I 113th CONGRESS 1st Session H. R. 2888 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. Lofgren , Ms. McCollum , Mr. McDermott , Ms. Moore , Mr. Moran , and Ms. Speier ) 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. Short title This Act may be cited as the Obstetric Fistula Prevention, Treatment, Hope, and Dignity Restoration Act of 2013 . 2. Findings Congress finds the following: (1) Every minute, one woman dies from pregnancy-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 survive but experience pregnancy-related disabilities. One of the most severe is obstetric fistula, which occurs when a woman who needs trained medical assistance for a safe delivery, usually a cesarean section, cannot get it. (3) Obstetric fistula is a hole that is formed between 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 experience 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 leaking of urine or feces, frequent bladder infections, infertility, and foul odor. (6) Although data on obstetric fistula are scarce, the World Health Organization (WHO) estimates 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 development of obstetric fistula and permanent incontinence. . (8) Obstetric fistula was once common throughout the world, but over the last century was eliminated in Europe, North America, and other developed regions through improved access to medical interventions, particularly emergency obstetric care for those women who need it. The first fistula hospital in the world stood where the Waldorf-Astoria Hotel is now located in New York City. (9) The social consequences for women living with obstetric fistula include isolation, divorce or abandonment, ridicule and shame, loss of social belonging 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 consequences, such as feelings of hopelessness, self-hatred, sadness, depression, and suicide, because of stigma and lack of awareness that their condition is treatable. Fistula victims need regular medical attention 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 divorced 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, including midwives, 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 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 theater and to attentive postoperative care. When performed 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 nutrition, the ability of women to access health-related knowledge and services is fundamental to the health of their babies, older children and other family members. Over the long-term, the health of women enhances 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 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 further 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 further 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 ministries of health, other pertinent ministries, United Nations agencies, international and national nongovernmental organizations, civil society organizations, 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 funding through the ACQUIRE Project managed by EngenderHealth to support services in two countries: Bangladesh and Uganda. In 2007, USAID provided a five-year cooperative 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 organizations, 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 Millennium 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, including through efforts to reduce maternal mortality by 30 percent, prevent 54,000,000 unintended pregnancies by reaching a modern contraceptive prevalence rate of 35 percent, and reducing to 20 percent the number of first births by women under 18 across assisted countries. 3. Prevention and treatment of obstetric fistula (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 nongovernmental 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 sexual and reproductive health services, including skilled attendance at birth, comprehensive emergency obstetric care, prenatal and antenatal care, contraception (family planning), and supporting comprehensive sexuality education; (2) building local capacity and improving national 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 address obstetric fistula, including supporting qualitative research and data collection on the incidence and prevalence of obstetric fistula, development of sustainable financing mechanisms to encourage facility 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 childbirth, and increasing access to formal and non-formal education; (5) supporting reintegration and training programs to help women who have undergone treatment return to full and productive lives; and (6) promoting public awareness to increase understanding of obstetric fistula, and thereby improve prevention and treatment efforts, to help reduce stigma and violence against women and girls with obstetric fistula. 4. Coordination, reporting, research, monitoring, 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, multilateral institutions, the private sector, nongovernmental and civil society organizations, and governments in order to support comprehensive prevention and treatment of obstetric fistula; and (2) be used for the development and implementation of evidence-based programs, including monitoring, evaluation, and research to measure the effectiveness and efficiency of such programs throughout 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 activities undertaken pursuant to this Act during the preceding 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 obstetric fistula.