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

Abstract

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-025-02143-6.

Introduction

The provision of skilled care during the perinatal period is crucial for safeguarding the lives of mothers and their newborns [1]. In high- and upper-middle-income countries, 99% of births are attended by skilled personnel; however, this percentage declines to 84% in lower-middle-income countries and 73% in low-income countries [1, 2]. The lack of access to skilled care, along with poor quality of care (characterised by disrespect and abuse, as evidenced by women’s reported experience measures [WREM]), a shortage of adequately trained providers, and broader systemic challenges (such as climate and humanitarian crises), significantly contribute to low skilled birth attendance [3–5]. Addressing these barriers at both the health system and societal levels is imperative for improving global maternal health outcomes [5]. This situation necessitates urgent, evidence-based, and contextualised initiatives to enhance maternal health services and bridge the critical gaps that jeopardise the lives of women and newborns [5].

Respectful Maternity Care (RMC) is a crucial component of high-quality maternal healthcare throughout the perinatal continuum [6]. It prioritises privacy, confidentiality, protection from harm, informed decision-making, and continuous support [6]. RMC fosters nurturing, communicative, compassionate, and dignified care [7, 8], enhancing positive childbirth experiences beyond merely preventing mistreatment [9].

Respectful maternity care is most effective when its drivers and barriers are clearly identified, measured, and integrated into maternal and newborn care through stakeholder advocacy [10]. The White Ribbon Alliance (WRA) Charter affirms the independent rights of both women and newborns, advocating respectful, ethical, and high-quality maternity care that upholds the dignity of both [11]. The WRA emphasises the importance of empowering women with information to make informed decisions for themselves and their newborns, while also recognising newborns as individuals with their own autonomous rights [11].

In recent years, researchers in low- and middle-income countries (LMICs) [8, 12–16] and high-resource countries have increasingly focused on defining and measuring RMC [17]. The accurate measurement of RMC implementation as an intervention plays a crucial role in improving maternal and child health [18]. Previous research has outlined seven key RMC domains to improve maternity care quality: abuse-free care, privacy, confidentiality, consent, discrimination-free care, non-neglect, and non-detention [19, 20]. However, important domains such as culturally sensitive care, safety, communication, and optimal birth settings were not included in these frameworks [18]. Differences in geographic resource contexts also affect the measurement of mistreatment [21, 22]. Clark et al. (2022) used the Delphi method to validate RMC indicators in high-resource settings, establishing measurable benchmarks for respectful care practices [17]. The scope of RMC domains and indicators, identified in high-resource countries, has not been adequately contextualised for low-income settings and remains underexplored in resource-limited contexts [8]. This gap represents a missed opportunity to strengthen maternity care and improve the broader health system [12].

There is a lack of validated indicators and core principles for measuring RMC, particularly in resource-limited settings. This absence of robust measurement tools contributes to the persistence of disrespect and abuse during childbirth, undermining both maternal health outcomes and women’s rights [23]. This gap affects a broad range of stakeholders, including maternity care providers, program implementers, researchers, and, most importantly, women receiving care [24]. To address this issue, tool developers emphasise contextual adaptation and the need for consensus-driven approaches to standardise RMC LMICs [24, 25].

The development of standardised, yet context-specific indicators is essential, not only to enable meaningful cross-country comparisons but also to strengthen accountability [15], guide the creation of context-appropriate policies and guidelines, and inform policymakers [17]. This is particularly critical in resource-limited settings, where workforce shortages, infrastructure constraints, and sociocultural dynamics pose ongoing challenges to care delivery [26]. In response to these gaps, this study aimed to identify and validate the core principles and indicators of RMC within the Ethiopian context, with a view to their applicability in other resource-limited settings. The gap in previous studies identifying key indicators of RMC, along with the lack of studies in low-income settings, underscores the need for valid core principles and indicators of RMC.

Methods

Study settings and period

This three-round online Delphi study was conducted in Ethiopia. This study was conducted across higher education institutions and healthcare facilities in Ethiopia. The study period was from January 01 to 30 February 2025.

Sample & recruitment

Maternity care professionals in Ethiopia, including researchers, midwifery educators, representatives of midwifery associations, registered midwives, and obstetricians familiar with RMC, were recruited via email. Additional professionals were recruited through referrals from the participants. Evidence of their expertise included being an author of relevant books or articles related to RMC and over five years of work experience in the maternity care field. Invitations, including consent forms and information sheets, were emailed to potential participants. Non-responders were emailed a single reminder after two weeks. Participants’ details were anonymous to each other, but a summary of their opinions was available to other participants after completion of each round. This condition minimises the risk of an individual’s opinions influencing the opinions of others, thus avoiding bias [27].

