I 115th CONGRESS 2d Session H. R. 5068 IN THE HOUSE OF REPRESENTATIVES February 16, 2018 Mrs. Carolyn B. Maloney of New York 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 2018 . 2. Findings Congress finds the following: (1) Every two minutes, one woman dies from pregnancy-related complications. This means approximately 830 women die from pregnancy- or childbirth-related complications around the world every day. 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) Obstetric fistula is one of the most severe and tragic pregnancy-related injuries, which occurs when a woman experiences prolonged, obstructed labor in the absence of trained medical assistance, which is most commonly a Caesarean section, necessary for a safe delivery. (3) Obstetric fistula is a hole that is formed between the bladder and the vagina, or the rectum and the vagina (or both). 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 dies and sloughs off, resulting in the abnormal opening or hole. (4) In approximately 90 percent of obstetric fistula cases, the baby will be stillborn. A mother will experience physical pain and multiple physical disabilities, as well as social and emotional trauma from living with incontinence and from the loss of her child. (5) In addition to constant uncontrollable leaking of urine, feces, or both, the physical con­se­quences of obstetric fistula may include frequent bladder infections, painful sores, kidney failure, infertility, foul odor, orthopedic injury, nerve damage that makes normal walking impossible and internal genital scarring that destroys normal sexual function. (6) Women and girls with obstetric fistula are commonly ostracized by their families and communities, leading to depression, anxiety, post-traumatic stress disorder, social isolation and discrimination, suicidal thoughts or actions, and lack of adequate economic opportunities, resulting in deepening poverty, isolation, and vulnerability. (7) Although data on obstetric fistula are scarce, the World Health Organization (WHO) estimates there are more than 2,000,000 women and girls living with fistula, and 50,000 to 100,000 new cases each year. (8) Obstetric fistula was once common throughout the world, but over the last century has been virtually eliminated in Europe, North America, and other developed regions through improved access to high-quality, timely medical interventions, particularly emergency obstetric care including Caesarean section. (9) Obstetric fistula is preventable through timely medical interventions and providing access to family planning for all women who need it. Social interventions such as alleviating poverty, delaying early marriage and early childbearing, educating and empowering young women, remedying gender and socioeconomic inequalities, and addressing malnutrition can also help prevent this complication. (10) The majority of obstetric fistula can be surgically treated. When performed by a skilled, competent surgeon, the procedure is relatively inexpensive with high rates of success. (11) In 2003, the United Nations Population Fund (UNFPA), EngenderHealth, and other partners launched a global Campaign to End Fistula (the 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. Operating in more than 50 countries across Africa, Asia, and the Arab region, the Campaign has four main goals: the prevention of fistula cases, treatment of existing fistula cases, social reintegration and follow up for fistula survivors, and advocacy for ending fistula. (12) In order to meet these goals, The Campaign supports and participates in the emerging safe surgery community of practice that strengthens surgical ecosystems in low- and middle-income countries (LMIC) towards better access to essential and life-saving surgeries, which includes improved training, equipment, supplies, infrastructure and health worker density for timely access to Caesarean section and for environments that optimize outcomes of fistula surgery. (13) Since 2003, UNFPA has directly supported more than 85,000 fistula repairs, with additional repairs supported by Campaign partners. (14) USAID, in accordance with the United States Government’s commitment to ending preventable maternal and newborn deaths and disabilities, currently supports fistula treatment services in 137 sites in six countries. USAID addresses prevention in those sites and thirty-six more. Since 2004, more than 39,000 women have received fistula repairs with USAID support. (15) The United States has committed to joining multilateral efforts involving the United Nations and others to make progress toward achieving the Sustainable Development Goals (SDGs), including through the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030). Eliminating obstetric fistula is key to achieving the SDGs’ vision of leaving no one behind. . (16) In his 2016 statement on the International Day to End Obstetric Fistula, United Nations Secretary General Ban Ki-Moon boldly laid forth a new global vision and goal of ending obstetric fistula within a generation, saying that, The persistence of fistula in some countries and regions is an indicator of very poor access to quality maternal health services. To end it, we must strengthen health systems and address broader development and human rights issues affecting women and girls: poverty, gender inequality, early marriage, early childbearing, and lack of education. Let us use the momentum of the Sustainable Development Goals together with strong political leadership, accelerated investment and action, and passionate and committed champions, to achieve this historic and transformative goal. . 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, structural, health, and human rights issues that lead to obstetric fistula; (2) support treatment of obstetric fistula that includes strengthening the safe surgery and safe anesthesia environment in every country where fistula persists and where obstetric services do not meet an acceptable standard of care; and (3) address and acknowledge the urgency of ensuring that all women who need a Caesarean section are able to have access to such life-saving surgery in a timely, safe, and high-quality care environment, and address the growing threat of iatrogenic fistula that most often results from Caesarean delivery done poorly and under conditions with inadequate staff, supplies, or equipment. (b) Activities Assistance provided pursuant to this section and section 4 shall focus on the following: (1) Increasing prevention of obstetric fistula through access to sexual and reproductive health services, including skilled attendance at birth, comprehensive emergency obstetric and newborn care, timely, safe, high-quality Caesarean section when necessary, prenatal and antenatal care, contraception and family planning, and comprehensive reproductive health education. (2) Building local capacity and improving national health systems to ensure that all women in need have access to safe surgery, including timely, and high-quality life-saving obstetric and newborn care services to prevent and treat obstetric fistula. (3) Supporting tools to enable countries to address obstetric fistula, including the following: (A) Supporting research to better identify the key factors causing persistence of obstetric fistula in certain regions. (B) Quantitative data collection on the incidence and prevalence of obstetric fistula, and development of sustainable universal health care financing mechanisms to enable all women to have access to skilled and life-saving health care during pregnancy, delivery, and the postpartum period. (C) Providing fistula survivors access to free or affordable treatment. (D) Training of midwives and skilled birth attendants. (E) Provision of basic obstetric care at the community level. (4) Ensuring that countries address surgery, anesthesia, and obstetrics ecosystem deficits in stan­dard­ized healthcare worker education, cre­den­tial­ing, and retention, WASH and power in facilities, equipment and materials, transport, and healthcare financing. (5) Addressing social and economic inequities that are correlated with higher incidence of obstetric fistula by empowering women and girls, alleviating poverty, reducing incidence of child marriage, promoting delay and spacing of childbirth, and increasing access to formal and nonformal education. (6) Supporting reintegration and education to help women who have undergone treatment or are awaiting treatment to obtain medical and mental health services, legal counseling, basic education, and income generating skills as needed, to return to full and productive lives. (7) Promoting public awareness in communities to increase understanding of obstetric fistula, and thereby improve prevention and treatment efforts, and to help reduce stigma, exclusion, and violence against women and girls with obstetric fistula. 4. Coordination, reporting, research, monitoring, and evaluation Assistance authorized under this Act shall— (1) promote the UNFPA-led global Campaign to End Fistula and the International Obstetric Fistula Working Group; 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. 5. 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.