I 

116TH CONGRESS 

2D SESSION H. R. 8971 

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 15, 2020 

Mrs. CAROLYN B. MALONEY of New York 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 2020’’. 

7 SEC. 2. FINDINGS. 

8 Congress finds the following: 

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

10 pregnancy-related complications. This means apVerDate Sep 11 2014 21:30 Dec 29, 2020 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H8971.IH H8971

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1 proximately 830 women die from pregnancy- or 

2 childbirth-related complications around the world 

3 every day. Of these deaths, 99 percent occur in de4 veloping countries. Over half of these deaths are in 

5 sub-Saharan Africa and one-third are in South Asia. 

6 (2) Obstetric fistula is one of the most severe 

7 and tragic pregnancy-related injuries, which occurs 

8 when a woman experiences prolonged, obstructed 

9 labor in the absence of trained medical assistance, 

10 which is most commonly a Caesarean section, nec11 essary for a safe delivery. 

12 (3) Obstetric fistula is a hole that is formed be13 tween the bladder and the vagina, or the rectum and 

14 the vagina (or both). In the struggle to pass through 

15 the birth canal, the fetus puts constant pressure, 

16 sometimes for several days, on the bladder and vag17 inal or rectal walls, destroying the tissue that then 

18 dies and sloughs off, resulting in the abnormal open19 ing or hole. 

20 (4) In approximately 90 percent of obstetric fis21 tula cases, the baby will be stillborn. A mother will 

22 experience physical pain and multiple physical dis23 abilities, as well as social and emotional trauma 

24 from living with incontinence and from the loss of 

25 her child. 


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1 (5) In addition to constant uncontrollable leak2 ing of urine, feces, or both, the physical conse3 quences of obstetric fistula may include frequent 

4 bladder infections, painful sores, kidney failure, in5 fertility, foul odor, orthopedic injury, nerve damage 

6 that makes normal walking impossible and internal 

7 genital scarring that destroys normal sexual func8 tion. 

9 (6) Women and girls with obstetric fistula are 

10 commonly ostracized by their families and commu11 nities, leading to depression, anxiety, post-traumatic 

12 stress disorder, social isolation and discrimination, 

13 suicidal thoughts or actions, and lack of adequate 

14 economic opportunities, resulting in deepening pov15 erty, isolation, and vulnerability. 

16 (7) Although data on obstetric fistula are 

17 scarce, the World Health Organization (WHO) esti18 mates there are more than 2,000,000 women and 

19 girls living with fistula, and 50,000 to 100,000 new 

20 cases each year. 

21 (8) Obstetric fistula was once common through22 out the world, but over the last century has been vir23 tually eliminated in Europe, North America, and 

24 other developed regions through improved access to 

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1 larly emergency obstetric care including Caesarean 

2 section. 

3 (9) Obstetric fistula is preventable through 

4 timely medical interventions and providing access to 

5 family planning for all women who need it. Social 

6 interventions such as alleviating poverty, delaying 

7 early marriage and early childbearing, educating and 

8 empowering young women, remedying gender and 

9 socioeconomic inequalities, and addressing malnutri10 tion can also help prevent this complication. 

11 (10) The majority of obstetric fistula can be 

12 surgically treated. When performed by a skilled, 

13 competent surgeon, the procedure is relatively inex14 pensive with high rates of success. 

15 (11) In 2003, the United Nations Population 

16 Fund (UNFPA), EngenderHealth, and other part17 ners launched a global Campaign to End Fistula 

18 (the Campaign) to identify and address obstetric fis19 tula in an effort to develop a means to treat and 

20 support those women who are suffering and provide 

21 the necessary health services to prevent further 

22 cases. Operating in more than 50 countries across 

23 Africa, Asia, and the Arab region, the Campaign has 

24 four main goals: the prevention of fistula cases, 

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1 tion and follow up for fistula survivors, and advocacy 

2 for ending fistula. 

3 (12) In order to meet these goals, The Cam4 paign supports and participates in the emerging 

5 ‘‘safe surgery’’ community of practice that strength6 ens surgical ecosystems in low- and middle-income 

7 countries (LMIC) towards better access to essential 

8 and life-saving surgeries, which includes improved 

9 training, equipment, supplies, infrastructure and 

10 health worker density for timely access to Caesarean 

11 section and for environments that optimize outcomes 

12 of fistula surgery. 

13 (13) Since 2003, UNFPA has directly sup14 ported more than 85,000 fistula repairs, with addi15 tional repairs supported by Campaign partners. 

16 (14) USAID, in accordance with the United 

17 States Government’s commitment to ending prevent18 able maternal and newborn deaths and disabilities, 

19 currently supports fistula treatment services in 137 

20 sites in six countries. USAID addresses prevention 

21 in those sites and thirty-six more. Since 2004, more 

22 than 39,000 women have received fistula repairs 

23 with USAID support. 