The size of a Delphi study is not standardised and can vary from 10 to 1000 [28]. Delphi studies do not always rely on statistical power; instead, they rely on group dynamics to reach a consensus [29]. Homogeneous panels may include as few as five participants and are more likely to reach and even require 100% consensus [30]. Heterogeneous participants, such as those in this proposed study, benefit from the diversity of member experience and opinion; thus, a relatively high number of participants are recommended to capture that diversity [31]. This Delphi study incorporated expertise from a diverse range of backgrounds, including academic, practice, advocacy, and lived experience [32]. In this study, 30–50 volunteers were planned to be recruited purposefully or through the study team’s networks using constrained snowball sampling [33]. The Delphi approach was modified to accommodate the time commitments of busy professionals, allowing the rounds to continue as new participants were recruited as needed.

Delphi study stages

The development of the RMC core principles and indicators involved a multi-phase process (Fig. 1). First, a literature review was conducted to identify the initial items. These were then refined by removing duplicates and irrelevant entries from the list. Maternal health experts participated in a three-round Delphi study. In the first round, the indicators were rated based on importance, relevance and clarity. In the second round, the revisions were reviewed to reach a consensus. In the final round, the study participants validated and confirmed their agreement on the core principles and indicators of RMC. The details are presented in Fig. 1.

Fig. 1.

Diagram representation of the methods and stages of Delphi study

Indicators identification strategy

The literature search was conducted across five major electronic databases: Web of Science, Scopus, PubMed, Embase, and CINAHL. Studies using validated tools to assess respectful or disrespectful perinatal care in low-resource settings were included in this review. The literature search included studies that investigated indicators or items designed to measure various aspects of the RMC. Existing conceptual frameworks were assessed and evaluated. The studies were required to be original research published in peer-reviewed English-language journals between 2010 and 2024.

Initial indicators from the literature review were analysed for inclusion in the Delphi study. A total of 338 indicators of disrespectful or respectful maternity care were identified through the literature review. Finally, 75 indicators were selected for validation after the removal of irrelevant and duplicate indicators (Supplementary File 1). To facilitate the Delphi participants’ evaluation, the indicators were securely uploaded to Qualtrics^® for digital distribution. The findings from the literature review phase informed the initial pool of items to be assessed during the Delphi rounds.

Round one online survey

In this phase, we distributed the initial list of core principles and indicators derived from the literature review to the study participants for rating. Participants were asked to assess the importance, relevance, clarity, and applicability of each item in the questionnaire. Their quantitative ratings and free-text feedback were analysed and used to refine the list of indicators. The first round of the Delphi online survey primarily consisted of closed and open-ended questions with free-text responses [34]. Open-ended questions were developed to provide feedback on whether revisions were needed and to add new indicators. Examples of the open-ended questions included: Do you think the core principles and indicators we have listed are relevant in your setting or experience? Why or why not? Are the identified core principles and indicators of RMC clear and easy to understand? If not, what should be changed? What other core principles or indicators would you suggest adding, and why?

The survey was administered electronically via email and was available for four weeks. All study participants provided written consent before commencing the survey. Participants who had not completed the survey within two weeks were sent an automatic reminder from Qualtrics^®, which included the option to withdraw at any time. Indicators were evaluated on a four-point Likert scale for importance, relevance, and clarity. Responses were analysed to identify consensus through quantitative, qualitative, or a combination of both methods, and the results were reported to all participants who completed the prior round [35]. The estimated time to complete the survey sections of each round of the Delphi survey was approximately 45 min.

Generating round two indicators of respectful maternity care

This round consisted of both open- and closed-ended questions, as well as various consensus statements regarding the items. In Round Two, participants were provided with a summary of the Round One results, including the level of agreement for each indicator, along with a comparison of the original and revised versions of the indicators and core principles. An explanation of the changes made based on their feedback is also included. The participants were then asked to confirm their agreement with the revised items or suggest further modifications. Based on the feedback and ratings from Round One, we revised the indicators (e.g. merged, removed, or reworded items) and sent them to the participants to regroup them under the refined core principles of RMC. The updated list was then returned to the same group of participants for re-evaluation. We explicitly included a summary of Round One results, and highlighted changes made, asking participants to confirm agreement or suggest further revisions. This phase served as both a validation step and a mechanism to confirm the consensus. This approach has been identified as a useful measure of consensus in Delphi studies [36].

Round three online survey

The final version of the core principles and indicators of RMC was compiled and sent to participants who had completed both earlier rounds of the survey. The indicators were organised under the most appropriate core principles, reflecting the consensus reached in the previous rounds. Participants were invited to provide final feedback and asked to confirm their agreement if they were satisfied with the outcomes of the process.

