I 115th CONGRESS 2d Session H. R. 7301 IN THE HOUSE OF REPRESENTATIVES December 13, 2018 Ms. DeLauro (for herself, Ms. Norton , Mr. Grijalva , Ms. Jackson Lee , Mr. McGovern , Ms. McCollum , and Ms. Lofgren ) introduced the following bill; which was referred to the Committee on Foreign Affairs A BILL To authorize assistance to train and retain obstetrician-gynecologists and sub-specialists in urogynecology and to help improve the quality of care to meet the health care needs of women in least developed countries, and for other purposes.

1. Short title This Act may be cited as the Physician Education for Fistula Treatment Act . 2. Findings Congress finds the following: (1) Historically, obstetric fistulas affected women in the United States and around the world. Advances in obstetric care and access to improved surgical techniques resulted in a drastic reduction in obstetric fistula by the early 20th century in the United States. (2) Each year between 50,000 to 100,000 women worldwide are affected by obstetric fistulas, an abnormal opening between a woman’s genital tract and her urinary tract or rectum. (3) Women who experience an obstetric fistula suffer constant incontinence, shame, and social segregation and health problems. It is estimated that 2 to 3 million women live with untreated obstetric fistulas, a scourge of epidemic proportions. (4) A lack of available resources and training programs to develop expertise in comprehensive advanced pelvic reconstructive surgery continues to pose a challenge for the health care workforce in least developed countries. (5) Retention rates of OB–GYNs and sub-specialists in urogynecology have seen improvement with fellowships, residencies, and programs that provide resources and training. (6) Today, obstetric fistula primarily affects the poorest women in the poorest parts of the world. Obstetric fistulas typically occur because women do not have timely access to emergency obstetric care during obstructed labor, and continue to have fistulas due to lack of access to adequate surgical services once they sustain the injury. (7) Left untreated, an obstetric fistula afflicts a woman with devastating physical conditions: incontinence, painful ulcers, and constant and uncontrollable emission of offensive odors. These symptoms leave a woman indelibly and perpetually stigmatized by her condition. (8) Because obstetric fistulas are not themselves fatal, millions of women live with this horrific condition and have been overlooked by the international medical community. At present, humanitarian aid and nongovernmental programs treat fistula cases on a small scale and are not equipped to systematically prevent, treat, and eradicate obstetric fistula. (9) Obstetric fistula can be prevented when women and their families are educated about the birthing process and are provided timely access to emergency obstetric care. Basic interventions to identify and repair obstetric fistula have achieved meaningful and cost-effective results. The impact of an obstetric fistula-repair surgery is immediate and women can be reintegrated into society. However, access to prevention, effective midwifery services, and OB–GYN care can significantly decrease childbirth-related injuries. 3. International OB/GYN and Urogynecology Promotion Program (a) Purpose The purpose of assistance under this section is to train and retain obstetrician-gynecologists (OB–GYNs) and sub-specialists in urogynecology and to help improve the quality of care to meet the health care needs of women in least developed countries. (b) Authorization (1) In general To carry out the purpose of subsection (a), the President, acting through the Director of the John E. Fogarty International Center for Advanced Study in the Health Sciences, is authorized to provide assistance for least developed countries to support the activities described in subsection (c). (2) Reference Assistance authorized under this section may be referred to as the International OB/GYN and Urogynecology Promotion Program . (c) Activities supported Activities that may be supported by assistance under subsection (b) include the following: (1) Fellowship and residency programs Establishment of fellowship and residency programs to be carried out in coordination with institutions of higher education (as such term is defined in section 101 of the Higher Education Act of 1965 ( 20 U.S.C. 1001 )), institutions of higher learning, midwifery programs, and existing clinical centers in least developed countries— (A) to support existing academic curricula for education training for midwifery students; (B) to develop and help sustain existing specialized curriculum training for medical students and residents to become knowledgeable and proficient in women’s health care; and (C) to allow medical students, residents, and midwifery students to practice and develop expertise in geographical areas in which childbirth-related injuries are most prevalent. (2) Training centers Establishment of training centers— (A) to address the shortage of OB–GYNs and sub-specialists in the urogynecology profession; and (B) to carry out specialized programs that are located at health care institutions that provide exceptionally high concentrations of expertise and related resources related to these medical professions and are delivered in a comprehensive and interdisciplinary fashion. 4. Comprehensive 10-year strategy to address the shortage of physicians in least developed countries (a) In general The President, acting through the Director of the John E. Fogarty International Center for Advanced Study in the Health Sciences, shall establish a comprehensive, integrated, 10-year strategy to address the shortage of physicians in least developed countries. (b) Elements Such strategy shall maintain sufficient flexibility and remain responsive to the needs of women afflicted with childbirth-related injuries and shall include the following: (1) A plan for implementation and coordination of programs and activities under this Act, including grants and contracts for prevention, treatment, and monitoring of childbirth-related injuries. (2) Specific objectives, multi-sector approaches, and specific strategies to treat women who suffer from childbirth-related injuries and to prevent further occurrences of childbirth-related injuries. (3) Assignment of priorities for relevant executive branch agencies. (4) Public health and health care delivery system research on the prevention, repair, and rehabilitation of childbirth-related injuries. (5) Social science research in fields such as anthropology, sociology, and related fields to monitor and evaluate the underlying social and economic factors that contribute to childbirth-related injuries. (6) Development, implementation, and evaluation of evidence-based systems of care connecting maternity care facilities with local care delivery and community education programs. Such systems of care should promote rapid and long-term prevention of childbirth-related injuries, including— (A) culturally appropriate childbirth education, preparation, and planning; and (B) access to obstetrician-gynecologists (OB–GYNs), urogynecology care, or midwifery care. (7) Expansion of training centers and partnerships with institutions of higher learning for medical students and residents. (8) Priorities for the distribution of resources based on factors such as the size and demographics of the population suffering from childbirth-related injuries, the needs of that population, and the existing infrastructure or funding levels that may exist to treat and prevent childbirth-related injuries, including obstetric fistula. (9) A plan for institutional capacity-building of partnerships to strengthen universities, research centers, health-profession training programs, and government institutes to build the in-country capacity needed to eradicate childbirth-related injuries in least developed countries. (c) Report Not later than 2 years after the date of the enactment of this Act, the President shall submit to Congress a report that contains the strategy required under this section. 5. Report (a) In general The President, acting through the Director of the John E. Fogarty International Center for Advanced Study in the Health Sciences, shall submit to Congress, on an annual basis, a report on the implementation of this Act for the preceding year. (b) Matters To be included The report required under subsection (a) shall include an evaluation of the effectiveness and performance of the International OB/GYN and Urogynecology Promotion Program established under section 3 and all related community outreach and medical programs. 6. Definitions In this Act: (1) Childbirth-related injuries The term childbirth-related injuries means injuries associated with obstructed labor, including— (A) pelvic organ prolapse; (B) a displacement of pelvic organs such as the uterus, bladder, or bowel; and (C) obstetric fistula. (2) Low-income country The term low-income country means a country with a per capita gross national income of $1,035 or less. (3) Least developed country The term least developed country means a country that— (A) is a low-income country; and (B) according to the United Nations Economic Analysis and Policy Division, is confronting severe structural impediments to sustainable development. (4) Relevant executive branch agencies The term relevant executive branch agencies means the Department of State, the United States Agency for International Development, and any other department or agency of the United States that participates in international health and humanitarian activities pursuant to the authorities of such department or agency or the Foreign Assistance Act of 1961.