24 (15) The United States has committed to join25 ing multilateral efforts involving the United Nations 


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1 and others to make progress toward achieving the 

2 Sustainable Development Goals (SDGs), including 

3 through the Global Strategy for Women’s, Children’s 

4 and Adolescents’ Health (2016–2030). Eliminating 

5 obstetric fistula is key to achieving the SDGs’ vision 

6 of ‘‘leaving no one behind.’’. 

7 (16) In his 2016 statement on the International 

8 Day to End Obstetric Fistula, United Nations Sec9 retary General Ban Ki-Moon boldly laid forth a new 

10 global vision and goal of ending obstetric fistula 

11 within a generation, saying that, ‘‘The persistence of 

12 fistula in some countries and regions is an indicator 

13 of very poor access to quality maternal health serv14 ices. To end it, we must strengthen health systems 

15 and address broader development and human rights 

16 issues affecting women and girls: poverty, gender in17 equality, early marriage, early childbearing, and lack 

18 of education. Let us use the momentum of the Sus19 tainable Development Goals together with strong po20 litical leadership, accelerated investment and action, 

21 and passionate and committed champions, to achieve 

22 this historic and transformative goal.’’. 


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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, structural, health, and 

9 human rights issues that lead to obstetric fistula; 

10 (2) support treatment of obstetric fistula that 

11 includes strengthening the safe surgery and safe an12 esthesia environment in every country where fistula 

13 persists and where obstetric services do not meet an 

14 acceptable standard of care; and 

15 (3) address and acknowledge the urgency of en16 suring that all women who need a Caesarean section 

17 are able to have access to such life-saving surgery in 

18 a timely, safe, and high-quality care environment, 

19 and address the growing threat of iatrogenic fistula 

20 that most often results from Caesarean delivery done 

21 poorly and under conditions with inadequate staff, 

22 supplies, or equipment. 

23 (b) ACTIVITIES.—Assistance provided pursuant to 

24 this section and section 4 shall focus on the following: 

25 (1) Increasing prevention of obstetric fistula 

26 through access to sexual and reproductive health 


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1 services, including skilled attendance at birth, com2 prehensive emergency obstetric and newborn care, 

3 timely, safe, high-quality Caesarean section when 

4 necessary, prenatal and antenatal care, contracep5 tion and family planning, and comprehensive repro6 ductive health education. 

7 (2) Building local capacity and improving na8 tional health systems to ensure that all women in 

9 need have access to safe surgery, including timely, 

10 and high-quality life-saving obstetric and newborn 

11 care services to prevent and treat obstetric fistula. 

12 (3) Supporting tools to enable countries to ad13 dress obstetric fistula, including the following: 

14 (A) Supporting research to better identify 

15 the key factors causing persistence of obstetric 

16 fistula in certain regions. 

17 (B) Quantitative data collection on the in18 cidence and prevalence of obstetric fistula, and 

19 development of sustainable universal health care 

20 financing mechanisms to enable all women to 

21 have access to skilled and life-saving health care 

22 during pregnancy, delivery, and the postpartum 

23 period. 

24 (C) Providing fistula survivors access to 

25 free or affordable treatment. 


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1 (D) Training of midwives and skilled birth 

2 attendants. 

3 (E) Provision of basic obstetric care at the 

4 community level. 

5 (4) Ensuring that countries address surgery, 

6 anesthesia, and obstetrics ecosystem deficits in stan7 dardized healthcare worker education, credentialing, 

8 and retention, WASH and power in facilities, equip9 ment and materials, transport, and healthcare fi10 nancing. 

11 (5) Addressing social and economic inequities 

12 that are correlated with higher incidence of obstetric 

13 fistula by empowering women and girls, alleviating 

14 poverty, reducing incidence of child marriage, pro15 moting delay and spacing of childbirth, and increas16 ing access to formal and nonformal education. 

17 (6) Supporting reintegration and education to 

18 help women who have undergone treatment or are 

19 awaiting treatment to obtain medical and mental 

20 health services, legal counseling, basic education, 

21 and income generating skills as needed, to return to 

22 full and productive lives. 

23 (7) Promoting public awareness in communities 

24 to increase understanding of obstetric fistula, and 

25 thereby improve prevention and treatment efforts, 


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1 and to help reduce stigma, exclusion, and violence 

2 against women and girls with obstetric fistula. 

3 SEC. 4. COORDINATION, REPORTING, RESEARCH, MONI4 TORING, AND EVALUATION. 

5 Assistance authorized under this Act shall— 

6 (1) promote the UNFPA-led global Campaign 

7 to End Fistula and the International Obstetric Fis8 tula Working Group; and 

9 (2) be used for the development and implemen10 tation of evidence-based programs, including moni11 toring, evaluation, and research to measure the ef12 fectiveness and efficiency of such programs through13 out their planning and implementation phases. 

14 SEC. 5. REPORTING. 

15 Not later than one year after the date of the enact16 ment of this Act and annually thereafter, the President 

17 shall transmit to Congress a report on activities under18 taken pursuant to this Act during the preceding fiscal year 

19 to reduce the incidence of and increase treatment for ob20 stetric fistula, and how such activities fit into existing na21 tional action plans to prevent and treat obstetric fistula. 

Æ 


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