In 2013 around 289,000 women died from what was categorised as maternal complications. This figure is likely to be higher as only 40% of the world has an adequately function health reporting system (WHO et al 2014, p.1). Severe bleeding causes around 27% of all maternal deaths; this is the single biggest threat to pregnancy and childbirth. Moreover, maternal complications are the second biggest cause of death for women of reproductive age globally. The risks women and girls face through pregnancy and childbirth are the outcome of socio-cultural structures and norms, which increase the inequalities in many societies. The decisions we make, the choices we have, and the actions we carry out are a product of our social system’s structures and norms. Humanitarian crises painfully display the divisiveness and destruction that these structures and norms can have on the members of that system. But, crises also offer an opportunity to either, rebuild structures and norms in a way that reduces inequality and protects the vulnerable, or a regression to more traditional, more patriarchal and more hierarchical structures and norms which will ultimately disadvantage women and girls further in their plight for equality. There is a vicious circle of poverty and mortality that can be triggered by maternal death. In order to prevent these cycles from continuing, creative, simple and appropriate strategies need to be developed for humanitarian response that build on the knowledge systems and capacities of those affected, as well as the experience and expertise of practitioners. Instead of a discussion between development or humanitarian, the conversation should try to find ways for all interventions to be more homophilious with those affected and ensure that they do not worsen the structures protecting the most vulnerable. Innovation has long since been seen as a process for those who ‘have’, and not for those who ‘have not’. Criticisms of increasing inequality through a division based on socio-economic markers have only led to self-fulfilling stereotypes of who is innovative and who is not. This research is trying to shift the focus from one that is divisive to a more inclusionary approach. To address maternal mortality caused by severe bleeding, it is imperative to understand the context in which it is happening. Who is affected? Why? What do they think and believe? What happens to the family, the community? How are the structures and norms of the society affecting it? What solutions have been offered? In answering these questions it is clear how far the impact of maternal mortality can reach. It is the hope of this research, that its can be used to reduce and lessen this impact through better-targeted and tailored responses using appropriate tools – such as the non-pneumatic anti-shock garment, implemented in a mind frame of sustainability and resilience in an environment receptive to innovation. There is a need for fresh ideas and approaches to reduce a burden that does not exist in resource stable parts of the world, and a burden that has come to be seen as a problem of the poor. The non-pneumatic anti-shock garment is a game changer. It has the potential to inspire interest and access health systems, yet implementation thus far has been limited in humanitarian response. This research investigates maternal mortality caused by postpartum haemorrhage in humanitarian crises, in an endeavour to improve the discussion on including the NASG into the MISP as an appropriate tool to fight maternal mortality and the inequality that is found at its root.

Background: This thesis presents three research papers that evaluate the current tools and methods used to assess the availability of health resources and services during humanitarian emergencies. Methods: A systematic review of peer-reviewed and grey literature was conducted to locate all known health facilities assessment tools currently in use in low- and middle-income countries. The results of this review were used to generate a framework of essential health facilities assessment domains, representative of seven health systems building blocks. Using this framework, a field-based evaluation of tools used to assess the availability of health resources and services in emergencies in Haiti and the Darfur states of Sudan was conducted. The collected assessment tools from these countries were compared against the framework from the systematic review, as well as the Minimum Standards for Health Action in the Sphere Humanitarian Charter and Minimum Standards in Humanitarian Response, and the Global Health Cluster’s Set of Core Indicators and Benchmarks by Category. A coding system was developed using all of these frameworks that enabled the comparison of the assessments collected in both countries. Field-based interviews were conducted with key informants using a convergent interviewing methodology, to gain perspectives on data collection and the use of evidence in formulating health systems interventions in emergencies. Results: 10 health facility assessments were located in the systematic review of the literature, generating an assessment framework comprised of 41 assessment domains. Of the included assessments, none contained assessment criteria corresponding to all 41 domains, suggesting a need to standardize these assessments based on a structured health systems framework. In Haiti and Sudan, a total of 9 (Haiti, n=8; Sudan, n=1) different assessment tools were located that corresponded to assessments of the availability of health resources and services. Of these, few collected data that could reasonably have corresponded to the different assessment domains of the health facilities assessment framework or the Sphere Standards, nor could many have provided the necessary inputs for calculating the Global Health Cluster’s indicators or benchmarks. The exception to this was the one tool located in Sudan, which fared reasonably well against these criteria. The interviews with participants revealed that while evidence was viewed as important, systematically-collected data were not routinely being integrated into program planning in emergency settings. This was, in part, due to the absence of reliable information or the perceived weaknesses of the data available, but also due uncertainty as to how to best integrate large amounts of health system data into programs. Conclusions: Greater emphasis is needed to ensure that data on the availability and functionality of health services during major emergencies is collected using methodologically-sound approaches, by field staff with expertise in health systems. There is a need to ensure that baseline data on the health system is available at the outside of emergency response, and that humanitarian health interventions are based on reliable evidence of needs and capacities from within the health system.

The aim of this study was to identify and describe the viability of using cell phones to conduct rapid assessments, pass key health messages and conduct monitoring and evaluation in complex emergencies. The study setting was in a cholera outbreak response situation in Mogadishu, the capital of war torn Somalia. Qantitative, descriptive research was conducted to determine the feasibility. Data collection was done using structured questionnaires, self-response mailed questionnaires as well as follow-up telephone interviews. Three groups of respondents participated in the study. The respondent groups included 383 internally displaced persons (IDPs), 5 water, sanitation and hygiene (WASH) specialists and 5 specialists from 5 mobile phone providers in Mogadishu. The study showed that there is good potential for an effective, cost efficient and scalable short message service (SMS) based public health education platform in Somalia. The study has also come up with recommendations on key considerations to ensure viability of the Public health education platform. It is envisaged that the recommended platform shall increase speed, access, spontaneity, coverage and reduced cost per capita, a combination of which form the hallmark of a good emergency health response. Ultimately this effort shall contribute to improved health, reduced suffering and reduced deaths in fragile humanitarian contexts. / Health Studies / M. (Public Health)

The aim of this study was to identify and describe the viability of using cell phones to conduct rapid assessments, pass key health messages and conduct monitoring and evaluation in complex emergencies. The study setting was in a cholera outbreak response situation in Mogadishu, the capital of war torn Somalia. Qantitative, descriptive research was conducted to determine the feasibility. Data collection was done using structured questionnaires, self-response mailed questionnaires as well as follow-up telephone interviews. Three groups of respondents participated in the study. The respondent groups included 383 internally displaced persons (IDPs), 5 water, sanitation and hygiene (WASH) specialists and 5 specialists from 5 mobile phone providers in Mogadishu. The study showed that there is good potential for an effective, cost efficient and scalable short message service (SMS) based public health education platform in Somalia. The study has also come up with recommendations on key considerations to ensure viability of the Public health education platform. It is envisaged that the recommended platform shall increase speed, access, spontaneity, coverage and reduced cost per capita, a combination of which form the hallmark of a good emergency health response. Ultimately this effort shall contribute to improved health, reduced suffering and reduced deaths in fragile humanitarian contexts. / Health Studies / M.A. (Public Health)