I 114th CONGRESS 1st Session H. R. 4148 IN THE HOUSE OF REPRESENTATIVES December 1, 2015 Mrs. Carolyn B. Maloney of New York (for herself, Mr. Grijalva , Mr. Johnson of Georgia , Ms. Moore , and Mr. Conyers ) 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 2015 . 2. Findings Congress finds the following: (1) Every two minutes, 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. Most of these deaths are preventable, which represents both a tragedy and an opportunity. (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 is experiencing prolonged, obstructed labor and 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 without timely, adequate medical intervention. 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 or hole. (4) In the majority of obstetric fistula cases, the baby will be stillborn and the mother will experience physical pain and disability, as well as social and emotional trauma from living with incontinence and from the loss of her child. (5) In addition to incontinence or constant uncontrollable leaking of urine, feces, or both, the physical consequences of obstetric fistula may include frequent bladder infections, infertility, foul odor, and nerve damage. (6) Mental, emotional, and social side effects of obstetric fistula may include depression, social isolation and discrimination, suicidal thoughts or actions, and lack of adequate economic opportunities, resulting in deepening poverty and vulnerability. Girls with obstetric fistula are also often unable to continue schooling. Women and girls with fistula suffer psychological consequences, such as feelings of hopelessness because of stigma and lack of awareness that their condition is treatable. Fistula survivors need regular medical attention and support, but too often adequate services are unavailable or the women and their families cannot afford them. Women may lose property if they are divorced or abandoned by their husbands and family. Some lose jobs or are denied work, while others may quit their jobs out of shame, leading to deepened poverty and vulnerability to repeat fistulas. (7) 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. (8) The primary cause of obstetric fistula is a lack of timely, adequate emergency obstetric care, such as a cesarean section. Poverty, malnutrition, poor health services, early childbearing, and gender discrimination are interlinked root causes of obstetric fistula. (9) 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. As highlighted by the United Nations Secretary General in his 2015 statement on the occasion of the International Day to End Obstetric Fistula (May 23rd), in which he called upon world leaders to commit to ending the scourge of obstetric fistula in our lifetime, The fact that fistula persists primarily among the poorest and most marginalized women and girls in the world is an egregious outcome of social, economic and gender inequalities, the denial of human rights and inadequate access to quality reproductive health services, including maternal and newborn care. . (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) The majority of obstetric fistula can be surgically treated. Surgery requires a specially trained, qualified surgeon and support staff, and access to an operating theater and to attentive postoperative care. When performed by a skilled, competent surgeon, success rates can be as high as 90 percent and cost an estimated $400. (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 not only their own health and well-being, but also that of their babies, older children and other family members. Over the long-term, the health and well-being of women, in addition to being essential in its own right, 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 and support those women who are suffering and provide the necessary health services to prevent further cases. The UNFPA-led Campaign to End Fistula is now present in more than 50 countries across Africa, Asia, and the Arab region and is comprised of over 90 partners at the global level and many more at the regional and national levels. The Campaign has three main focuses: the prevention of fistula cases, treatment of existing cases of fistula, and social reintegration and follow up for fistula survivors. The Campaign supports fistula surgery, training of doctors, nurses, and other health workers, community outreach to prevent further cases, identification of women suffering fistula who need care, and supporting provision of rehabilitative care for women after treatment in order to break the cycle of poverty and marginalization that rendered them vulnerable to fistula in the first place and to enable them to reclaim their dignity and hope and return to full and productive lives. Since 2003, UNFPA has directly supported more than 57,000 fistula repairs, and additional repairs have been supported by Campaign partners. (14) The 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, academic institutions, and health providers (and professional associations), in support of national processes and fistula eradication efforts, including strategies to eradicate end-stage prolonged or obstructed labor that causes not only fistula, but a host of newborn and maternal reproductive, mental, neurologic and orthopedic conditions, that have detrimental consequences for women’s lives. A key focus is national capacity strengthening to reach the regional backlogs of women living with fistula in remote regions, suffering needlessly, sometimes for decades. (15) In 2004, the United States Agency for International Development (USAID) provided funding through the ACQUIRE Project managed by EngenderHealth to support services in Bangladesh and Uganda. From 2007 to 2013, USAID funded the Fistula Care project, and in 2013, USAID awarded a new 5-year cooperative agreement to EngenderHealth for the Fistula Care Plus project to support national fistula programs in Africa and Asia, expand access to care, assess the backlog of cases, test new approaches to improve the efficiency and quality of care, and improve health outcomes. USAID currently supports fistula treatment services in 137 sites in six countries and addresses prevention in those sites and 36 more. The ceiling for the Fistula Care Plus project is $74,490,000. Since 2004, more than 39,000 women have received fistula repairs with USAID support. (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, and thereafter the Sustainable Development Goals, through the United Nations Secretary General’s Every Woman Every Child initiative. (17) The United States, through its commitment to Ending Preventable Maternal and Child Deaths, has set several targets that will reduce the incidence of fistula, including through efforts to reduce maternal mortality to 50 maternal deaths per 100,000 live births by 2035, and support voluntary family planning and reproductive health programs to reach 120,000,000 additional women and girls with family planning information, commodities and services by 2020. The USAID Maternal Health Vision for Action calls for an increased focus on averting and addressing maternal morbidity and disability. 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 nonformal 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.