directly informed the subsequent revisions of the feedback tool. The analysis and tool refinement process were completed over one month in February 2025.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStakeholder Engagement and Iterative Tool Refinement\u003c/h2\u003e\u003cp\u003eDuring March and April 2025, the study team, in collaboration with the designer, conducted two structured rounds of follow-up engagement with all stakeholders who participated in the validation workshop. These sessions focused on reviewing the revised content and design of the maternity-specific feedback tool. Based on the feedback received, the tool was finalized and prepared for pilot testing in May 2025. The results of this pilot phase will be presented in a separate publication.\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eEthical\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapproval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Kamuzu University of Health Sciences Research Ethics Committee (P.07/23-0167) and the University of Liverpool Ethics Committee (UoL13920). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and relevant institutional guidelines. Participation in this study was entirely voluntary, with written informed consent (see Additional file 7) obtained from all stakeholders. Anonymity and confidentiality were maintained throughout the process by ensuring that all data collected was non-identifiable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDistribution of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA\u0026nbsp;total\u0026nbsp;of\u0026nbsp;58\u0026nbsp;stakeholders\u0026nbsp;were\u0026nbsp;invited\u0026nbsp;to\u0026nbsp;the\u0026nbsp;co-design\u0026nbsp;workshop,\u0026nbsp;and\u0026nbsp;53\u0026nbsp;to\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop.\u0026nbsp;Of\u0026nbsp;these,\u0026nbsp;83%\u0026nbsp;(n\u0026nbsp;=\u0026nbsp;48) attended\u0026nbsp;the\u0026nbsp;co-design\u0026nbsp;workshop,\u0026nbsp;and\u0026nbsp;74%\u0026nbsp;(n\u0026nbsp;=\u0026nbsp;39)\u0026nbsp;participated\u0026nbsp;in\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop\u0026nbsp;(see\u0026nbsp;Additional\u0026nbsp;file\u0026nbsp;1).\u0026nbsp;Among\u0026nbsp;the co-design workshop participants, 96% (n = 46) actively engaged in all group discussions and interactive rotations (see Additional\u0026nbsp;file\u0026nbsp;4).\u0026nbsp;Similarly,\u0026nbsp;95%\u0026nbsp;(n\u0026nbsp;=\u0026nbsp;37)\u0026nbsp;of\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop\u0026nbsp;participants\u0026nbsp;participated\u0026nbsp;in\u0026nbsp;all\u0026nbsp;group\u0026nbsp;activities\u0026nbsp;(see Additional file 5).\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;median\u0026nbsp;number\u0026nbsp;of\u0026nbsp;stakeholders\u0026nbsp;per\u0026nbsp;group\u0026nbsp;was\u0026nbsp;eight\u0026nbsp;for\u0026nbsp;the\u0026nbsp;co-design\u0026nbsp;workshop\u0026nbsp;and\u0026nbsp;six\u0026nbsp;for\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop\u0026nbsp;(see\u0026nbsp;Additional files 4 and 5). Participants represented a broad range of stakeholder categories, including officials from the Ministry of Health and various government departments, training institutions, professional associations and organizations, community and patient representatives, clinical service providers, local non-governmental organisations (NGOs), organizations representing people with disabilities, key donors and international partners, and research institutions (see Additional file 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCo-design\u003c/strong\u003e\u003cstrong\u003eWorkshop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase\u003c/strong\u003e\u003cstrong\u003eOne:\u003c/strong\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring\u0026nbsp;the\u0026nbsp;first\u0026nbsp;phase\u0026nbsp;of\u0026nbsp;the\u0026nbsp;co-design\u0026nbsp;workshop,\u0026nbsp;all\u0026nbsp;six\u0026nbsp;groups\u0026nbsp;focused\u0026nbsp;on\u0026nbsp;identifying\u0026nbsp;key\u0026nbsp;indicators\u0026nbsp;for\u0026nbsp;inclusion\u0026nbsp;in\u0026nbsp;a maternity-specific\u0026nbsp;feedback\u0026nbsp;tool.\u0026nbsp;Discussions\u0026nbsp;were\u0026nbsp;structured\u0026nbsp;to\u0026nbsp;capture\u0026nbsp;client\u0026nbsp;feedback\u0026nbsp;across\u0026nbsp;the\u0026nbsp;entire\u0026nbsp;continuum\u0026nbsp;of maternal\u0026nbsp;care,\u0026nbsp;covering\u0026nbsp;general\u0026nbsp;health\u0026nbsp;system\u0026nbsp;issues,\u0026nbsp;antenatal\u0026nbsp;care,\u0026nbsp;labour\u0026nbsp;and\u0026nbsp;delivery,\u0026nbsp;and\u0026nbsp;the\u0026nbsp;postnatal\u0026nbsp;period.\u003c/p\u003e\n\u003cp\u003eEach group documented their outputs using sticky notes and flip charts, which facilitated collaborative brainstorming and visual organisation of ideas. These materials enabled participants to cluster related themes and build consensus around core content elements to be included in the tool (see Figure 2).\u003c/p\u003e\n\u003cp\u003eCommon themes consistently emerged across all six groups and were subsequently synthesised into key components\u0026nbsp;reflecting recognised domains of maternity care quality. These components included: Respectful and dignified care; Effective communication and information sharing; Emotional support and companionship; Accessibility and timeliness of services; Continuity and coordination of care; Provision of care and services received; and Overall client satisfaction (see Table 1 for a summary of these domains and associated indicators). In selecting these indicators, we prioritized feasibility and\u0026nbsp;psychometrics to ensure content validity. The decision to include 27 antenatal, 28 labor and delivery, and 32 postnatal indicators was based on their comprehensive coverage of critical aspects of each care phase while balancing the practicality of implementation. These numbers reflect an optimal trade-off between depth of insight and manageability for health workers.\u003c/p\u003e\n\u003cp\u003eWithin\u0026nbsp;the\u0026nbsp;domain\u0026nbsp;of\u0026nbsp;respectful\u0026nbsp;and\u0026nbsp;dignified\u0026nbsp;care,\u0026nbsp;participants\u0026nbsp;emphasized\u0026nbsp;the\u0026nbsp;importance\u0026nbsp;of\u0026nbsp;assessing\u0026nbsp;client\u0026nbsp;experiences\u0026nbsp;related to privacy, informed consent, respectful treatment by healthcare workers, provider attitudes, and the inclusiveness of care for persons with disabilities. The presence or absence of a chosen companion during care was also highlighted as a key indicator.\u003c/p\u003e\n\u003cp\u003eFor effective communication and information sharing, suggested indicators included the quality of provider-client rapport,\u0026nbsp;clarity and relevance of information shared, and the type of health education delivered at each stage of the maternity care continuum.\u003c/p\u003e\n\u003cp\u003eIn the domain of emotional support and companionship, stakeholders recommended incorporating questions about the presence\u0026nbsp;of\u0026nbsp;a\u0026nbsp;companion\u0026nbsp;during\u0026nbsp;care\u0026nbsp;and\u0026nbsp;the\u0026nbsp;availability\u0026nbsp;of\u0026nbsp;follow-up\u0026nbsp;emotional\u0026nbsp;or\u0026nbsp;psychosocial\u0026nbsp;support,\u0026nbsp;especially\u0026nbsp;in\u0026nbsp;contexts involving loss or high-risk experiences.