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. LOF-
GREN, Ms. MCCOLLUM, Mr. MCDERMOTT, Ms. MOORE, Mr. MORAN, and 
Ms. SPEIER) introduced the following bill; which was referred to the Com-
mittee 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 2013’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
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(1) Every minute, one woman dies from preg-
nancy-related complications. Of these deaths, 99 
percent occur in developing countries. Over half of 
these deaths are in sub-Saharan Africa and one 
third are in South 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 
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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-
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 Department of State, 
‘‘The combination of pregnancy at an early age, 
chronic maternal malnutrition, and a lack of skilled 
care at delivery can all contribute to the develop-
ment of obstetric fistula and permanent inconti-
nence.’’. 
(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. The first fistula hos-
pital in the world stood where the Waldorf-Astoria 
Hotel is now located in New York City. 
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(9) The social consequences for women living 
with obstetric fistula include isolation, divorce or 
abandonment, ridicule and shame, loss of social be-
longing and association, illness and malnutrition, 
risk of violence, and lack of economic opportunities. 
Girls with obstetric fistula are also often unable to 
continue schooling. Victims suffer psychological con-
sequences, such as feelings of hopelessness, self-ha-
tred, sadness, depression, and suicide, because of 
stigma and lack of awareness that their condition is 
treatable. Fistula victims need regular medical at-
tention and an extra supply of soap to keep clean, 
placing a huge financial burden on already poor 
families. They also lose property when they are di-
vorced or abandoned by their husbands and family. 
Some lose jobs or are denied work, while others quit 
their jobs out of shame, leading to deepened poverty 
and vulnerability to repeat fistulas. 
(10) Obstetric fistula is preventable through 
medical interventions, such as skilled attendance, in-
cluding midwives, present during labor and child-
birth, providing access to family planning, and emer-
gency obstetric care for women who develop child-
birth complications, as well as social interventions 
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such as delaying early marriage 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.’’. 
(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 
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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. 
(15) In 2004, the United States Agency for 
International Development (USAID) provided fund-
ing through the ACQUIRE Project managed by 
EngenderHealth to support services in two coun-
tries: Bangladesh and Uganda. In 2007, USAID 
provided a five-year cooperative agreement to 
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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 Fis-
tula 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 
the number of first births by women under 18 across 
assisted countries. 
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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 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, 
contraception (family planning), and supporting 
comprehensive sexuality education; 
(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 obstetric fistula, including supporting quali-
tative research and data collection on the incidence 
and prevalence of obstetric fistula, development of 
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sustainable financing mechanisms to encourage facil-
ity deliveries and provide fistula survivors access to 
free or affordable treatment, training of midwives 
and skilled birth attendants, promoting ‘‘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; 
(5) supporting reintegration and training pro-
grams to help women who have undergone treatment 
return to full and productive lives; and 
(6) promoting public awareness to increase un-
derstanding of obstetric fistula, and thereby improve 
prevention and treatment efforts, to help reduce 
stigma and violence against women and girls with 
obstetric fistula. 
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, 
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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-
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 one year after the 
date of the enactment of this Act and annually thereafter, 
the President shall transmit to Congress a report on ac-
tivities undertaken pursuant to this Act during the pre-
ceding fiscal year to reduce the incidence of and increase 
treatment for obstetric fistula, and how such activities fit 
into existing national action plans to prevent and treat ob-
stetric fistula. 
Æ 
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