Data analysis methods

Qualitative data were derived from open-ended questions, allowing free-text responses. Thematic analysis was conducted as per Braun and Clark [37], extracting keywords and iteratively developing themes and subthemes. The primary author completed the initial coding, and the co-authors resolved any conflicts that emerged. These codes were subsequently collated into subthemes. Finally, the subthemes were collated into overarching themes. The themes were summarised and presented in paragraph form for each round. The synthesis involved refining the language, merging overlapping items, and regrouping indicators under more appropriate core principles based on participant suggestions.

A simple descriptive analysis was performed on categorical demographic data, with variables reported as counts (n) and percentages (%). Quantitative data from the Likert scales were collated to determine consensus. During collation, responses rated as “very important/relevant/clear” and “important/relevant/clear” on the Likert scale were grouped to indicate agreement. Items rated as “less important/relevant/clear” and “not important/relevant/clear” were grouped as disagreements and excluded. Once an 80% consensus was reached on the collated groups, the items were presented again in subsequent rounds. The second round was also analysed thematically and descriptively.

Results

Round one participants’ socio-demographic characteristics

Invitations to complete the round one online survey were emailed to 103 expert panel members. Twenty-eight participants were excluded because of non-functional, returned, or duplicated email addresses. Seventy-five participants initiated the survey, and 42 did not complete it. Ultimately, 33 participants provided complete data for this stage. The demographic data of the participants are presented in Table 1. Participants’ characteristics were described through self-identification of background, including gender, age, researcher/academic status, registered midwife/practitioner status, membership in midwives’ associations, and duration of work experience. Most participants were male, reflecting the high proportion of male midwives and the predominance of male educators and researchers in Ethiopian higher education institutions. The participants had diverse backgrounds and expertise, including national and international specialists in respectful maternity care (n = 2) and an expert in psychometric properties and measurement (n = 1).

Table 1.

Round one socio-demographic characteristics of the study participants

Characteristics	Categories	Count	Percentage
Participants’ professional background	Academic	25	75.8%
	Obstetrician or Gynaecologist	1	3%
	Midwife Practitioner	13	39.4%
	Maternal Health Researcher	13	39.4%
	Midwives’ Association	3	9%
Age	< 35 years	20	60.6%
	≥ 35 years	13	39.4%
Gender	Female	2	6%
	Male	31	94%
Work experience in years	< 10 years	12	36.4%
	≥ 10 years	21	63.6%

Quantitative findings of the first-round online survey

The set of indicators derived from the literature review was evaluated. Four-point Likert scales were used to assess the ratings of importance, relevance, and clarity (ranging from “not important/not relevant/unclear” to “very important/very relevant/very clear). The respondents indicated their preferences for retaining, revising, or discarding each indicator. A text box was provided for feedback on the modification. The total number of indicators included in the round one online instrument was 75. Item number 76 was a free-text solicitation for any additional feedback and indicators that the participants wished to contribute.

Content validity of the first-round indicators

The median ratings and indicator-level content validation index (CVI) were calculated using the Likert ratings for each indicator’s importance, relevance, and clarity. Most indicators exhibited a median rating of four for importance (n = 73), relevance (n = 73), and clarity (n = 73). The Content Validity Index (CVI) for importance and relevance ranged from 0.66 to 1.00. A small number of indicators (n = 3 [Indicators 5, 14, and 63]) did not meet the established cut-off value of 0.80 for the item-level CVI for importance, relevance, or both. Therefore, these three indicators were eliminated. The indicator-level CVI for clarity ranged from 0.90 to 1.00. The Scale Level Content Validity Index (S-CVI) for both importance and relevance was 0.94, and for clarity, it was 0.98 after the second round of revision. Based on the quantitative and qualitative analyses, three new items were incorporated, and most items were consolidated. Many indicators were revised based on the feedback from participants. Consequently, 60 RMC indicators were prepared for the second round of the Delphi survey. Twelve RMC indicators were merged with other indicators.

Indicators acceptance rate by participants

In addition to the CVI, the proportion of respondents supporting the indicator was determined to reflect the acceptability of each indicator. This proportion was calculated using the number of participants who selected “Leave item as it is” response to the question “What would you like to do with this item?“. The distribution of participants’ support for each indicator is presented in Fig. 2.

Fig. 2.