\u003c/p\u003e\n\u003cp\u003eRegarding\u0026nbsp;accessibility\u0026nbsp;and\u0026nbsp;timeliness,\u0026nbsp;feedback\u0026nbsp;centred\u0026nbsp;on\u0026nbsp;waiting\u0026nbsp;times\u0026nbsp;between\u0026nbsp;services,\u0026nbsp;the\u0026nbsp;number\u0026nbsp;and\u0026nbsp;timeliness\u0026nbsp;of antenatal contacts, and the physical environment of the health facility, including cleanliness, infrastructure condition, and comfort within facilities.\u003c/p\u003e\n\u003cp\u003eWithin continuity and coordination of care, participants highlighted the need to assess follow-up services, availability and function of bereavement care (where applicable), the presence and visibility of the ombudsman or complaints office, and consistency\u0026nbsp;in\u0026nbsp;obtaining\u0026nbsp;informed\u0026nbsp;consent\u0026nbsp;throughout\u0026nbsp;care.\u003c/p\u003e\n\u003cp\u003eIn\u0026nbsp;the\u0026nbsp;provision\u0026nbsp;of\u0026nbsp;care\u0026nbsp;and\u0026nbsp;services\u0026nbsp;category,\u0026nbsp;participants\u0026nbsp;recommended\u0026nbsp;evaluating\u0026nbsp;the\u0026nbsp;range\u0026nbsp;and\u0026nbsp;quality\u0026nbsp;of\u0026nbsp;services\u0026nbsp;received across antenatal, intrapartum, and postnatal care. They also proposed indicators on whether any informal payments were requested, and how clients perceived the quality of the services provided.\u003c/p\u003e\n\u003cp\u003eLastly,\u0026nbsp;for\u0026nbsp;client\u0026nbsp;satisfaction,\u0026nbsp;participants\u0026nbsp;recommended\u0026nbsp;that\u0026nbsp;the\u0026nbsp;tool\u0026nbsp;should\u0026nbsp;capture\u0026nbsp;both\u0026nbsp;overall\u0026nbsp;satisfaction\u0026nbsp;levels\u0026nbsp;and\u0026nbsp;more detailed reflections on specific aspects of care. This would enable facilities and policymakers to identify areas of excellence and those that require targeted improvement.\u003c/p\u003e\n\u003cp\u003eA comprehensive summary of the proposed tool content, mapped across the maternity care continuum, is provided in Additional file 8.\u003c/p\u003e\n\u003cp\u003eTable 1. Summary of indicators to include in the Maternity-specific Feedback Tool\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComponent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeedback Elements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1. Respectful and Dignified Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Respect and rights (RMC)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Privacy and confidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Informed consent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; HCW attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Disability-friendly services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; \u0026nbsp;Bereavement care (if applicable)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Companionship\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2. Effective Communication and Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Establishing a rapport\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Health education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Information giving\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. Emotional Support and Companionship\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Companionship \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Follow-up care (as emotional support)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4. Accessibility and Timeliness of Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Waiting time\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Number of visits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Sanitation and environment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Disability-friendly services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5. Continuity and Coordination of Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Follow-up care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Bereavement care (if applicable)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Ombudsman office\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Consent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6. Provision of Care and Services Received\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Services received\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Areas of care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Payment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7. Client Satisfaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Satisfaction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 414px;\"\u003e\n \u003cp\u003e\u0026middot; Areas of improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants also contributed insights on the most appropriate level of the health system (primary, secondary, or tertiary) at which each feedback indicator would be most applicable (see Figure 2). This mapping exercise enhanced alignment between participant-generated feedback and established maternal health quality frameworks, reinforcing the contextual relevance and coherence of the tool\u0026rsquo;s design.\u003c/p\u003e\n\u003cp\u003eWhile\u0026nbsp;most\u0026nbsp;indicators\u0026nbsp;were\u0026nbsp;considered\u0026nbsp;applicable\u0026nbsp;across\u0026nbsp;all\u0026nbsp;levels\u0026nbsp;of\u0026nbsp;care,\u0026nbsp;some\u0026nbsp;issues\u0026nbsp;were\u0026nbsp;identified\u0026nbsp;as\u0026nbsp;level-specific.\u0026nbsp;For instance, referral pathways, the availability of specialist care, and surgical interventions, such as caesarean sections, were deemed more relevant for assessment at secondary and tertiary facilities (Figure 2). This differentiation ensured that the feedback tool would remain adaptable and meaningful across varying facility contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWorld\u003c/strong\u003e\u003cstrong\u003eCaf\u0026eacute;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the World Caf\u0026eacute; session (see Figure 3), participants engaged in two rounds of focused dialogue, with each discussion table addressing a specific aspect of the feedback tool\u0026rsquo;s structure and content. The key thematic areas included clarity and simplicity of language, relevance of questions to women\u0026rsquo;s lived experiences, and comprehensiveness of the proposed feedback domains. Participants offered concrete, user-centred suggestions to enhance the tool\u0026rsquo;s usability, cultural appropriateness, and ability to elicit meaningful responses. All contributions were carefully documented and later analysed. These insights directly informed subsequent revisions to the tool, contributing to a more refined, accessible, and contextually grounded feedback instrument.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase\u003c/strong\u003e\u003cstrong\u003eTwo:\u003c/strong\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003ediscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the co-design workshop, Groups 1-5 were each assigned one of five delivery methods for the maternity-specific feedback tool (paper-based, electronic, mobile application, audio-based (ACASI), and combined approaches). Discussions highlighted\u0026nbsp;the\u0026nbsp;distinct\u0026nbsp;strengths,\u0026nbsp;limitations,\u0026nbsp;and\u0026nbsp;feasibility\u0026nbsp;of\u0026nbsp;each\u0026nbsp;method\u0026nbsp;across\u0026nbsp;healthcare\u0026nbsp;settings\u0026nbsp;in\u0026nbsp;Malawi.