SAFE Strategy Development Tool

Name: SAFE Strategy Development Tool: A guide for developing strategies to improve skilled attendance at delivery.

To tool: http://www.abdn.ac.uk/dugaldbairdcentre/safe/pdfs/sdt_manual.pdf (PDF)

Origin / Source: SAFE International Research Partnership, The Dugald Baird Centre for Research on Women's Health, University of Aberdeen

Technical area: Maternal and Newborn health

Basic Description: The SDT enables program managers in developing countries to systematically gather and interpret information and to plan for strategies to increase the proportion of deliveries with skilled attendance.

Country Applications: The SDT has been applied in Bangladesh, Ghana, Jamaica, Malawi, and Mexico.

Language(s) Available: English

Purpose: Monitoring/ situation analysis/ needs assessment

Technical Scope/Purpose: The SDT guides the systematic collection and interpretation of information for the development of alternative strategic options for improving skilled attendance at delivery.

Design: Cross-sectional

Method: qualitative and quantitative

Frequency of Administration: To date, the tool has only been applied once in each country. However, application of the SDT for the first time can provide the essential baseline information needed in order to measure progress. Subsequent applications of selected modules in the SDT can then be used to chart progress over time and across areas.

Key Users of the Information: Program managers, policy makers

Objectives and Scope of the Tool: The objectives of applying the SDT may include one or more of the following:

  • to identify and prioritize the main problems with regard to Skilled Attendance;
  • to investigate the problems in more detail;
  • to develop strategy options which address the identified problems;
  • to establish a baseline prior to commencing an intervention strategy for Skilled Attendance;
  • to determine whether progress is being made in improving Skilled Attendance during the course of implementing a strategy.

Key Indicators: Percentage of births attended by a health professional; percentage of births at health facilities; availability of basic essential obstetric care; availability of comprehensive essential obstetric care

Tool Design: This SDT takes advantage of a variety of research methods to help program managers and policy makers assess the skilled attendance situation and develop strategies to improve skilled attendance. The tool consists of five modules that guide users through key informant interviews, focus groups, and a comprehensive review of existing skilled attendance data. Each of the modules is described below.

Module 1, Problem Identification, is a preliminary diagnostic exercise using qualitative methods to establish key informants' views on local priorities.

Module 2, Situation Analysis, is divided into two sections. The first section, Module 2a, Document and Literature Review, provides a guide for the identification, analysis, interpretation and organization of existing data. Module 2b, Further Analysis of Population-based Surveys, provides guidelines to analyze existing datasets from DHS and other similar population-based surveys.

Module 3, Needs Assessment of the Poor, outlines qualitative methods for determining the needs of the poorest.

Module 4, Quality of Clinical Care, uses delivery records to measure the clinical quality of care provided at health facilities. This module introduces the Skilled Attendance Index (SAI), a summary measure of the percentages of criteria met in each delivery record.

Implementation and Training: Implementation requires the assembly of a team of researchers with a variety of research skills (e.g. qualitative, quantitative, etc.). The amount of external technical assistance required to implement the SDT will depend on the capacity of local researchers. The tool has been successfully implemented in some countries with minimal external technical assistance, if any. Other countries required training and technical assistance. The fieldwork is carried out by a research team of about 5-6 researchers who are familiar with the country context and can help identify sources of information such as policy documents and key informants. Because the SDT encourages the use of existing data sources and rapid appraisal methods, the timetable for implementation is usually 3-5 months for data collection and analysis.

Manuals and Guidelines (if applicable): The tool includes guidelines for use. In addition, a separate costing manual is available. A policy brief is also available for policy makers interested in the SDT.

Data Processing and Analysis: Some modules (e.g. Module 2b, Module 4) require statistical software packages for data analysis. The research team should include at least one researcher with data analysis, preferably multivariate analysis skills. The SDT is accompanied by a compact disc, which includes sample programs for analysis of data using SPSS and STATA. These are programs are designed to analyze DHS data and may require minor modifications depending on the country context. With more significant modification, they can be used to analyze population-based survey data from other (non-DHS) sources or as a guide to calculate indicators of skilled attendance from other sources.

Reporting and Dissemination of Results (if applicable): It is recommended that the research team include the program managers and policy makers who will develop the skilled attendance strategy. Including the target audience as members of the research team reduces the need for dissemination. However, because the findings of the SDT could be valuable to other stakeholders, dissemination of the findings of some modules is recommended. For example, it is recommended that the results of the case extractions be shared with the participating health facilities so they can develop their own strategies to improve skilled attendance. Similarly, if the results of the PRA are shared with community leaders, they may take steps to improve skilled attendance at the community level.

Costing: During the pilot phase, the approximate costs of implementing the tool are between $12,900 and $15,600 for applications at the district or sub-district level. These figures may underestimate the cost of applying the SDT because during the piloting of the SDT, some countries did not complete all five of the modules. A costing manual, which can be applied in parallel with the SDT to record costs, is available.

Lessons from Experience: Lessons learnt from the experience of applying the SDT in five countries as part of the SAFE research initiative include:

  • Skilled attendance comprises not only a skilled attendant, but also an enabling environment.
  • It should not be assumed that health professionals are necessarily skilled in delivery care. The widely used indicator of percentage of deliveries with health professionals is not necessarily an accurate proxy of skilled attendance. Data collected when applying the SDT can be used to supplement global indicators at local level.
  • Existing data should be interpreted systematically in order to guide and focus any collection of new data.
  • National level data can mask sub-national variations. Target populations and strategy goals need to be clearly defined and assessed in order to address issues of equity in the development of strategies.
  • Policy makers should be involved at key points in research to enable the incorporation of research findings in policy and practice.
  • A certain degree of flexibility is encouraged when using the SDT, but caution should be exercised as too much flexibility could invalidate the methods.
  • Future research needs identified by SAFE are in the areas of referral, over-medicalization and quality of delivery care outside health facilities.

Contact Person: For more information on the SAFE Strategy Development Tool, please contact:

Dr. Julia Hussein
Dugald Baird Centre for Research on Women's Health
Department of Obstetrics and Gynaecology
University of Aberdeen
Aberdeen Maternity Hospital, Cornhill Road
Aberdeen AB25 2ZL Scotland
Tel: ++ 44 1224 554474
Fax: ++ 44 1224 404925
Email: j.hussein@abdn.ac.uk

For more information on the Inventory of Maternal and Newborn Health Tools, please contact: Silvia Alayón, MEASURE Evaluation. Tel: (301) 572 0850; Fax: (301) 572 0999; e-mail:Silvia.Alayon@orcmacro.com