Participants’ support for each indicator during the first round assessment

First round qualitative findings

The qualitative analysis of expert feedback on RMC indicators revealed several critical areas for refinement to ensure that the tools used to assess RMC are both valid and meaningful, particularly in resource-limited settings. Participants raised concerns regarding the complexity and inaccessibility of several indicators. They emphasised the need to simplify language, avoid jargon and double-barrelled items, and use clear and plain phrasing in the active voice and present tense. These revisions aimed to enhance comprehension across educational levels and ensure that all women, including those with limited formal education, could engage meaningfully with the survey content.

Cultural and contextual adaptation has emerged as an important consideration. Respondents noted that some indicators were misaligned with local norms, beliefs, and health care realities. References to gender identity or assumptions about physical infrastructure, such as private rooms, were considered economically and culturally inappropriate or practically unfeasible in resource-limited healthcare facilities. They recommended revising these items to reflect local practices and resource constraints, ensuring that the indicators are respectful, acceptable, and implementable in diverse settings.

Further concerns were raised regarding the conceptual integrity and measurability of the indicators. Several items were identified as containing multiple concepts, which could potentially confuse the respondents and compromise the measurement reliability. Participants suggested disaggregating complex questions and focusing on observable, measurable, and actionable indicators. Emphasis was placed on aligning the questions with the lived experiences of women and the operational realities of healthcare delivery in Ethiopia and other resource-limited settings. Some indicators were viewed as failing to uphold women’s rights to informed consent, autonomy, and non-discrimination. Experts stressed that indicators should affirm ethical standards by promoting privacy, dignity, and equitable care, regardless of a woman’s marital status, HIV status, or ability to pay for the service.

Respondents highlighted the need to consider women’s emotional and psychological experiences during childbirth. They emphasised the importance of capturing women’s experiences, focusing on empathy, communication, and emotional support from caregivers. Emotional mistreatment, including verbal abuse or harsh language, was identified as a pervasive but under-measured component of disrespectful care that must be captured in the RMC assessment.

Finally, the experts addressed the structural and practical feasibility of the proposed indicators. They observed that many items placed undue focus on individual provider behaviour while neglecting broader systemic challenges such as staff shortages, supply availability, and facility conditions. They recommended adding indicators that reflect accurate standards of care and adapting tools for use across various health facilities.

Round two online survey results

Second round participants’ characteristics and response rate

Invitations to complete the round two online survey were sent to all 33 individuals who had participated in the first round, yielding a response rate of 90.9%. Similar demographic and background data were collected as in round one. Of the 33 invited participants, three did not complete the survey, resulting in a final sample of 30 experts who provided complete data for this round of the study. All participants provided informed consent before beginning the survey. The demographic data of the expert panel members are presented in Table 2.

Table 2.

Second round participants’ demographic characteristics

Characteristics	Categories	Count	Percentage
Participants’ professional background	Academic	24	80%
	Obstetrician or Gynaecologist	1	3.33%
	Midwife Practitioner	13	43.33%
	Researcher	11	36.66%
	Midwives’ Association	3	10%%
Age	< 35 years	18	60%
	≥ 35 years	12	40%
Gender	Female	1	3.33%
	Male	29	96.67%
Work experience in years	< 10 years	12	40%
	≥ 10 years	18	60%

Second round qualitative results

In the second round, the participants helped define the core principles of RMC and categorised each indicator under the most appropriate core principle. Based on the findings of the literature review, we initially identified 13 core principles of RMC. These were presented to the participants for review and feedback. They were also invited to provide feedback and, if desired, to suggest additional core principles. Following their input, three core principles (compassionate care, informed care, and privacy) were merged with others owing to conceptual overlap, resulting in a final consensus on ten core principles.

The study participants demonstrated strong agreement with the indicators aligned with each core principle. Based on the participants’ feedback, several terms were revised. ‘Attentive care’ was modified to ‘Attentive and compassionate care’. ‘Consented care’ was revised to ‘Informed and consented care’. ‘Privacy’ and ‘confidentiality’ were consolidated. ‘Equitable care’ was altered to ‘Equitable and inclusive care’. ‘Secure care’ was changed to ‘Safe care’. ‘Collaborative care’ was modified to ‘respectful communication’. ‘Culturally appropriate care’ was revised to ‘Culturally sensitive care’. Finally, the term ‘Optimal birth setting’ was updated to ‘Optimal birth setting and choice’. Table 3 presents the details of these findings in detail.

Table 3.

