I 

114TH CONGRESS 

1ST SESSION H. R. 4148 

To authorize assistance to aid in the prevention and treatment of obstetric 

fistula in foreign countries, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 1, 2015 

Mrs. CAROLYN B. MALONEY of New York (for herself, Mr. GRIJALVA, Mr. 

JOHNSON of Georgia, Ms. MOORE, and Mr. CONYERS) introduced the following bill; which was referred to the Committee on Foreign Affairs 

A BILL 

To authorize assistance to aid in the prevention and treatment of obstetric fistula in foreign countries, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Obstetric Fistula Pre5 vention, Treatment, Hope, and Dignity Restoration Act 

6 of 2015’’. 

7 SEC. 2. FINDINGS. 

8 Congress finds the following: 


smartinez on DSK4TPTVN1PROD with BILLS
2 

•HR 4148 IH

1 (1) Every two minutes, one woman dies from 

2 pregnancy-related complications. Of these deaths, 99 

3 percent occur in developing countries. Over half of 

4 these deaths are in sub-Saharan Africa and one5 third are in South Asia. Most of these deaths are 

6 preventable, which represents both a tragedy and an 

7 opportunity. 

8 (2) For every woman who dies from pregnancy9 related complications, an estimated 20 women sur10 vive but experience pregnancy-related disabilities. 

11 One of the most severe is obstetric fistula, which oc12 curs when a woman who is experiencing prolonged, 

13 obstructed labor and needs trained medical assist14 ance for a safe delivery, usually a cesarean section, 

15 cannot get it. 

16 (3) Obstetric fistula is a hole that is formed be17 tween the bladder and the vagina, or the rectum and 

18 the vagina (or both), after a woman suffers from 

19 prolonged, obstructed labor without timely, adequate 

20 medical intervention. In the struggle to pass through 

21 the birth canal, the fetus puts constant pressure, 

22 sometimes for several days, on the bladder and vag23 inal or rectal walls, destroying the tissue that then 

24 sloughs off, resulting in the abnormal opening or 

25 hole. 


smartinez on DSK4TPTVN1PROD with BILLS
3 

•HR 4148 IH

1 (4) In the majority of obstetric fistula cases, 

2 the baby will be stillborn and the mother will experi3 ence physical pain and disability, as well as social 

4 and emotional trauma from living with incontinence 

5 and from the loss of her child. 

6 (5) In addition to incontinence or constant un7 controllable leaking of urine, feces, or both, the 

8 physical consequences of obstetric fistula may in9 clude frequent bladder infections, infertility, foul 

10 odor, and nerve damage. 

11 (6) Mental, emotional, and social side effects of 

12 obstetric fistula may include depression, social isola13 tion and discrimination, suicidal thoughts or actions, 

14 and lack of adequate economic opportunities, result15 ing in deepening poverty and vulnerability. Girls 

16 with obstetric fistula are also often unable to con17 tinue schooling. Women and girls with fistula suffer 

18 psychological consequences, such as feelings of hope19 lessness because of stigma and lack of awareness 

20 that their condition is treatable. Fistula survivors 

21 need regular medical attention and support, but too 

22 often adequate services are unavailable or the 

23 women and their families cannot afford them. 

24 Women may lose property if they are divorced or 

25 abandoned by their husbands and family. Some lose 


smartinez on DSK4TPTVN1PROD with BILLS
4 

•HR 4148 IH

1 jobs or are denied work, while others may quit their 

2 jobs out of shame, leading to deepened poverty and 

3 vulnerability to repeat fistulas. 

4 (7) Although data on obstetric fistula are 

5 scarce, the World Health Organization (WHO) esti6 mates there are more than 2,000,000 women living 

7 with fistula, and 50,000 to 100,000 new cases each 

8 year. 

9 (8) The primary cause of obstetric fistula is a 

10 lack of timely, adequate emergency obstetric care, 

11 such as a cesarean section. Poverty, malnutrition, 

12 poor health services, early childbearing, and gender 

13 discrimination are interlinked root causes of obstet14 ric fistula. 

15 (9) Obstetric fistula was once common through16 out the world, but over the last century was elimi17 nated in Europe, North America, and other devel18 oped regions through improved access to medical 

19 interventions, particularly emergency obstetric care 

20 for those women who need it. The first fistula hos21 pital in the world stood where the Waldorf-Astoria 

22 Hotel is now located in New York City. As high23 lighted by the United Nations Secretary General in 

24 his 2015 statement on the occasion of the Inter25 national Day to End Obstetric Fistula (May 23rd), 


smartinez on DSK4TPTVN1PROD with BILLS
5 

•HR 4148 IH

1 in which he called upon world leaders to commit to 

2 ending the scourge of obstetric fistula in our life3 time, ‘‘The fact that fistula persists primarily among 

4 the poorest and most marginalized women and girls 

5 in the world is an egregious outcome of social, eco6 nomic and gender inequalities, the denial of human 

7 rights and inadequate access to quality reproductive 

8 health services, including maternal and newborn 

9 care.’’. 