\u0026nbsp;A\u0026nbsp;summary of the group discussions is presented in Additional File 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e1:\u003c/strong\u003e\u003cstrong\u003ePaper-based\u003c/strong\u003e\u003cstrong\u003etools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePaper-based tools were considered cost-effective, easy to use, and well-suited for environments with limited digital infrastructure. They do not require internet connectivity and support structured data collection that can minimise omissions. Participants noted that these tools are feasible for basic feedback mechanisms, such as suggestion boxes and exit interviews, but\u0026nbsp;require\u0026nbsp;substantial\u0026nbsp;investment\u0026nbsp;in\u0026nbsp;human\u0026nbsp;and\u0026nbsp;material\u0026nbsp;resources,\u0026nbsp;supervision,\u0026nbsp;and\u0026nbsp;storage\u0026nbsp;when\u0026nbsp;implemented\u0026nbsp;at\u0026nbsp;scale\u0026nbsp;or\u0026nbsp;in more complex formats (e.g., community scorecards or verbal autopsies). Challenges included the need for secure physical storage, vulnerability to data loss during disasters, and manual data management, which can delay analysis and compromise accuracy.\u0026nbsp;Implementing\u0026nbsp;these\u0026nbsp;tools\u0026nbsp;is\u0026nbsp;feasible\u0026nbsp;across\u0026nbsp;all\u0026nbsp;levels\u0026nbsp;of\u0026nbsp;healthcare\u0026nbsp;and\u0026nbsp;is\u0026nbsp;usually\u0026nbsp;overseen\u0026nbsp;by\u0026nbsp;hospital\u0026nbsp;ombudsmen\u0026nbsp;or human resources officers, taking around 30 minutes to complete.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e2:\u003c/strong\u003e\u003cstrong\u003eElectronic\u003c/strong\u003e\u003cstrong\u003eTools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElectronic tools were found to streamline data collection through efficient storage, rapid access to information, and minimal spatial\u0026nbsp;requirements.\u0026nbsp;Their\u0026nbsp;feasibility\u0026nbsp;was\u0026nbsp;considered\u0026nbsp;high\u0026nbsp;with\u0026nbsp;moderate\u0026nbsp;resource\u0026nbsp;input.\u0026nbsp;Limitations\u0026nbsp;included\u0026nbsp;the\u0026nbsp;exclusion\u0026nbsp;of illiterate clients, high maintenance and operational costs, risks of equipment theft, and the need for trained personnel. Electronic\u0026nbsp;feedback\u0026nbsp;mechanisms\u0026nbsp;are\u0026nbsp;suitable\u0026nbsp;for\u0026nbsp;all\u0026nbsp;facility\u0026nbsp;levels\u0026nbsp;and\u0026nbsp;can\u0026nbsp;be\u0026nbsp;self-administered,\u0026nbsp;preferably\u0026nbsp;under\u0026nbsp;the\u0026nbsp;guidance of\u0026nbsp;a\u0026nbsp;neutral\u0026nbsp;party\u0026nbsp;such\u0026nbsp;as\u0026nbsp;an\u0026nbsp;ombudsman.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e3:\u003c/strong\u003e\u003cstrong\u003eMobile\u003c/strong\u003e\u003cstrong\u003eapplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMobile platforms, including SMS, WhatsApp, Facebook, voice calls, and CommCare, were valued for their flexibility, portability, and real-time data access. Their self-administration potential and short feedback duration (10\u0026ndash;15 minutes) were also seen as advantages. However, challenges include network instability, high data costs, and limited interaction (e.g., lack of real-time clarification\u0026nbsp;or\u0026nbsp;probing).\u0026nbsp;Moreover,\u0026nbsp;some\u0026nbsp;platforms,\u0026nbsp;like\u0026nbsp;CommCare,\u0026nbsp;are\u0026nbsp;not\u0026nbsp;entirely\u0026nbsp;self-administered\u0026nbsp;and\u0026nbsp;require\u0026nbsp;staff\u0026nbsp;support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e4:\u003c/strong\u003e\u003cstrong\u003eAudio\u003c/strong\u003e\u003cstrong\u003eTools\u003c/strong\u003e\u003cstrong\u003e(ACASI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACASI tools were highlighted for their suitability for clients with visual impairments and for ensuring standardised delivery across\u0026nbsp;sites.\u0026nbsp;They\u0026nbsp;reduce\u0026nbsp;printing\u0026nbsp;costs\u0026nbsp;and\u0026nbsp;improve\u0026nbsp;data\u0026nbsp;accuracy\u0026nbsp;through\u0026nbsp;automated\u0026nbsp;input.\u0026nbsp;Despite\u0026nbsp;their\u0026nbsp;potential,\u0026nbsp;these tools are resource-intensive, requiring technical infrastructure, trained staff, and financial support. Limitations include inaccessibility to clients with hearing impairments, limited flexibility for probing questions, and reliance on stable power sources. Implementation across all levels of care is possible, with tools typically requiring 15\u0026ndash;20 minutes to complete.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e5:\u003c/strong\u003e\u003cstrong\u003eCombined\u003c/strong\u003e\u003cstrong\u003eApproaches\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe combined approach integrates paper, electronic, mobile, and audio tools to enhance system resilience and data reliability, ensuring\u0026nbsp;continuity\u0026nbsp;and\u0026nbsp;accommodating\u0026nbsp;variations\u0026nbsp;in\u0026nbsp;infrastructure.\u0026nbsp;It\u0026nbsp;offers\u0026nbsp;flexibility\u0026nbsp;and\u0026nbsp;inclusivity,\u0026nbsp;especially\u0026nbsp;in\u0026nbsp;contexts\u0026nbsp;with intermittent electricity or diverse user needs. However, the approach demands significant logistical coordination, financial investment, and training. Preparatory steps would require planning for community sensitization, tool integration with existing systems (e.g., DHIS2), and health worker capacity building. Feasibility was considered moderate to high, contingent on facility context, and administration would typically be managed by personnel from the Ombudsman\u0026rsquo;s office. The tool duration may range from 10 to 20 minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003cstrong\u003e6: Comparative evaluation\u003c/strong\u003e\u003cstrong\u003eby experts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;technical\u0026nbsp;experts\u0026nbsp;in\u0026nbsp;Group\u0026nbsp;6\u0026nbsp;critically\u0026nbsp;assessed\u0026nbsp;all\u0026nbsp;five\u0026nbsp;tool\u0026nbsp;types\u0026nbsp;and\u0026nbsp;contributed\u0026nbsp;additional\u0026nbsp;practical\u0026nbsp;recommendations\u0026nbsp;(see Additional file 8). Paper-based forms were valued for simplicity and broad familiarity among most health personnel, as well as the ease of producing translated or disability-friendly versions (e.g., Braille). However, scalability, manual data handling, and potential timeliness of data analysis were noted as limitations. Electronic tools offer real-time integration with existing platforms, such as HMIS, and facilitate efficient analysis. However, they face barriers including internet connectivity issues, power supply limitations, cybersecurity concerns, and the need for technical expertise. Mobile applications improve flexibility and portability, but digital literacy and data privacy concerns must be addressed. Audio tools (ACASI) mitigate literacy barriers, but require technical support, stable electricity, and carry similar cost burdens. The combined approach was acknowledged for its resilience, but was described as resource-intensive, inheriting the implementation challenges of each format.