Respectful maternity care frameworks and core principles

Respectful maternity care domains	Bowser and Hill [38]	Bohren [39]	WRA [40]	MCHIP [41]	HCC [42]	WHO		Black Mama [43]	RMCT [19]	PCMC [44]	Australian WCCG [45]	AWHONN [46]	RMCP [18, 24]	FIGO [47]
						A [48]	B [6, 49]
Abuse and Violence Free Care
Physical abuse-free care	✓	✓	✓	✓		✓	✓	✓	✓			✓	✓	✓
Verbal abuse-free care		✓				✓	✓	✓	✓				✓	✓
Sexual abuse-free care		✓											✓	✓
Emotional abuse free care		✓						✓	✓			✓		✓
Systematic abuse free care		✓						✓					✓
Financial abuse free care	✓	✓	✓					✓				✓		✓
Attentive & Compassionate Care
Neglect free care	✓	✓	✓		✓	✓	✓					✓		✓
Informed & Consented Care
Informed consent and access to information	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Transparent care	✓	✓	✓	✓	✓	✓	✓	✓	✓		✓	✓	✓
Autonomous & Dignified Care
Right to choose and be heard			✓			✓	✓	✓	✓		✓	✓	✓	✓
Individualised and value-based care			✓					✓	✓	✓		✓	✓	✓
Privacy and Confidentiality
Confidentiality	✓	✓	✓	✓	✓	✓	✓		✓	✓	✓		✓	✓
Privacy	✓	✓	✓	✓	✓	✓	✓		✓	✓	✓		✓	✓
Equitable and Inclusive Care
Equality, discrimination-free care	✓	✓	✓	✓		✓	✓	✓	✓				✓	✓
Universal accessible health care								✓		✓			✓
Inclusiveness								✓	✓					✓
Safe & High-Quality Care
Timely care			✓	✓	✓	✓	✓						✓	✓
Continuity of care					✓	✓	✓	✓	✓		✓		✓	✓
Evidence-based care									✓					✓
Proactive care or safe care						✓	✓	✓			✓		✓
Collaborative & Respectful Communication
Effective communication	✓	✓				✓	✓		✓	✓	✓		✓
Mutual or collaborative understanding of care		✓									✓
Shared decision making						✓	✓	✓	✓				✓
Culturally Sensitive & Respectful Care
Culturally sensitive care					✓	✓	✓	✓	✓		✓		✓	✓
Family and community support					✓			✓	✓	✓	✓		✓	✓
Optimal Birth Setting & Choice		✓		✓	✓		✓			✓				✓

AWHONN Association of Women's Health, Obstetric and Neonatal Nurses, Australia WCCG Australian Woman-centred Care Guideline, FIGO Federation of International Gynaecology and Obstetrics, HCC Humanised childbirth care, MCHIP Maternal and Child Health Integrated Project, PCMC Person-centred Maternity Care, RMCP Respectful Maternity Pathway, RMCT Respectful Maternity Care Typology, USAID United States Agency for International Development, WHO World Health Organization, WRA White Ribbon Alliance

Second round final core principles and indicators of RMC

A total of 60 indicators and10 preliminary core principles of RMC were presented to the participants. The process of indicator selection for round two is illustrated in Fig. 3.

Fig. 3.

Process of indicator selection for round two online survey

Participants were then tasked with categorising the indicators under the most appropriate finalised core principles of RMC Table 4. Consensus was also reached on the categorisation of indicators within the ten core principles of RMC. Each indicator was assigned to a specific core principle of the RMC based on majority agreement among the participants.

Table 4.

