I 
117TH CONGRESS 
2D SESSION 
H. R. 7869 
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 
MAY 24, 2022 
Mrs. CAROLYN B. MALONEY of New York (for herself, Mr. JOHNSON of Geor-
gia, Ms. MOORE of Wisconsin, and Mr. GRIJALVA) introduced the fol-
lowing 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 2022’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
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(1) Every two minutes, one woman dies from 
pregnancy-related complications. This means ap-
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 
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from living with incontinence and from the loss of 
her child. 
(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, and nerve 
damage that makes normal walking impossible and 
internal genital scarring that destroys normal sexual 
function. 
(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 is scarce, 
the United Nations Population Fund (UNFPA) and 
Johns Hopkins University estimates that an esti-
mated 500,000 women and girls live with obstetric 
fistula with thousands more occurring annually. 
(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 
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other developed regions through improved access to 
high-quality, timely medical interventions, particu-
larly emergency obstetric care including Caesarean 
sections. 
(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 cases 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 UNFPA, EngenderHealth, 
and other partners launched a global Campaign to 
End Fistula (the Campaign) to identify and address 
obstetric fistula 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 55 countries 
across Africa, Asia, and the Arab region, the Cam-
paign has four main goals: the prevention of fistula 
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cases, treatment of existing fistula cases, social re-
integration 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 
sections and for environments that optimize out-
comes 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) The COVID–19 pandemic caused over-
loaded health systems and reallocation of human and 
financial resources with disruptions to services re-
sulting in an undermining of the sexual and repro-
ductive health and rights of women and girls. Begin-
ning in 2020, Fistula repairs were widely halted or 
slowed down due to COVID–19, as they were 
deemed nonurgent and unsafe during the pandemic. 
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This may result in an increased backlog of fistula 
cases. 
(15) The United States Agency for Inter-
national Development (USAID), in accordance with 
the United States Government’s commitment to end-
ing preventable maternal and newborn deaths and 
disabilities, currently supports fistula treatment 
services in seven countries. As part of a comprehen-
sive approach, USAID addresses fistula prevention 
as well as reintegration support to women as they 
re-enter their community and family life after sur-
gery. Cumulatively, USAID fistula support has 
trained thousands of medical personnel and volun-
teers, including 350 fistula surgeons. Since 2004, 
more than 56,200 women have received fistula re-
pairs with USAID support. 
(16) The United States has committed to join-
ing multilateral efforts involving the United Nations 
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.’’. 
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(17) In his July 2020 report prepared for the 
General Assembly called Intensifying efforts to end 
obstetric fistula within a decade, United Nations 
Secretary General Antonio Guterres underscored the 
urgency around action to end fistula in the wake of 
the COVID–19 pandemic, noting that ‘‘the pan-
demic caused by COVID–19 has disrupted health 
services 
and 
exacerbated 
gender-based, 
socio-
economic and intersectional inequalities. The health 
of women and girls, in particular those in fragile 
contexts, is adversely affected by the reallocation of 
resources and priorities. Essential health services in-
cluding contraception and emergency obstetric care 
remain critical to prevent maternal mortality and 
fistula. Since fistula surgery is considered to be elec-
tive care and, therefore, suspended during the pan-
demic to protect the safety of patients, new strate-
gies will be required in the post-COVID–19 recovery 
period to address the expected backlog of cases.’’. 
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, 
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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 
services, including skilled attendance at birth, com-
prehensive emergency obstetric and newborn care, 
timely, safe, high-quality Caesarean sections when 
necessary, prenatal and antenatal care, contracep-
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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. 
(D) Training of midwives and skilled birth 
attendants. 
(E) Provision of basic obstetric care at the 
community level. 
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(4) Ensuring that countries address surgery, 
anesthesia, and obstetrics ecosystem deficits in 
standardized 
healthcare 
worker 
education, 
credentialing, and retention, WASH and power in 
facilities, equipment and materials, transport, and 
healthcare financing. 
(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, 
and to help reduce stigma, exclusion, and violence 
against women and girls with obstetric fistula. 
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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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