I 
111TH CONGRESS 
2D SESSION 
H. R. 5441 
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 27, 2010 
Mrs. MALONEY (for herself, Mr. CASTLE, and Mrs. CAPPS) 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 2010’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) Every minute, one woman dies from preg-
nancy-related complications. Of these deaths, 99 
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percent occur in the developing world and 95 percent 
occur in Africa and Asia. 
(2) For every woman who dies from pregnancy- 
related complications, an estimated 20 women sur-
vive but experience pregnancy-related disabilities. 
One of the most severe is obstetric fistula, which oc-
curs when a woman who needs trained medical as-
sistance for a safe delivery, usually a cesarean sec-
tion, cannot get it. 
(3) Obstetric fistula is a hole that is formed be-
tween the bladder and the vagina, or the rectum and 
the vagina (or both), after a woman suffers from 
prolonged obstructed labor. In the struggle to pass 
through the birth canal, the fetus puts constant 
pressure, sometimes for several days, on the bladder 
and vaginal or rectal walls, destroying the tissue 
that then sloughs off, resulting in the abnormal 
opening. 
(4) In the majority of obstetric fistula cases, 
the baby will be stillborn and the mother will experi-
ence physical pain as well as social and emotional 
trauma from living with incontinence as well as the 
loss of her child. 
(5) The physical symptoms of obstetric fistula 
include incontinence or constant uncontrollable leak-
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ing of urine or feces, frequent bladder infections, in-
fertility, and foul odor. 
(6) Although data on obstetric fistula are 
scarce, the World Health Organization (WHO) esti-
mates there are more than 2,000,000 women living 
with fistula and 50,000 to 100,000 new cases each 
year. 
(7) According to the United States State De-
partment, ‘‘The combination of pregnancy at an 
early age, chronic maternal malnutrition, and a lack 
of skilled care at delivery can all contribute to the 
development of obstetric fistula and permanent in-
continence.’’. 
(8) Obstetric fistula was once common through-
out the world, but over the last century was elimi-
nated in Europe, North America, and other devel-
oped regions through improved access to medical 
interventions, particularly emergency obstetric care 
for those women who need it. 
(9) The social consequences for women living 
with obstetric fistula include isolation, divorce or 
abandonment, ridicule and shame, inability to start 
a family, illness, risk of violence, and lack of oppor-
tunity. 
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(10) Obstetric fistula is preventable through 
medical interventions such as skilled attendance 
present during labor and childbirth, providing access 
to family planning, and emergency obstetric care for 
women who develop childbirth complications as well 
as social interventions such as delaying early mar-
riage and educating and empowering young women. 
(11) Obstetric fistula can also be surgically 
treated. Surgery requires a specially trained surgeon 
and support staff, and access to an operating the-
ater and to attentive postoperative care. When per-
formed by a skilled surgeon, success rates can be as 
high as 90 percent and cost an estimated $300. 
(12) According to the Department of State, 
‘‘Because of their roles in child rearing, providing 
and seeking care, and managing water and nutri-
tion, the ability of women to access health-related 
knowledge and services is fundamental to the health 
of their babies, older children and other family mem-
bers. Over the long-term, the health of women en-
hances their productivity and social and economic 
participation and also acts as a positive multiplier, 
benefitting social and economic development through 
the health of future generations.’’. 
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(13) In 2002, the United Nations Population 
Fund (UNFPA) and EngenderHealth embarked on 
the first ever assessments in nine African countries 
to determine the need for and access to services to 
address obstetric fistula. In 2003, UNFPA and 
partners launched a global campaign to identify and 
address obstetric fistula in an effort to develop a 
means to treat those women who are suffering and 
provide the necessary health services to prevent fur-
ther cases. The campaign is currently active in more 
than 45 countries in Africa, Asia, and the Arab 
States region through support for fistula surgery, 
training of doctors and nurses, equipping hospitals, 
and undertaking community outreach to prevent fur-
ther cases, and supporting provision of rehabilitative 
care for women after treatment so they can return 
to full and productive lives. 
(14) The global Campaign to End Fistula 
works with national counterparts, including min-
istries of health, other pertinent ministries, United 
Nations agencies, international and national non-
governmental organizations, civil society organiza-
tions, and fistula providers, in support of national 
processes and fistula programmatic efforts. A key 
focus is national fistula capacity strengthening. 
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(15) In 2004, USAID provided funding through 
the ACQUIRE Project managed by EngenderHealth 
to support services in two countries, Bangladesh and 
Uganda. In 2007, USAID provided a five-year coop-
erative agreement to EngenderHealth for the Fistula 
Care project. USAID currently supports fistula 
treatment services in 34 sites in 11 countries and 
addresses prevention in those sites and 25 more. 
The ceiling for the Fistula Care project is 
$70,000,000. 
(16) One of the key global health principles of 
the United States Global Health Initiative is to 
strengthen and leverage key multilateral organiza-
tions, global health partnerships, and private sector 
engagement. The United States has committed to 
join multilateral efforts involving the United Nations 
and others to make progress toward achieving Mil-
lennium Development Goals 4, 5, and 6. 
(17) By 2014, the United States through its 
Global Health Initiative has committed to several 
targets that will reduce the incidence of fistula, in-
cluding through efforts to reduce maternal mortality 
by 30 percent; prevent 54,000,000 unintended preg-
nancies by reaching a modern contraceptive preva-
lence rate of 35 percent; and reducing to 20 percent 
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the number of first births by women under 18 across 
assisted countries. 
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 and health issues that 
lead to obstetric fistula; and 
(2) support treatment of obstetric fistula. 
(b) ACTIVITIES.—Assistance provided pursuant to 
subsection (a) shall focus on— 
(1) increasing prevention through access to sex-
ual and reproductive health services, including 
skilled attendance at birth, comprehensive emer-
gency obstetric care, prenatal and antenatal care, 
and contraception (family planning); 
(2) building local capacity and improving na-
tional health systems to prevent and treat obstetric 
fistula within the context of navigating pregnancy in 
good health overall; 
(3) supporting tools to enable countries to ad-
dress fistula, including supporting qualitative re-
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search, development of sustainable financing mecha-
nisms, training of skilled birth attendants, pro-
moting ‘‘south-to-south’’ training, and provision of 
basic obstetric care at the community level; 
(4) addressing underlying social and economic 
inequities, including empowering women and girls, 
reducing incidence of child marriage, delaying child-
birth, and increasing access to formal and non-for-
mal education; and 
(5) supporting reintegration and training pro-
grams to help women who have undergone treatment 
return to full and productive lives. 
SEC. 4. COORDINATION, REPORTING, RESEARCH, MONI-
TORING, AND EVALUATION. 
(a) IN GENERAL.—Assistance authorized under this 
Act shall— 
(1) promote the coordination facilitated by the 
International Obstetric Fistula Working Group, 
which coordinates between and among donors, multi-
lateral institutions, the private sector, nongovern-
mental and civil society organizations, and govern-
ments in order to support comprehensive prevention 
and treatment of obstetric fistula; and 
(2) be used for the development and implemen-
tation of evidence-based programs, including moni-
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toring, evaluation, and research to measure the ef-
fectiveness and efficiency of such programs through-
out their planning and implementation phases. 
(b) REPORTING.—Not later than December 31, 2011, 
and annually thereafter, the President shall transmit to 
Congress a report on activities undertaken pursuant to 
this Act during the preceding fiscal year to reduce the inci-
dence of and increase treatment for obstetric fistula, and 
how such activities fit into existing national action plans 
to prevent and treat obstetric fistula. 
Æ 
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