Core principles and indicators of respecful maternity care

Core principles of RMC	Indicators
1. Abuse-free care	1.1. Maternity care provider(s) refrained from using physical force (e.g., gagging, pinching, kicking, slapping, hitting, spitting, restraining, or forcing legs apart) on the woman, her newborn, or her companion.
	1.2. Maternity care provider(s) ensured that the woman received adequate pain relief during procedures such as episiotomy, suturing, or perineal tear repair, or upon request.
	1.3. Maternity care provider(s) prioritised the woman's well-being by avoiding unnecessary procedures such as, perineal stretching, frequent vaginal examinations, or routine episiotomies, unless medically necessary.
	1.4. Maternity care provider(s) refrained from using insults, coercion, blame, judgment, mockery, threats, body-shaming, or scolding toward the woman, her infant, or her support person.
	1.5. Maternity care provider(s) used supportive language and a respectful tone to ensure that the woman did not feel belittled, embarrassed, or discouraged during her care.
	1.6. Maternity care provider(s) refrained from engaging in sexual abuse, assault, coercion, or any inappropriate contact against the woman's will.
	1.7. Maternity care provider(s) ensured that the woman or her companion was not detained due to outstanding bills, accidental damage to hospital property, or delays in discharge documentation.
	1.8. Maternity care provider(s) refrained from requesting or expecting bribes, informal payments, or unnecessary fees during a woman's care.
2. Attentive & Compassionate Care	2.1. Maternity care provider(s) responded promptly and courteously to the woman's questions and concerns, including during emergencies.
	2.2. Maternity care provider(s) offered supportive and respectful counselling about sexual activity in a way that made the woman feel comfortable.
	2.3. Maternity care provider(s) introduced themselves and interacted with the women professionally and respectfully.
	2.4. Maternity care provider(s) addressed women by their preferred names during the care process.
	2.5. Maternity care provider(s) offered the women clear and detailed information about neonatal vaccination, breastfeeding, complementary feeding, infant nutrition, and hygiene.
	2.6. Maternity care provider(s) listened to the woman's concerns, respected her preferences, and provided kind, empathetic support during care.
	2.7. Maternity care provider(s) demonstrated an understanding of the woman's past experiences and challenges during the care process.
	2.8. Maternity care provider(s) ensured that both the woman and her baby were in good health before discharge.
	2.9. Maternity care provider(s) provide continuous and consistent care throughout a woman's pregnancy, labour, delivery, and postpartum period.
	2.10. Maternity care provider(s) supported uninterrupted bonding, such as skin-to-skin contact, by keeping the woman and her newborn together, unless separation was medically necessary.
	2.11. Maternity care provider(s) treated the women with dignity, even during busy periods.
3. Informed & Consented Care	3.1. Maternity care provider(s) obtained informed verbal or written consent from the women before performing any procedures or interventions.
	3.2. Maternity care provider(s) kept the women informed about their labour progress, including updates on procedures, test results, and what to expect after examinations.
	3.3. The healthcare facility respected the woman's autonomy by refraining from using her as an educational subject, avoiding prolonged bedside teaching sessions, and ensuring that physical examinations were not repeated without her informed consent.
	3.4. Maternity care provider(s) informed the woman that the healthcare facility had a system in place to address incidents of disrespect or mistreatment, including a clear process for reporting and taking appropriate action when needed.
4. Autonomous & Dignified Care	4.1. Maternity care provider(s) encouraged the women to eat or drink, move around, and choose their preferred birthing position during labour or the postnatal period, unless it was medically inappropriate.
	4.2. Maternity care provider(s) ensured that the women did not feel pressured to undergo medical interventions (e.g. contraceptive procedures, caesarean section, labour augmentation, induction, or instrumental delivery) without a clear medical necessity.
	4.3. Maternity care provider(s) encouraged the woman's chosen birth companion to stay with her whenever possible.
	4.4. Maternity care provider(s) supported the woman's ability to make informed decisions and ensured she felt comfortable accepting or declining the care options offered.
5. Privacy & Confidentiality	5.1. Maternity care provider(s) ensured the confidentiality of the woman's private or medical information by not sharing it with unauthorised individuals.
	5.2. Maternity care provider(s) ensured privacy in the woman's room by allowing access only to authorised personnel and maintaining a restricted entry policy.
	5.3. Maternity care provider(s) maintained the woman's privacy during counselling, procedures, transfers, and examinations using drapes, screens, or private rooms.
6. Equitable & Inclusive Care	6.1. Maternity care provider(s) ensured that healthcare services were cost-effective, transparent, and in line with the health institution's payment policy.
	6.2. Maternity care provider(s) treated the woman fairly and equally, without bias based on personal or social factors such as religion, culture, race, appearance, education, marital status, or financial situation.
7. Safe & High-Quality Care	7.1. Maternity care provider(s) ensured that the woman gave birth in a secure environment and was not left unattended in inappropriate locations, such as floors, corridors, or lavatories.
	7.2. Maternity care provider(s) implemented infection prevention measures, including handwashing, personal protective equipment, and proper waste disposal during care.
	7.3. Maternity care provider(s) informed the women about the proper use of sanitation facilities and waste management and provided the necessary personal protective equipment (if necessary) during childbirth.
	7.4. Maternity care provider(s) ensured the woman's safety and security within the healthcare facility by monitoring the environment, maintaining a secure environment, and addressing any safety concerns.
8. Respectful Communication	8.1. Maternity care provider(s) fostered understanding and rapport by communicating openly, professionally, and respectfully during the woman's care.
	8.2. Maternity care provider(s) engaged the woman and her companion in discussions about the assistance they might need during the care process.
	8.3. The healthcare institution sought feedback from women, family members, or a companion regarding their perceptions of the facility and the services provided.
9. Culturally Sensitive & Respectful Care	9.1. Maternity care provider(s) demonstrated acceptance of the woman's perspective without judging its correctness.
	9.2. Maternity care provider(s) acknowledged and respected the woman's religious or spiritual beliefs, as well as her preference for care providers from her racial, ethnic, or religious group while providing care.
	9.3. Maternity care provider(s) recognised the importance of and worked in alignment with the woman's cultural beliefs or practices throughout her care process.
	9.4. Maternity care provider(s) facilitated women's access to clergy, spiritual leaders, or community support during hospitalisation, in line with health facility policies.
	9.5. Maternity care provider(s) required language translators or interpreters or used easily understandable language when necessary.
10. Optimal Birth Setting & Choice	10.1. Maternity care provider(s) maintained a clean and hygienic environment throughout the woman's labour, birth, and postnatal period.
	10.2. The health institution provided necessary meals, sleep supplies, bedding, clothing, and hygiene items during the childbirth experience.
	10.3. Maternity waiting areas or wards offer accessible informational resources (e.g. brochures, visual aids, audio devices, display screens, and pictures or images of different racial or ethnic groups.
	10.4. During maternity care, the number of care providers was optimal, neither excessive nor insufficient, for the woman's situation.
	10.5. The healthcare facility possessed the necessary infrastructure, including beds, water, electricity, and medicinal supplies.