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCross-cutting\u003c/strong\u003e\u003cstrong\u003ethemes\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003epractical\u003c/strong\u003e\u003cstrong\u003eimplementation\u003c/strong\u003e\u003cstrong\u003econsiderations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral cross-cutting themes and practical implementation considerations emerged across all stakeholder groups as essential to the successful rollout and integration of the maternity feedback tool within Malawi\u0026rsquo;s health system. These include the need for robust community awareness and client sensitisation, sustained stakeholder engagement, targeted capacity building for implementers, and comprehensive sustainability planning, including resource mobilisation. Key enablers for implementation identified across all tool types include translation into local languages, assurance of confidentiality and data protection, fostering client and community acceptance, and securing sufficient logistical and financial support for piloting and scale-up across diverse regions. Building on this, Group 6 provided specific, actionable recommendations to guide effective implementation. These include upholding privacy, confidentiality, and informed consent throughout data collection; ensuring representative sampling by conducting interviews across weekdays, weekends, and public holidays; and selecting pilot districts based on resource availability, facility workload, and regional diversity. Group 6 further recommended assigning dedicated, trained data collectors to minimise disruption to routine care, translating the tool into all widely spoken local languages, and implementing secure data management protocols, such as storing data in locked cabinets within restricted-access areas. To build trust and ensure ethical compliance, clients and stakeholders must be reassured that their information will be handled with the highest standards of privacy and integrity. Finally, convening a dissemination meeting to share pilot findings and planning for potential adaptation of the tool for use in community-based and outreach settings was identified as a key strategy for supporting future scale-up. Detailed insights from Group 6 are provided in Additional File 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrototyping,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGallery\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eWalk,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSelection\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTool\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edelivery\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003emode\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing\u0026nbsp;three\u0026nbsp;months\u0026nbsp;of\u0026nbsp;collaboration\u0026nbsp;with\u0026nbsp;the\u0026nbsp;tool\u0026nbsp;designer\u0026nbsp;and\u0026nbsp;two\u0026nbsp;structured\u0026nbsp;rounds\u0026nbsp;of\u0026nbsp;stakeholder\u0026nbsp;feedback,\u0026nbsp;the\u0026nbsp;content of the maternity feedback tool was finalised and compiled into a paper-based format. The tool was systematically organised into three distinct modules, each addressing a specific stage of the maternity care continuum: antenatal care, labour and delivery, and postnatal care. This modular structure was designed to support focused, context-specific, and comprehensive data collection that aligns with each phase of the maternal health service delivery.\u003c/p\u003e\n\u003cp\u003eTo support further refinement and stakeholder consensus, a gallery exercise was conducted. This interactive process allowed all participant groups to rotate through stations where the components of the feedback tool were visually presented and analysed. Participants engaged with each tool module, reviewed the findings from other groups, and contributed additional suggestions (see Table 2). The exercise fostered deeper reflection, encouraged collaborative input, and served as a preparatory step for the subsequent voting process on preferred delivery modalities. Following the gallery walk and group presentations, stakeholders participated in a voting exercise to select the most appropriate feedback tool modality for pilot implementation (Figure 4). A total of 51 votes were cast, yielding the results shown in Table 3.\u003c/p\u003e\n\u003cp\u003eWhile\u0026nbsp;the\u0026nbsp;electronic\u0026nbsp;tool\u0026nbsp;received\u0026nbsp;the\u0026nbsp;highest\u0026nbsp;number\u0026nbsp;of\u0026nbsp;individual\u0026nbsp;votes,\u0026nbsp;participants\u0026nbsp;reached\u0026nbsp;a\u0026nbsp;consensus\u0026nbsp;to\u0026nbsp;pilot\u0026nbsp;both\u0026nbsp;the paper-based\u0026nbsp;and\u0026nbsp;electronic\u0026nbsp;modalities.\u0026nbsp;The\u0026nbsp;paper-based\u0026nbsp;tool\u0026nbsp;was\u0026nbsp;selected\u0026nbsp;for\u0026nbsp;its\u0026nbsp;accessibility\u0026nbsp;and\u0026nbsp;ease\u0026nbsp;of\u0026nbsp;use\u0026nbsp;across\u0026nbsp;all\u0026nbsp;levels\u0026nbsp;of the health system, particularly in low-resource settings. The electronic version was favoured for its potential to facilitate real-time data collection, analysis, and management. This dual-modality approach was endorsed as a practical and inclusive strategy for the pilot phase, ensuring both feasibility and future scalability of the feedback system.\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;maternity\u0026nbsp;feedback\u0026nbsp;tool\u0026nbsp;was\u0026nbsp;finalised\u0026nbsp;into\u0026nbsp;three\u0026nbsp;modular\u0026nbsp;forms:\u0026nbsp;antenatal,\u0026nbsp;labour\u0026nbsp;and\u0026nbsp;delivery,\u0026nbsp;and\u0026nbsp;postnatal\u0026nbsp;care,\u0026nbsp;each designed to capture clients\u0026rsquo; experiences across the continuum of care. Each form collected facility-level information and included 24\u0026ndash;25 questions covering reception, rapport-building, service provision, communication quality, respectful care, informal\u0026nbsp;payments,\u0026nbsp;disability\u0026nbsp;inclusion,\u0026nbsp;and\u0026nbsp;overall\u0026nbsp;satisfaction.\u0026nbsp;The\u0026nbsp;antenatal\u0026nbsp;form\u0026nbsp;focused\u0026nbsp;on\u0026nbsp;services\u0026nbsp;received\u0026nbsp;during\u0026nbsp;clinic visits; the labour form addressed delivery processes and immediate postpartum care; and the postnatal form assessed care provided to both mother and newborn at 48 hours, 7 days, and 6 weeks. All forms were developed in English and translated into Chichewa and were prepared in both paper-based and electronic formats for validation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidation\u003c/strong\u003e\u003cstrong\u003eWorkshop\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop,\u0026nbsp;participants\u0026nbsp;reviewed\u0026nbsp;the\u0026nbsp;maternity\u0026nbsp;feedback\u0026nbsp;tool\u0026nbsp;in\u0026nbsp;both\u0026nbsp;paper-based\u0026nbsp;and\u0026nbsp;electronic\u0026nbsp;formats, assessing clarity, language, design, and usability. Through group discussions and a gallery walk exercise (Figure 5), they evaluated each section (antenatal, labour and delivery, and postnatal care), providing consensus-based recommendations for refinement. Key revisions included simplifying medical language, expanding demographic details (e.g., age, education, disability), and rephrasing questions on respectful care, communication, satisfaction, and payments. Additional updates addressed labour-specific content (e.g., vaginal exams, delivery provider), postnatal needs (e.g., infant loss support, HIV exposure, kangaroo care), and accessibility considerations. A summary of the modifications is provided in Table 2, with more detailed modifications summarised in Additional File 9. Feedback from all five groups is summarized in Additional 10.