10 (10) Obstetric fistula is preventable through 

11 medical interventions, such as skilled attendance, in12 cluding midwives, present during labor and child13 birth, providing access to family planning, and emer14 gency obstetric care for women who develop child15 birth complications, as well as social interventions 

16 such as delaying early marriage and educating and 

17 empowering young women. 

18 (11) The majority of obstetric fistula can be 

19 surgically treated. Surgery requires a specially 

20 trained, qualified surgeon and support staff, and ac21 cess to an operating theater and to attentive post22 operative care. When performed by a skilled, com23 petent surgeon, success rates can be as high as 90 

24 percent and cost an estimated $400. 


smartinez on DSK4TPTVN1PROD with BILLS
6 

•HR 4148 IH

1 (12) According to the Department of State, 

2 ‘‘Because of their roles in child rearing, providing 

3 and seeking care, and managing water and nutri4 tion, the ability of women to access health-related 

5 knowledge and services is fundamental to not only 

6 their own health and well-being, but also that of 

7 their babies, older children and other family mem8 bers. Over the long-term, the health and well-being 

9 of women, in addition to being essential in its own 

10 right, enhances their productivity and social and eco11 nomic participation and also acts as a positive multi12 plier, benefitting social and economic development 

13 through the health of future generations.’’. 

14 (13) In 2002, the United Nations Population 

15 Fund (UNFPA) and EngenderHealth embarked on 

16 the first ever assessments in nine African countries 

17 to determine the need for and access to services to 

18 address obstetric fistula. In 2003, UNFPA and 

19 partners launched a global campaign to identify and 

20 address obstetric fistula in an effort to develop a 

21 means to treat and support those women who are 

22 suffering and provide the necessary health services 

23 to prevent further cases. The UNFPA-led Campaign 

24 to End Fistula is now present in more than 50 

25 countries across Africa, Asia, and the Arab region 


smartinez on DSK4TPTVN1PROD with BILLS
7 

•HR 4148 IH

1 and is comprised of over 90 partners at the global 

2 level and many more at the regional and national 

3 levels. The Campaign has three main focuses: the 

4 prevention of fistula cases, treatment of existing 

5 cases of fistula, and social reintegration and follow 

6 up for fistula survivors. The Campaign supports fis7 tula surgery, training of doctors, nurses, and other 

8 health workers, community outreach to prevent fur9 ther cases, identification of women suffering fistula 

10 who need care, and supporting provision of rehabili11 tative care for women after treatment in order to 

12 break the cycle of poverty and marginalization that 

13 rendered them vulnerable to fistula in the first place 

14 and to enable them to reclaim their dignity and hope 

15 and return to full and productive lives. Since 2003, 

16 UNFPA has directly supported more than 57,000 

17 fistula repairs, and additional repairs have been sup18 ported by Campaign partners. 

19 (14) The Campaign to End Fistula works with 

20 national counterparts, including ministries of health, 

21 other pertinent ministries, United Nations agencies, 

22 international and national nongovernmental organi23 zations, civil society organizations, academic institu24 tions, and health providers (and professional associa25 tions), in support of national processes and fistula 


smartinez on DSK4TPTVN1PROD with BILLS
8 

•HR 4148 IH

1 eradication efforts, including strategies to eradicate 

2 end-stage prolonged or obstructed labor that causes 

3 not only fistula, but a host of newborn and maternal 

4 reproductive, mental, neurologic and orthopedic con5 ditions, that have detrimental consequences for wom6 en’s lives. A key focus is national capacity strength7 ening to reach the regional backlogs of women living 

8 with fistula in remote regions, suffering needlessly, 

9 sometimes for decades. 

10 (15) In 2004, the United States Agency for 

11 International Development (USAID) provided fund12 ing through the ACQUIRE Project managed by 

13 EngenderHealth to support services in Bangladesh 

14 and Uganda. From 2007 to 2013, USAID funded 

15 the Fistula Care project, and in 2013, USAID 

16 awarded a new 5-year cooperative agreement to 

17 EngenderHealth for the Fistula Care Plus project to 

18 support national fistula programs in Africa and 

19 Asia, expand access to care, assess the backlog of 

20 cases, test new approaches to improve the efficiency 

21 and quality of care, and improve health outcomes. 