Third round results

The final ten core principles and forty-nine indicators of RMC were compiled and sent back to the participants for final review. All participants agreed on the final set of ten core principles and 49 indicators. The categorisation of indicators under the respective core principles was also accepted without further revision.

Discussion

This section presents an interpretation of the study’s findings. An iterative three-round online Delphi survey was conducted with diverse maternity health professionals to explore the key principles and indicators of RMC. The rigor of this study was reinforced by the key elements of the Delphi method, including the structured multi-round process, the quality of feedback provided by participants after each round, and the thoroughness of the ongoing analysis [28, 50]. Essential methodological components, such as anonymity, iterative feedback, and statistical aggregation of group responses, contribute to the credibility of this Delphi study [51]. The current study ensured anonymity by using online surveys and consolidating the findings, allowing participants to share their opinions openly and honestly. Anonymous surveys help reduce dominance and group conformity, allowing participants to share their honest opinions on complex issues [28]. However, the interpretation of items can sometimes be challenging in anonymous rounds, potentially impacting the consensus process [28]. To reduce misinterpretation in anonymous rounds, items were clearly worded, supported by brief explanations, and included space for feedback [51].

In a Delphi study, consensus is typically regarded as the primary outcome of interest. Consensus in Delphi studies is defined using various measures; however, inconsistencies exist [51, 52]. It represents a collective viewpoint, a shared sentiment among participants, or, in some cases, complete agreement among the experts [53]. A meta-analysis found that 73% of studies reported a consensus method, whereas only 68% included it in a predefined protocol [54]. Some studies claim to have achieved consensus without detailing the process [52, 54, 55]. In this study, the Content Validity Index (CVI ≥ 0.8) was used to assess the level of expert agreement on the core principles and indicators of the RMC. The CVI is preferred for its simplicity, clarity, and focus on consensus at both the item and scale levels [56]. The majority of scholars agree that a CVI of 0.78 or higher from three or more experts indicates strong content validity [56, 57]. In the final round, the study participants largely regarded the presented core principles and indicators as valid measures of RMC. Although assessing construct validity and reliability was beyond the scope of this Delphi study, the rigorous multi-round process provided strong face validity and expert endorsement of the proposed items [32].

The consistent agreement among participants across rounds reflects the stability of the consensus reached. Stability is defined as the consistency of responses between the successive rounds of a study [58]. Keeney et al., Dajani et al., and Chaffin et al. also believed that achieving a consensus is meaningless when responses are unstable [32, 59, 60]. The inclusion of participants from diverse backgrounds further strengthened the stability and validity of this study.

Conceptual clarity is essential for developing the core principles and indicators to assess RMC. Key among them were the domains of RMC developed by Browser and Hills [38], Bohren [39], and the WHO’s guidance on eliminating disrespect and abuse in maternity care [48]. Rights-based frameworks have also played a central role in shaping and validating core principles and indicators. These include the White Ribbon Alliance’s RMC Charter [40], USAID’s Maternal and Child health Integrated Program [41], the Humanised Childbirth Care model [42], and WHO’s 2016 and 2018 Recommendations [49]. Other frameworks included were the Black Mamas Matter Alliance [43], AWOHN’s RMC toolkit [46], the Respectful Maternity Pathway Framework [18], Woman-centred Care [45], RMC Typology [19], and FIGO’s Ethical Framework for RMC During Pregnancy and Childbirth [47]. The combination of qualitative feedback and quantitative analysis helped refine unclear indicators and merge those that were considered too similar [61]. The iterative and interactive nature of the Delphi process further strengthened the clarity of the statements and built expert consensus [28].