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStakeholders\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003eengagement\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003eiterative\u003c/strong\u003e\u003cstrong\u003etool\u003c/strong\u003e\u003cstrong\u003erefinement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;tool\u0026nbsp;underwent\u0026nbsp;adjustments\u0026nbsp;based\u0026nbsp;on\u0026nbsp;recommendations\u0026nbsp;provided\u0026nbsp;during\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;workshop,\u0026nbsp;where\u0026nbsp;the\u0026nbsp;study\u0026nbsp;team and\u0026nbsp;designer\u0026nbsp;implemented\u0026nbsp;changes\u0026nbsp;and\u0026nbsp;conducted\u0026nbsp;two\u0026nbsp;structured\u0026nbsp;rounds\u0026nbsp;of\u0026nbsp;feedback\u0026nbsp;with\u0026nbsp;all\u0026nbsp;stakeholders\u0026nbsp;who\u0026nbsp;participated in\u0026nbsp;the\u0026nbsp;validation\u0026nbsp;meeting\u0026nbsp;over\u0026nbsp;two months.\u003c/p\u003e\n\u003cp\u003eThe final antenatal form had 27 indicators, 28 for labour and delivery, and 32 for the postnatal form (Table 2). The tool is now ready for piloting, and sample outputs for the forms are shown in Figure 6 below. The forms are available in both paper-based and electronic versions, which will be administered as a survey during the piloting phase.\u003c/p\u003e\n\u003cp\u003eTable 2. Summary of maternity feedback tool structure, content, and revisions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"886\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFocus areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKey features\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKey revisions from Validation workshop (Group Discussions \u0026amp; Gallery Walk)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAntenatal Care (ANC) Feedback Form\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Facility details (name, level, ownership, SLA status, location)\u003cbr\u003e\u0026nbsp;- Client reception and orientation\u003cbr\u003e\u0026nbsp;- Services received (history, exam, labs, drugs/vaccines, health education)\u003cbr\u003e\u0026nbsp;- Waiting times and respectful care\u003cbr\u003e\u0026nbsp;- Mistreatment or abuse\u003cbr\u003e\u0026nbsp;- Communication and provider interaction\u003cbr\u003e\u0026nbsp;- Informal payments\u003cbr\u003e\u0026nbsp;- Expectation fulfilment, disability inclusiveness, accessibility challenges, and satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Focused on both initial and follow-up ANC visits\u003cbr\u003e\u0026nbsp;- Emphasis on respectful maternity care, service quality, and access barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Rephrased form title and simplified medical terms\u003cbr\u003e\u0026nbsp;- Expanded demographic section (age, education, disability)\u003cbr\u003e\u0026nbsp;- Reworded questions on rapport, abuse, communication, expectations, and satisfaction\u003cbr\u003e\u0026nbsp;- Disability items repositioned\u003cbr\u003e\u0026nbsp;- Added prompt for explanation of payments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabour \u0026amp; Delivery Feedback Form\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Facility and reception details\u003cbr\u003e\u0026nbsp;- Orientation to the labour ward\u003cbr\u003e\u0026nbsp;- Delivery process and procedures\u003cbr\u003e\u0026nbsp;- Informed consent and provider identity\u003cbr\u003e\u0026nbsp;- Services for mother and newborn\u003cbr\u003e\u0026nbsp;- Respectful care, mistreatment\u003cbr\u003e\u0026nbsp;- Communication, provider interaction\u003cbr\u003e\u0026nbsp;- Informal payments\u003cbr\u003e\u0026nbsp;- Expectations met, disability inclusion, access issues, and overall satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Mirrors ANC structure\u003cbr\u003e\u0026nbsp;- Additional focus on informed consent, delivery experience, and immediate newborn care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Updates mirrored ANC form revisions\u003cbr\u003e\u0026nbsp;- Revised questions on vaginal exams, contractions, and companionship\u003cbr\u003e\u0026nbsp;- Added demographics on the baby\u0026rsquo;s condition\u003cbr\u003e\u0026nbsp;- New items: time of delivery, baby\u0026rsquo;s sex\u003cbr\u003e\u0026nbsp;- Reworded questions on payments and satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostnatal Care (PNC) Feedback Form\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 questions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Facility and ward orientation\u003cbr\u003e\u0026nbsp;- Services within PNC timeline (48 hrs., 7 days, 6 weeks)\u003cbr\u003e\u0026nbsp;- Maternal and newborn care received\u003cbr\u003e\u0026nbsp;- Client involvement and information received\u003cbr\u003e\u0026nbsp;- Waiting times, respectful care\u003cbr\u003e\u0026nbsp;- Mistreatment, communication quality\u003cbr\u003e\u0026nbsp;- Informal payments, accessibility\u003cbr\u003e\u0026nbsp;- Expectation fulfilment, disability inclusion, satisfaction, and improvement suggestions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Tracks care across the WHO-recommended postnatal timeline\u003cbr\u003e\u0026nbsp;- Assesses continuity of care and client engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Incorporated changes from ANC and labour forms\u003cbr\u003e\u0026nbsp;- Added: date and mode of delivery, care for mother vs baby, mental health support for infant loss\u003cbr\u003e\u0026nbsp;- New questions on nursery admission, HIV exposure, and kangaroo care\u003cbr\u003e\u0026nbsp;- Standardized language and payment-related items\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Voting exercise results\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTool modality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of votes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eElectronic-based tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePaper-based tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMobile application\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAudio (ACASI) tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCombined approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to co-develop a maternity-specific feedback tool that is contextually grounded and reflective of stakeholder priorities by employing participatory approaches. By engaging a broad spectrum of maternity care stakeholders, including service users, healthcare providers, policymakers, and community representatives, the process ensured the inclusion of diverse perspectives, cultural sensitivity, and the prioritization of lived experience. Methods such as group discussions, gallery walks, and World Caf\u0026eacute; sessions were employed to facilitate meaningful dialogue, collective reflection, and the co-construction of quality indicators aligned with people-centered care and the WHO framework for quality maternal and newborn health services (16, 23). This discussion highlights two key dimensions of the study: (1) the methodological strengths and challenges of participatory approaches in health tool design, and (2) the practical and policy relevance of the emergent quality indicators for strengthening maternity care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological\u003c/strong\u003e\u003cstrong\u003estrengths\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003echallenges\u003c/strong\u003e\u003cstrong\u003eof\u003c/strong\u003e\u003cstrong\u003eparticipatory\u003c/strong\u003e\u003cstrong\u003eapproaches\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;participatory\u0026nbsp;methods\u0026nbsp;used\u0026nbsp;in\u0026nbsp;this\u0026nbsp;study\u0026nbsp;proved\u0026nbsp;highly\u0026nbsp;effective\u0026nbsp;in\u0026nbsp;generating\u0026nbsp;rich,\u0026nbsp;contextually\u0026nbsp;relevant\u0026nbsp;insights\u0026nbsp;and\u0026nbsp;fostering shared ownership of the final tool. The iterative, dialogic design promoted reciprocal learning between service users and providers, supporting the co-production of knowledge in a manner consistent with the principles of community-based participatory research (24,25). Group discussions facilitated the integration of multiple viewpoints, ranging from personal experiences of care to system-level constraints, resulting in a feedback tool that reflects both user priorities and operational realities.