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 treat-
ment of obstetric fistula in foreign countries, and for 
other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Obstetric Fistula Pre-
vention, Treatment, Hope, and Dignity Restoration Act 
of 2020’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) Every two minutes, one woman dies from 
pregnancy-related complications. This means ap-
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proximately 830 women die from pregnancy- or 
childbirth-related complications around the world 
every day. Of these deaths, 99 percent occur in de-
veloping countries. Over half of these deaths are in 
sub-Saharan Africa and one-third are in South Asia. 
(2) Obstetric fistula is one of the most severe 
and tragic pregnancy-related injuries, which occurs 
when a woman experiences prolonged, obstructed 
labor in the absence of trained medical assistance, 
which is most commonly a Caesarean section, nec-
essary for a safe delivery. 
(3) Obstetric fistula is a hole that is formed be-
tween the bladder and the vagina, or the rectum and 
the vagina (or both). In the struggle to pass through 
the birth canal, the fetus puts constant pressure, 
sometimes for several days, on the bladder and vag-
inal or rectal walls, destroying the tissue that then 
dies and sloughs off, resulting in the abnormal open-
ing or hole. 
(4) In approximately 90 percent of obstetric fis-
tula cases, the baby will be stillborn. A mother will 
experience physical pain and multiple physical dis-
abilities, as well as social and emotional trauma 
from living with incontinence and from the loss of 
her child. 
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(5) In addition to constant uncontrollable leak-
ing of urine, feces, or both, the physical conse-
quences of obstetric fistula may include frequent 
bladder infections, painful sores, kidney failure, in-
fertility, foul odor, orthopedic injury, nerve damage 
that makes normal walking impossible and internal 
genital scarring that destroys normal sexual func-
tion. 
(6) Women and girls with obstetric fistula are 
commonly ostracized by their families and commu-
nities, leading to depression, anxiety, post-traumatic 
stress disorder, social isolation and discrimination, 
suicidal thoughts or actions, and lack of adequate 
economic opportunities, resulting in deepening pov-
erty, isolation, and vulnerability. 
(7) Although data on obstetric fistula are 
scarce, the World Health Organization (WHO) esti-
mates there are more than 2,000,000 women and 
girls living with fistula, and 50,000 to 100,000 new 
cases each year. 
(8) Obstetric fistula was once common through-
out the world, but over the last century has been vir-
tually eliminated in Europe, North America, and 
other developed regions through improved access to 
high-quality, timely medical interventions, particu-
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larly emergency obstetric care including Caesarean 
section. 
(9) Obstetric fistula is preventable through 
timely medical interventions and providing access to 
family planning for all women who need it. Social 
interventions such as alleviating poverty, delaying 
early marriage and early childbearing, educating and 
empowering young women, remedying gender and 
socioeconomic inequalities, and addressing malnutri-
tion can also help prevent this complication. 
(10) The majority of obstetric fistula can be 
surgically treated. When performed by a skilled, 
competent surgeon, the procedure is relatively inex-
pensive with high rates of success. 
(11) In 2003, the United Nations Population 
Fund (UNFPA), EngenderHealth, and other part-
ners launched a global Campaign to End Fistula 
(the Campaign) to identify and address obstetric fis-
tula in an effort to develop a means to treat and 
support those women who are suffering and provide 
the necessary health services to prevent further 
cases. Operating in more than 50 countries across 
Africa, Asia, and the Arab region, the Campaign has 
four main goals: the prevention of fistula cases, 
treatment of existing fistula cases, social reintegra-
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tion and follow up for fistula survivors, and advocacy 
for ending fistula. 
(12) In order to meet these goals, The Cam-
paign supports and participates in the emerging 
‘‘safe surgery’’ community of practice that strength-
ens surgical ecosystems in low- and middle-income 
countries (LMIC) towards better access to essential 
and life-saving surgeries, which includes improved 
training, equipment, supplies, infrastructure and 
health worker density for timely access to Caesarean 
section and for environments that optimize outcomes 
of fistula surgery. 
(13) Since 2003, UNFPA has directly sup-
ported more than 85,000 fistula repairs, with addi-
tional repairs supported by Campaign partners. 
(14) USAID, in accordance with the United 
States Government’s commitment to ending prevent-
able maternal and newborn deaths and disabilities, 
currently supports fistula treatment services in 137 
sites in six countries. USAID addresses prevention 
in those sites and thirty-six more. Since 2004, more 
than 39,000 women have received fistula repairs 
with USAID support. 
(15) The United States has committed to join-
ing multilateral efforts involving the United Nations 
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and others to make progress toward achieving the 
Sustainable Development Goals (SDGs), including 
through the Global Strategy for Women’s, Children’s 
and Adolescents’ Health (2016–2030). Eliminating 
obstetric fistula is key to achieving the SDGs’ vision 
of ‘‘leaving no one behind.’’. 