In round two of this study, participants were asked to indicate their level of agreement with the identified ten core principles of RMC. The Delphi study conducted by Butler et al. [62] endorsed items across 12 RMC domains proposed by Shakibazadeh et al. [19] emphasising respect, autonomy, dignity, informed consent, and culturally sensitive care. In the current study, new domains, such as safe and high-quality care, respectful communication, and optimal birth setting and choice, have been added. These domains were added based on the findings of previous studies [17, 18]. All women are entitled to maternity care that is effective, safe, culturally appropriate, and respects, protects, and promotes their human rights [63, 64]. The identified core principles align with the WHO’s call for urgent action to ensure that healthcare systems provide dignified and respectful care for all women during pregnancy and childbirth [65].

In the current study, participants successfully categorised RMC indicators into their corresponding core principles based on shared concepts. This outcome is supported by several factors, including alignment with established theoretical frameworks, such as the WHO guidelines on RMC [6], and the participants’ expertise. This is also consistent with prior research that identified similar domains, such as respect and dignity, informed consent, abuse-free care, privacy, and confidentiality [19]. The use of methodological approaches, such as qualitative data analysis, pilot testing, or cross-cultural validation, further strengthens the validity, reliability, and universality of the categorisations [66]. These elements collectively demonstrate that the participants’ ability to categorise RMC indicators was credible and methodologically sound.

Strenghts and limitations of the study

This Delphi study complements existing measures, such as the Mothers Autonomy in Decision Making (MADM) scale [14], the Mothers on Respect Index (MORI) [15], RMC tools from Tanzania [8] and the WHO [20]. Although the Delphi process is strengthened by participants’ anonymity, controlled feedback, and iterative discussions, this study has certain limitations. Gender imbalance among participants was one of the limitations of this study. This reflects broader structural issues in the study context, where men are overrepresented in academic and leadership roles in health, and male maternity care providers comprise over 33% of the workforce [67]. We recognise the need for more inclusive representation in future research on RMC. Participants’ ratings and comments in the first round indicated that many indicators were unclear or repetitive, which may have contributed to response fatigue during the online evaluation phase. Despite the proactive recruitment of experts, the participation rates varied across the rounds. Variation in the participant rate may affect the stability of the responses. The first round of this study was comprehensive and required a significant time commitment to complete. Although adding consumer experience provides a more comprehensive method for measuring RMC, this survey did not include service users as participants.

Implications of the study

Validating the fundamental principles and indicators of RMC in low-income countries has significant implications for education, clinical practice, and research. The current findings facilitate evidence-based, culturally relevant content in health professional training, enhancing competencies in woman-centred healthcare [62, 68]. In clinical practice, this evidence guides providers, enhances accountability, and builds trust between women and care providers, thereby improving service use [24, 69]. The validated RMC principles and indicators provide an evidence-based response to the WHO’s call for identifying valid RMC indicators in clinical settings [6]. Validated indicators enable consistent measurement and evidence-based interventions while incorporating community voices to monitor quality care [68]. These implications transform maternal health systems toward dignity, equity, and respectful care for women in need.

Conclusion

This Delphi study successfully validated ten core principles and forty-nine indicators of RMC specifically adapted for low-income settings. These core principles and indicators of RMC are instrumental in promoting consistency across research, education, and practice. This study serves as a blueprint, offering structured guidance for sustainable improvements in RMC practice and assessment. The identified core principles and indicators support RMC training by aiding maternity care providers in understanding and promoting respectful maternity care [62].

Future research should explore additional dimensions of validity, including construct, convergent, and discriminant validity, as well as the reliability of these indicators among perinatal women. Moreover, enhancing the implementation of respectful maternity care through targeted change management interventions is essential.

Authors’ contributions

EY contributed to the study design, conceptualisation, and drafting of the original manuscript. EY, CH, DC, LG, and NT were actively involved in article selection, data extraction, interpretation, and analysis. CH, DC, LG, NT, EE, and GM provided substantial feedback and contributed meaningfully to refining the manuscript. All authors contributed to the critical revision and editing of the manuscript. All authors have read and approved the final version of this manuscript. All authors agreed to be accountable for all aspects of the work, ensuring that any questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

All relevant data for the review are included in the paper or uploaded as an additional file.

Declarations

Ethics approval and consent to participate

The ethical approvals for this Delphi study were obtained from Griffith University (Reference No. GU/HREC 2024/861) and the Ambo University College of Health Sciences and Referral Hospital (AU/CMHS-RCS/02/2025). Confidentiality and privacy of the participants were ensured by obtaining informed consent, removing personal identifiers, and assigning unique codes to the participants. Data were securely stored in password-protected files accessible only to the research team. All procedures followed the established guidelines for research involving human participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.