22 USAID currently supports fistula treatment services 

23 in 137 sites in six countries and addresses preven24 tion in those sites and 36 more. The ceiling for the 

25 Fistula Care Plus project is $74,490,000. Since 


smartinez on DSK4TPTVN1PROD with BILLS
9 

•HR 4148 IH

1 2004, more than 39,000 women have received fistula 

2 repairs with USAID support. 

3 (16) One of the key global health principles of 

4 the United States Global Health Initiative is to 

5 strengthen and leverage key multilateral organiza6 tions, global health partnerships, and private sector 

7 engagement. The United States has committed to 

8 join multilateral efforts involving the United Nations 

9 and others to make progress toward achieving Mil10 lennium Development Goals 4, 5, and 6, and there11 after the Sustainable Development Goals, through 

12 the United Nations Secretary General’s Every 

13 Woman Every Child initiative. 

14 (17) The United States, through its commit15 ment to Ending Preventable Maternal and Child 

16 Deaths, has set several targets that will reduce the 

17 incidence of fistula, including through efforts to re18 duce maternal mortality to 50 maternal deaths per 

19 100,000 live births by 2035, and support voluntary 

20 family planning and reproductive health programs to 

21 reach 120,000,000 additional women and girls with 

22 family planning information, commodities and serv23 ices by 2020. The USAID Maternal Health Vision 

24 for Action calls for an increased focus on averting 

25 and addressing maternal morbidity and disability. 


smartinez on DSK4TPTVN1PROD with BILLS
10 

•HR 4148 IH

1 SEC. 3. PREVENTION AND TREATMENT OF OBSTETRIC FIS2 TULA. 

3 (a) AUTHORIZATION.—The President is authorized, 

4 in accordance with this section and section 4, to provide 

5 assistance, including through international organizations, 

6 national governments, and international and local non7 governmental organizations, to— 

8 (1) address the social and health issues that 

9 lead to obstetric fistula; and 

10 (2) support treatment of obstetric fistula. 

11 (b) ACTIVITIES.—Assistance provided pursuant to 

12 subsection (a) shall focus on— 

13 (1) increasing prevention through access to sex14 ual and reproductive health services, including 

15 skilled attendance at birth, comprehensive emer16 gency obstetric care, prenatal and antenatal care, 

17 contraception (family planning), and supporting 

18 comprehensive sexuality education; 

19 (2) building local capacity and improving na20 tional health systems to prevent and treat obstetric 

21 fistula within the context of navigating pregnancy in 

22 good health overall; 

23 (3) supporting tools to enable countries to ad24 dress obstetric fistula, including supporting quali25 tative research and data collection on the incidence 

26 and prevalence of obstetric fistula, development of 


smartinez on DSK4TPTVN1PROD with BILLS
11 

•HR 4148 IH

1 sustainable financing mechanisms to encourage facil2 ity deliveries and provide fistula survivors access to 

3 free or affordable treatment, training of midwives 

4 and skilled birth attendants, promoting ‘‘south-to5 south’’ training, and provision of basic obstetric care 

6 at the community level; 

7 (4) addressing underlying social and economic 

8 inequities, including empowering women and girls, 

9 reducing incidence of child marriage, delaying child10 birth, and increasing access to formal and nonformal 

11 education; 

12 (5) supporting reintegration and training pro13 grams to help women who have undergone treatment 

14 return to full and productive lives; and 

15 (6) promoting public awareness to increase un16 derstanding of obstetric fistula, and thereby improve 

17 prevention and treatment efforts, to help reduce 

18 stigma and violence against women and girls with 

19 obstetric fistula. 

20 SEC. 4. COORDINATION, REPORTING, RESEARCH, MONI21 TORING, AND EVALUATION. 

22 (a) IN GENERAL.—Assistance authorized under this 

23 Act shall— 

24 (1) promote the coordination facilitated by the 

25 International Obstetric Fistula Working Group, 


smartinez on DSK4TPTVN1PROD with BILLS
12 

•HR 4148 IH

1 which coordinates between and among donors, multi2 lateral institutions, the private sector, nongovern3 mental and civil society organizations, and govern4 ments in order to support comprehensive prevention 

5 and treatment of obstetric fistula; and 

6 (2) be used for the development and implemen7 tation of evidence-based programs, including moni8 toring, evaluation, and research to measure the ef9 fectiveness and efficiency of such programs through10 out their planning and implementation phases. 

11 (b) REPORTING.—Not later than one year after the 

12 date of the enactment of this Act and annually thereafter, 

13 the President shall transmit to Congress a report on ac14 tivities undertaken pursuant to this Act during the pre15 ceding fiscal year to reduce the incidence of and increase 

16 treatment for obstetric fistula, and how such activities fit 

17 into existing national action plans to prevent and treat ob18 stetric fistula. 

Æ 


smartinez on DSK4TPTVN1PROD with BILLS