\u003c/p\u003e\n\u003cp\u003eParticipants\u0026nbsp;noted\u0026nbsp;the\u0026nbsp;value\u0026nbsp;of\u0026nbsp;including\u0026nbsp;indicators\u0026nbsp;related\u0026nbsp;to\u0026nbsp;respectful\u0026nbsp;communication,\u0026nbsp;emotional\u0026nbsp;support\u0026nbsp;during\u0026nbsp;childbirth, and decision-making autonomy, domains often underrepresented in conventional metrics. Such insights underscore the importance\u0026nbsp;of\u0026nbsp;grounding\u0026nbsp;feedback\u0026nbsp;tools\u0026nbsp;in\u0026nbsp;the\u0026nbsp;lived\u0026nbsp;experiences\u0026nbsp;of\u0026nbsp;users\u0026nbsp;to\u0026nbsp;ensure\u0026nbsp;their\u0026nbsp;salience\u0026nbsp;and\u0026nbsp;utility\u0026nbsp;in\u0026nbsp;driving\u0026nbsp;quality improvement\u0026nbsp;(26,27).\u003c/p\u003e\n\u003cp\u003eInclusivity\u0026nbsp;was\u0026nbsp;further\u0026nbsp;enhanced\u0026nbsp;by\u0026nbsp;the\u0026nbsp;involvement\u0026nbsp;of\u0026nbsp;a\u0026nbsp;diverse\u0026nbsp;range\u0026nbsp;of\u0026nbsp;stakeholders,\u0026nbsp;including\u0026nbsp;healthcare\u0026nbsp;workers,\u0026nbsp;facility\u0026nbsp;managers, district health officials, researchers, representatives from disability organizations, and local community leaders. This broad participation fostered legitimacy and promoted the future acceptability and integration of the tool into routine health systems (25,28). Engaging underrepresented groups, especially community and disability stakeholders, was essential in ensuring the tool addressed equity and access dimensions often neglected in traditional tool development.\u003c/p\u003e\n\u003cp\u003eThe World Caf\u0026eacute; approach emerged as a potent participatory method. By enabling rotating small-group conversations in a relaxed setting, it supported open dialogue, idea refinement, and the surfacing of shared priorities. Its informal structure helped reduce hierarchical barriers, creating space for all participants to contribute equitably (29,30). Similarly,\u0026nbsp;the\u0026nbsp;gallery\u0026nbsp;walk\u0026nbsp;technique\u0026nbsp;promoted\u0026nbsp;collaborative\u0026nbsp;learning\u0026nbsp;through\u0026nbsp;visual\u0026nbsp;and\u0026nbsp;interactive\u0026nbsp;engagement.\u0026nbsp;It\u0026nbsp;facilitated the iterative refinement of indicators and ensured clarity and consensus around their interpretation, particularly among participants who were less comfortable with verbal discussions (31,32).\u003c/p\u003e\n\u003cp\u003eNotably,\u0026nbsp;the\u0026nbsp;participatory\u0026nbsp;process\u0026nbsp;itself\u0026nbsp;acted\u0026nbsp;as\u0026nbsp;a\u0026nbsp;capacity-building\u0026nbsp;mechanism.\u0026nbsp;Stakeholders\u0026nbsp;reported\u0026nbsp;increased\u0026nbsp;awareness of care standards, rights, and responsibilities, suggesting that the development process may have benefits beyond the tool itself, by fostering accountability and shared understanding of quality benchmarks (22,33).\u003c/p\u003e\n\u003cp\u003eNonetheless,\u0026nbsp;participatory\u0026nbsp;approaches\u0026nbsp;are\u0026nbsp;not\u0026nbsp;without\u0026nbsp;challenges.\u0026nbsp;Balancing\u0026nbsp;diverse\u0026nbsp;perspectives,\u0026nbsp;particularly\u0026nbsp;between\u0026nbsp;users and\u0026nbsp;providers,\u0026nbsp;required\u0026nbsp;deliberate\u0026nbsp;facilitation\u0026nbsp;to\u0026nbsp;avoid\u0026nbsp;dominance\u0026nbsp;by\u0026nbsp;any\u0026nbsp;one\u0026nbsp;group.\u0026nbsp;Facilitator\u0026nbsp;training\u0026nbsp;was\u0026nbsp;therefore\u0026nbsp;integral, ensuring inclusive, respectful, and equitable engagement. Managing power asymmetries was especially critical when integrating experiential insights from users with system-level constraints described by providers and policy actors.\u003c/p\u003e\n\u003cp\u003eAdditionally,\u0026nbsp;these\u0026nbsp;methods\u0026nbsp;are\u0026nbsp;resource-intensive.\u0026nbsp;They\u0026nbsp;require\u0026nbsp;significant\u0026nbsp;time,\u0026nbsp;logistical\u0026nbsp;coordination,\u0026nbsp;and\u0026nbsp;skilled\u0026nbsp;facilitation, factors that may hinder scalability in resource-limited settings (34,35). However, our early collaboration with the Ministry of Health,\u0026nbsp;particularly\u0026nbsp;through\u0026nbsp;the\u0026nbsp;Reproductive\u0026nbsp;Health\u0026nbsp;Directorate\u0026nbsp;(RHD)\u0026nbsp;and\u0026nbsp;Quality\u0026nbsp;Management\u0026nbsp;Directorate\u0026nbsp;(QMD),\u0026nbsp;helped\u0026nbsp;to navigate\u0026nbsp;these\u0026nbsp;constraints.\u0026nbsp;Engagement\u0026nbsp;with\u0026nbsp;institutional\u0026nbsp;actors\u0026nbsp;familiar\u0026nbsp;with\u0026nbsp;the\u0026nbsp;health\u0026nbsp;system\u0026nbsp;streamlined\u0026nbsp;coordination\u0026nbsp;and strengthened\u0026nbsp;the\u0026nbsp;relevance\u0026nbsp;of\u0026nbsp;stakeholder\u0026nbsp;input.\u003c/p\u003e\n\u003cp\u003eCompared\u0026nbsp;to\u0026nbsp;more\u0026nbsp;conventional,\u0026nbsp;often\u0026nbsp;top-down\u0026nbsp;methods\u0026nbsp;such\u0026nbsp;as\u0026nbsp;structured\u0026nbsp;interviews\u0026nbsp;or\u0026nbsp;surveys,\u0026nbsp;our\u0026nbsp;approach\u0026nbsp;enabled\u0026nbsp;richer interactions and reflections. Participatory methods facilitated real-time co-creation and mutual learning, elements often absent in more extractive forms of consultation (36,37). This enhanced the contextual relevance and credibility of the tool, improving its likelihood of uptake and sustained use in routine maternal care systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmerging themes\u003c/strong\u003e\u003cstrong\u003eand quality\u003c/strong\u003e\u003cstrong\u003eindicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality indicators generated through this participatory process reflect key dimensions of maternity care that are consistently highlighted in the global literature and LMIC contexts (15, 38, 39). These included respectful and dignified treatment,\u0026nbsp;clear\u0026nbsp;and\u0026nbsp;compassionate\u0026nbsp;communication,\u0026nbsp;emotional\u0026nbsp;support,\u0026nbsp;timely\u0026nbsp;and\u0026nbsp;equitable\u0026nbsp;access\u0026nbsp;to\u0026nbsp;services,\u0026nbsp;continuity\u0026nbsp;and coordination\u0026nbsp;of\u0026nbsp;care,\u0026nbsp;technical\u0026nbsp;quality\u0026nbsp;of\u0026nbsp;care,\u0026nbsp;and\u0026nbsp;overall\u0026nbsp;client\u0026nbsp;satisfaction.\u0026nbsp;Such\u0026nbsp;themes\u0026nbsp;align\u0026nbsp;closely\u0026nbsp;with\u0026nbsp;global\u0026nbsp;evidence\u0026nbsp;on what women value most during maternity care [15,38\u0026ndash;40] and correspond with the WHO Quality of Care framework, which emphasizes both clinical effectiveness and the experience of care as integral to service quality (16).