(16) In his 2016 statement on the International 
Day to End Obstetric Fistula, United Nations Sec-
retary General Ban Ki-Moon boldly laid forth a new 
global vision and goal of ending obstetric fistula 
within a generation, saying that, ‘‘The persistence of 
fistula in some countries and regions is an indicator 
of very poor access to quality maternal health serv-
ices. To end it, we must strengthen health systems 
and address broader development and human rights 
issues affecting women and girls: poverty, gender in-
equality, early marriage, early childbearing, and lack 
of education. Let us use the momentum of the Sus-
tainable Development Goals together with strong po-
litical leadership, accelerated investment and action, 
and passionate and committed champions, to achieve 
this historic and transformative goal.’’. 
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SEC. 3. PREVENTION AND TREATMENT OF OBSTETRIC FIS-
TULA. 
(a) AUTHORIZATION.—The President is authorized, 
in accordance with this section and section 4, to provide 
assistance, including through international organizations, 
national governments, and international and local non-
governmental organizations, to— 
(1) address the social, structural, health, and 
human rights issues that lead to obstetric fistula; 
(2) support treatment of obstetric fistula that 
includes strengthening the safe surgery and safe an-
esthesia environment in every country where fistula 
persists and where obstetric services do not meet an 
acceptable standard of care; and 
(3) address and acknowledge the urgency of en-
suring that all women who need a Caesarean section 
are able to have access to such life-saving surgery in 
a timely, safe, and high-quality care environment, 
and address the growing threat of iatrogenic fistula 
that most often results from Caesarean delivery done 
poorly and under conditions with inadequate staff, 
supplies, or equipment. 
(b) ACTIVITIES.—Assistance provided pursuant to 
this section and section 4 shall focus on the following: 
(1) Increasing prevention of obstetric fistula 
through access to sexual and reproductive health 
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services, including skilled attendance at birth, com-
prehensive emergency obstetric and newborn care, 
timely, safe, high-quality Caesarean section when 
necessary, prenatal and antenatal care, contracep-
tion and family planning, and comprehensive repro-
ductive health education. 
(2) Building local capacity and improving na-
tional health systems to ensure that all women in 
need have access to safe surgery, including timely, 
and high-quality life-saving obstetric and newborn 
care services to prevent and treat obstetric fistula. 
(3) Supporting tools to enable countries to ad-
dress obstetric fistula, including the following: 
(A) Supporting research to better identify 
the key factors causing persistence of obstetric 
fistula in certain regions. 
(B) Quantitative data collection on the in-
cidence and prevalence of obstetric fistula, and 
development of sustainable universal health care 
financing mechanisms to enable all women to 
have access to skilled and life-saving health care 
during pregnancy, delivery, and the postpartum 
period. 
(C) Providing fistula survivors access to 
free or affordable treatment. 
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(D) Training of midwives and skilled birth 
attendants. 
(E) Provision of basic obstetric care at the 
community level. 
(4) Ensuring that countries address surgery, 
anesthesia, and obstetrics ecosystem deficits in stan-
dardized healthcare worker education, credentialing, 
and retention, WASH and power in facilities, equip-
ment and materials, transport, and healthcare fi-
nancing. 
(5) Addressing social and economic inequities 
that are correlated with higher incidence of obstetric 
fistula by empowering women and girls, alleviating 
poverty, reducing incidence of child marriage, pro-
moting delay and spacing of childbirth, and increas-
ing access to formal and nonformal education. 
(6) Supporting reintegration and education to 
help women who have undergone treatment or are 
awaiting treatment to obtain medical and mental 
health services, legal counseling, basic education, 
and income generating skills as needed, to return to 
full and productive lives. 
(7) Promoting public awareness in communities 
to increase understanding of obstetric fistula, and 
thereby improve prevention and treatment efforts, 
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and to help reduce stigma, exclusion, and violence 
against women and girls with obstetric fistula. 
SEC. 4. COORDINATION, REPORTING, RESEARCH, MONI-
TORING, AND EVALUATION. 
Assistance authorized under this Act shall— 
(1) promote the UNFPA-led global Campaign 
to End Fistula and the International Obstetric Fis-
tula Working Group; and 
(2) be used for the development and implemen-
tation of evidence-based programs, including moni-
toring, evaluation, and research to measure the ef-
fectiveness and efficiency of such programs through-
out their planning and implementation phases. 
SEC. 5. REPORTING. 
Not later than one year after the date of the enact-
ment of this Act and annually thereafter, the President 
shall transmit to Congress a report on activities under-
taken pursuant to this Act during the preceding fiscal year 
to reduce the incidence of and increase treatment for ob-
stetric fistula, and how such activities fit into existing na-
tional action plans to prevent and treat obstetric fistula. 
Æ 
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