I 

113TH CONGRESS 

1ST SESSION H. R. 2888 

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 

JULY 31, 2013 

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

CROWLEY, Mr. FARR, Mr. GRIJALVA, Mr. JOHNSON of Georgia, Ms. LOFGREN, Ms. MCCOLLUM, Mr. MCDERMOTT, Ms. MOORE, Mr. MORAN, and 

Ms. SPEIER) 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 2013’’. 

7 SEC. 2. FINDINGS. 

8 Congress finds the following: 


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1 (1) Every minute, one woman dies from preg2 nancy-related complications. Of these deaths, 99 

3 percent occur in developing countries. Over half of 

4 these deaths are in sub-Saharan Africa and one 

5 third are in South Asia. 

6 (2) For every woman who dies from pregnancy7 related complications, an estimated 20 women sur8 vive but experience pregnancy-related disabilities. 

9 One of the most severe is obstetric fistula, which oc10 curs when a woman who needs trained medical as11 sistance for a safe delivery, usually a cesarean sec12 tion, cannot get it. 

13 (3) Obstetric fistula is a hole that is formed be14 tween the bladder and the vagina, or the rectum and 

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

16 prolonged obstructed labor. In the struggle to pass 

17 through the birth canal, the fetus puts constant 

18 pressure, sometimes for several days, on the bladder 

19 and vaginal or rectal walls, destroying the tissue 

20 that then sloughs off, resulting in the abnormal 

21 opening. 

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

23 the baby will be stillborn and the mother will experi24 ence physical pain as well as social and emotional 


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1 trauma from living with incontinence, as well as the 

2 loss of her child. 

3 (5) The physical symptoms of obstetric fistula 

4 include incontinence or constant uncontrollable leak5 ing of urine or feces, frequent bladder infections, in6 fertility, and foul odor. 

7 (6) Although data on obstetric fistula are 

8 scarce, the World Health Organization (WHO) esti9 mates there are more than 2,000,000 women living 

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

11 year. 

12 (7) According to the Department of State, 

13 ‘‘The combination of pregnancy at an early age, 

14 chronic maternal malnutrition, and a lack of skilled 

15 care at delivery can all contribute to the develop16 ment of obstetric fistula and permanent inconti17 nence.’’. 

18 (8) Obstetric fistula was once common through19 out the world, but over the last century was elimi20 nated in Europe, North America, and other devel21 oped regions through improved access to medical 

22 interventions, particularly emergency obstetric care 

23 for those women who need it. The first fistula hos24 pital in the world stood where the Waldorf-Astoria 

25 Hotel is now located in New York City. 


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1 (9) The social consequences for women living 

2 with obstetric fistula include isolation, divorce or 

3 abandonment, ridicule and shame, loss of social be4 longing and association, illness and malnutrition, 

5 risk of violence, and lack of economic opportunities. 

6 Girls with obstetric fistula are also often unable to 

7 continue schooling. Victims suffer psychological con8 sequences, such as feelings of hopelessness, self-ha9 tred, sadness, depression, and suicide, because of 

10 stigma and lack of awareness that their condition is 

11 treatable. Fistula victims need regular medical at12 tention and an extra supply of soap to keep clean, 

13 placing a huge financial burden on already poor 

14 families. They also lose property when they are di15 vorced or abandoned by their husbands and family. 

16 Some lose jobs or are denied work, while others quit 

17 their jobs out of shame, leading to deepened poverty 

18 and vulnerability to repeat fistulas. 

19 (10) Obstetric fistula is preventable through 

20 medical interventions, such as skilled attendance, in21 cluding midwives, present during labor and child22 birth, providing access to family planning, and emer23 gency obstetric care for women who develop child24 birth complications, as well as social interventions 


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1 such as delaying early marriage and educating and 

2 empowering young women. 

3 (11) Obstetric fistula can also be surgically 

4 treated. Surgery requires a specially trained surgeon 

5 and support staff, and access to an operating the6 ater and to attentive postoperative care. When per7 formed by a skilled surgeon, success rates can be as 

8 high as 90 percent and cost an estimated $300. 

9 (12) According to the Department of State, 

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

11 and seeking care, and managing water and nutri12 tion, the ability of women to access health-related 

13 knowledge and services is fundamental to the health 

14 of their babies, older children and other family mem15 bers. Over the long-term, the health of women en16 hances their productivity and social and economic 

17 participation and also acts as a positive multiplier, 

18 benefitting social and economic development through 

19 the health of future generations.’’. 

20 (13) In 2002, the United Nations Population 

21 Fund (UNFPA) and EngenderHealth embarked on 

22 the first ever assessments in nine African countries 

23 to determine the need for and access to services to 

24 address obstetric fistula. In 2003, UNFPA and 

25 partners launched a global campaign to identify and 


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1 address obstetric fistula in an effort to develop a 

2 means to treat those women who are suffering and 

3 provide the necessary health services to prevent fur4 ther cases. The campaign is currently active in more 

5 than 45 countries in Africa, Asia, and the Arab 

6 states region through support for fistula surgery, 

7 training of doctors and nurses, equipping hospitals, 

8 and undertaking community outreach to prevent fur9 ther cases, and supporting provision of rehabilitative 

10 care for women after treatment so they can return 

11 to full and productive lives. 

12 (14) The Global Campaign to End Fistula 

13 works with national counterparts, including min14 istries of health, other pertinent ministries, United 

15 Nations agencies, international and national non16 governmental organizations, civil society organiza17 tions, and fistula providers, in support of national 

18 processes and fistula programmatic efforts. A key 

19 focus is national fistula capacity strengthening. 

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

21 International Development (USAID) provided fund22 ing through the ACQUIRE Project managed by 

23 EngenderHealth to support services in two coun24 tries: Bangladesh and Uganda. In 2007, USAID 

25 provided a five-year cooperative agreement to 


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1 EngenderHealth for the Fistula Care project. 

2 USAID currently supports fistula treatment services 

3 in 34 sites in 11 countries and addresses prevention 

4 in those sites and 25 more. The ceiling for the Fis5 tula Care project is $70,000,000. 

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

7 the United States Global Health Initiative is to 

8 strengthen and leverage key multilateral organiza9 tions, global health partnerships, and private sector 

10 engagement. The United States has committed to 

11 join multilateral efforts involving the United Nations 

12 and others to make progress toward achieving Mil13 lennium Development Goals 4, 5, and 6. 

14 (17) By 2014, the United States, through its 

15 Global Health Initiative, has committed to several 

16 targets that will reduce the incidence of fistula, in17 cluding through efforts to reduce maternal mortality 

18 by 30 percent, prevent 54,000,000 unintended preg19 nancies by reaching a modern contraceptive preva20 lence rate of 35 percent, and reducing to 20 percent 

21 the number of first births by women under 18 across 

22 assisted countries. 


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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 


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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 non-for11 mal 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, 


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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 


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