\u003c/p\u003e\n\u003cp\u003eNotably,\u0026nbsp;the\u0026nbsp;participatory\u0026nbsp;process\u0026nbsp;enabled\u0026nbsp;the\u0026nbsp;prioritization\u0026nbsp;of\u0026nbsp;relational\u0026nbsp;and\u0026nbsp;experiential\u0026nbsp;elements\u0026nbsp;of\u0026nbsp;care,\u0026nbsp;such\u0026nbsp;as\u0026nbsp;autonomy,\u0026nbsp;trust, and respectful interactions, that are often underrepresented in conventional performance metrics. The inclusion of these elements was facilitated by the participatory methods employed, which created a space for service users to articulate nuanced expectations and experiences. By doing so, the tool localizes global standards, thereby enhancing cultural and contextual relevance and ultimately improving its potential for acceptability and sustained use in routine care settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003epractice\u003c/strong\u003e\u003cstrong\u003eimplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese\u0026nbsp;findings\u0026nbsp;offer\u0026nbsp;practical\u0026nbsp;insights\u0026nbsp;for\u0026nbsp;health\u0026nbsp;systems\u0026nbsp;seeking\u0026nbsp;to\u0026nbsp;institutionalize\u0026nbsp;people-centred\u0026nbsp;quality\u0026nbsp;improvement processes.\u0026nbsp;By\u0026nbsp;embedding\u0026nbsp;user\u0026nbsp;perspectives\u0026nbsp;into\u0026nbsp;the\u0026nbsp;development\u0026nbsp;of\u0026nbsp;quality\u0026nbsp;indicators,\u0026nbsp;the\u0026nbsp;feedback\u0026nbsp;tool\u0026nbsp;supports\u0026nbsp;enhanced\u0026nbsp;accountability, responsiveness, and continuous learning within maternity care services. Involving maternity staff in the design process further promoted buy-in and fostered a shared understanding between users and providers, contributing to trust and collaborative\u0026nbsp;problem-solving.\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;participatory\u0026nbsp;approach\u0026nbsp;offers\u0026nbsp;a\u0026nbsp;scalable\u0026nbsp;model\u0026nbsp;for\u0026nbsp;other\u0026nbsp;LMICs\u0026nbsp;advancing\u0026nbsp;national\u0026nbsp;maternal\u0026nbsp;health\u0026nbsp;and\u0026nbsp;universal\u0026nbsp;health coverage agendas. As countries operationalize their quality-of-care strategies, integrating such feedback mechanisms into existing\u0026nbsp;health\u0026nbsp;management\u0026nbsp;and\u0026nbsp;information\u0026nbsp;systems\u0026nbsp;can\u0026nbsp;enhance\u0026nbsp;their\u0026nbsp;sustainability\u0026nbsp;and\u0026nbsp;effectiveness\u0026nbsp;(22,41).\u0026nbsp;At\u0026nbsp;a\u0026nbsp;policy level, the tool provides a locally validated, low-cost mechanism for routinely capturing client feedback to inform quality assurance processes. Its alignment with both national and international quality frameworks increase its potential for integration and scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA\u0026nbsp;key\u0026nbsp;strength\u0026nbsp;of\u0026nbsp;this\u0026nbsp;study\u0026nbsp;lies\u0026nbsp;in\u0026nbsp;its\u0026nbsp;inclusive\u0026nbsp;and\u0026nbsp;methodologically\u0026nbsp;diverse\u0026nbsp;participatory\u0026nbsp;design,\u0026nbsp;which\u0026nbsp;involved\u0026nbsp;a\u0026nbsp;wide\u0026nbsp;range of stakeholders and drew on multiple interactive methods to generate and refine indicators. The use of group discussions, gallery\u0026nbsp;walks,\u0026nbsp;and\u0026nbsp;World\u0026nbsp;Caf\u0026eacute;\u0026nbsp;approaches\u0026nbsp;facilitated\u0026nbsp;the\u0026nbsp;co-production\u0026nbsp;of\u0026nbsp;relevant,\u0026nbsp;user-informed\u0026nbsp;indicators\u0026nbsp;grounded\u0026nbsp;in\u0026nbsp;lived experience\u0026nbsp;and\u0026nbsp;aligned\u0026nbsp;with\u0026nbsp;established\u0026nbsp;quality\u0026nbsp;frameworks.\u003c/p\u003e\n\u003cp\u003eHowever,\u0026nbsp;several\u0026nbsp;limitations\u0026nbsp;must\u0026nbsp;be\u0026nbsp;acknowledged.\u0026nbsp;First,\u0026nbsp;although\u0026nbsp;the\u0026nbsp;sample\u0026nbsp;was\u0026nbsp;diverse,\u0026nbsp;it\u0026nbsp;may\u0026nbsp;not\u0026nbsp;have\u0026nbsp;fully\u0026nbsp;captured\u0026nbsp;the perspectives\u0026nbsp;of\u0026nbsp;sub-groups\u0026nbsp;such\u0026nbsp;as\u0026nbsp;adolescents\u0026nbsp;or\u0026nbsp;women\u0026nbsp;who\u0026nbsp;experienced\u0026nbsp;severe\u0026nbsp;obstetric\u0026nbsp;complications\u0026nbsp;or\u0026nbsp;adverse outcomes, potentially limiting the generalizability of some indicators. To address this in future studies, we plan to incorporate tailored\u0026nbsp;sampling\u0026nbsp;strategies\u0026nbsp;designed\u0026nbsp;to\u0026nbsp;involve\u0026nbsp;these\u0026nbsp;hard-to-reach\u0026nbsp;populations,\u0026nbsp;such\u0026nbsp;as\u0026nbsp;outreach\u0026nbsp;through\u0026nbsp;community\u0026nbsp;groups that support adolescents and women with complications. Additionally, we acknowledge that despite efforts to mitigate power dynamics, the presence of healthcare professionals and policymakers in mixed-group discussions may have inhibited some service users from providing critical feedback. Third, this study does not evaluate the tool\u0026rsquo;s implementation, fidelity, or long-term impact within health facilities. These are important areas for future research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003cstrong\u003efor\u003c/strong\u003e\u003cstrong\u003efuture\u003c/strong\u003e\u003cstrong\u003eresearch\u003c/strong\u003e\u003cstrong\u003eand\u003c/strong\u003e\u003cstrong\u003epractice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on these findings, several recommendations can guide future research and implementation. Firstly, the feedback tool should be piloted in diverse settings, including rural primary facilities, urban centers, and referral hospitals, to assess its usability, acceptability, and responsiveness. This piloting is currently underway and will be reported in a subsequent publication. Secondly, future studies should examine how the routine use of the tool influences provider behavior, patient satisfaction, and maternal health outcomes over time. Thirdly, training facility-level staff in data interpretation and the application of feedback for action planning will be essential to operationalize the tool effectively. Lastly, policymakers should consider embedding such feedback tools into national monitoring and quality assurance frameworks to institutionalize user-centered metrics in maternal health systems.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates the feasibility and added value of using participatory approaches to co-develop a maternity-specific feedback tool that reflects the shared priorities of service users, healthcare providers, policymakers, and community stakeholders. The resulting indicators address both technical and experiential aspects of care, providing a practical, contextually grounded mechanism for improving maternity service delivery. The co-design process itself strengthened stakeholder ownership, fostered mutual understanding, and promoted trust; elements critical for sustaining quality improvement efforts. As global health systems continue to prioritize respectful, equitable, and responsive maternity care, participatory development of feedback tools should be recognized not only as a methodological innovation but also as a strategic imperative for policy and practice. We invite policymakers and clinicians to reflect on their roles in sustaining these participatory feedback mechanisms by reflecting on their contributions to shared stewardship and ensuring the integration of feedback into ongoing improvements. This challenge is an opportunity to energize action and commitment toward these goals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACASI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAudio Computer-Assisted Self-Interviewing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntenatal Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDHIS2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDistrict Health Information Software\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHMIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Management Information System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNGOs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-Governmental Organizations\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSQ-18\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Satisfaction Questionnaire (18-item)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality Management Directorate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReproductive Health Directorate. RMC:Respectful Maternity Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapproval\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econsent\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eto\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eparticipate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch ethics approval was sent to the College of Medicine Research Ethics Committee (P.07/23-0167) and the University of Liverpool Ethics Committee (13920). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and relevant institutional guidelines. Participation in this study was entirely voluntary, and anonymity was ensured using non-identifiable data. Written informed consent was obtained from all stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003efor\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003epublication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants gave written informed consent for their personal details to be published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edata\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ematerials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eInterests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the NIHR (NIHR 134781: Improving the quality of maternal healthcare in Africa), utilizing UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eContribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eALNM, DL, and EC conceptualized the project. ALNM, MJG, and CK supervised the project. DL and ALNM acquired funding and took responsibility for the manuscript. MJG, CK, LM, AK, BM, CB, LG, LK, EC, EC, and ALNM planned the project, developed methods, and discussion guides. MJG, CK, AK, LM, CB, EC, LK, and ALNM facilitated the discussions. MJG, CK, AK, and CB transcribed the data. MJG, CK, AK, and ALNM developed the analysis plan. MJG performed formal data analysis. MJG drafted the manuscript, and YC, CK, LM, AK, BM, CB, LG, LK, EC, EC, DL, and ALNM critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank everyone involved in the co-design and validation workshop for their valuable contributions. We also thank the Ministry of Health Directorates (RHD and QMD) for their participation and coordination. Special thanks to Sonia Whyte and Nancy Medley from the University of Liverpool for helping to proofread the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Trends in maternal mortality 2000\u0026ndash;2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]., Geneva; 2023 [cited 2025 April 29]. 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Lancet. 2016;388(10057):2307\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternity care, Feedback tool, Quality indicators, Participatory research, Maternal health, Service user engagement, Respectful care, World Café, Gallery Walk, Low-resource settings","lastPublishedDoi":"10.21203/rs.3.rs-7643760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7643760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFeedback from maternity service users is critical to improving the quality of care, yet existing tools often lack contextual relevance and fail to capture experiential aspects of care. This study aimed to co-develop a maternity-specific feedback tool by engaging service users and relevant stakeholders in identifying meaningful quality indicators using participatory methods.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative, consensus-driven design was employed across two multi-stakeholder workshops held in July 2024 and February 2025 in Malawi. Participants included service users (individuals who received maternity care), service providers (health professionals), policymakers, and community representatives. Participatory techniques, specifically the World Caf\u0026eacute; (a structured conversational process that supports open and intimate discussion), gallery walks (an activity where participants review and provide feedback on visual displays), and group discussions, were employed to elicit and prioritize quality indicators and assess delivery modalities for the tool. Data from transcripts, notes, visual materials, and observations were analyzed thematically, with triangulation of visual (pictures, charts) and verbal data enhancing the depth of insights. Two structured rounds of stakeholder feedback were used to refine the tool iteratively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e A total of 95% (N\u0026thinsp;=\u0026thinsp;46) of the invited stakeholders participated in the co-design workshop, and 95% (N\u0026thinsp;=\u0026thinsp;39) attended the validation workshop. The resulting tool includes 27 antenatal, 28 labour and delivery, and 32 postnatal indicators across seven domains: respectful and dignified care, communication and education, emotional support, timely and equitable access, continuity and coordination of care, quality of services received, and overall satisfaction. The tool will be piloted in two formats, paper-based and electronic. These findings demonstrate that the tool comprehensively captures user experiences and is considered contextually relevant by stakeholders.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003e The participatory co-design process yielded a maternity feedback tool that aligns with user priorities and is tailored to Malawi\u0026rsquo;s health system. The feedback tool systematically captures women\u0026rsquo;s experiences using indicators valued by stakeholders, enabling scalable quality improvement in maternal care.\u003c/p\u003e","manuscriptTitle":"Measuring Women’s Experiences with Maternity Services: Development of a Feedback Tool in Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-08 15:24:42","doi":"10.21203/rs.3.rs-7643760/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-11T06:14:24+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"169415579076682805825200803774966592750","date":"2025-11-12T09:12:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T18:53:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-04T10:59:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227018924788666183100293350568817811141","date":"2025-11-04T10:47:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15787218638627025610912105644774013630","date":"2025-11-04T06:41:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T06:28:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T09:19:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-03T03:55:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-01T04:05:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-30T21:25:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dda7e2fc-0b4b-4c35-8b42-c0d1a5ffdada","owner":[],"postedDate":"November 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T07:38:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-08 15:24:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7643760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7643760","identity":"rs-7643760","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}