Intensifying ou efforts to end obstetric fistula.

Resolution A/RES/73/147 on the intensification of efforts to end obstetric fistula calls upon States and the international community to accelerate actions to end fistula and reiterates the need for urgent efforts and significantly increased investment to improve maternal health by addressing sexual and reproductive, maternal, newborn and child health. The document further outlines key recommendations and actions, and calls for the development of a Global Road Map to End Fistula within a decade.

The General Assembly, 

Recalling its resolutions 62/138 of 18 December 2007, 63/158 of 18 December 2008, 65/188 of 21 December 2010 and 67/147 of 20 December 2012 on supporting efforts to end obstetric fistula and its resolutions 69/148 of 18 December 2014 and 71/169 of 19 December 2016 on the intensification of efforts to end obstetric fistula, Reaffirming the Beijing Declaration and Platform for Action, 1 the outcomes of the twenty-third special session of the General Assembly, entitled “Women 2000: gender equality, development and peace for the twenty-first century”,2 the Programme of Action of the International Conference on Population and Development 3 and the Programme of Action of the World Summit for Social Development, 4 and their reviews, and the international commitments in the field of social development and to gender equality and the empowerment of women and girls made at the World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance 5 and the 2005 World Summit, 6 as well as those made in the outcome document of the United Nations summit for the adoption of the post-2015 development agenda, entitled “Transforming our world: the 2030 Agenda for Sustainable Development”, Reaffirming also the Universal Declaration of Human Rights, 8 which marks its seventieth anniversary in 2018, as well as the Convention on the Elimination of All Forms of Discrimination against Women, 9 and the Convention on the Rights of the Child, 10 recalling the International Covenant on Economic, Social and Cultural Rights and the International Covenant on Civil and Political Rights, 11 and urging States that have not done so to consider, as a matter of priority, signing, ratifying or acceding to those conventions and the optional protocols thereto, 12 Taking note of the report of the Secretary-General 13 and the conclusions and recommendations contained therein, Recognizing that intensified national ownership and leadership, political commitment and scaled-up national capacity are urgently needed to accelerate progress towards the elimination of fistula, including by implementing strategies to prevent new cases and treating all existing cases with special attention paid to countries with the highest maternal mortality and morbidity levels, Stressing the interlinkages between poverty, malnutrition, lack of or inadequate or inaccessible health-care services, early childbearing, child, early and forced marriage, violence against young women and girls, sociocultural barriers, marginalization, illiteracy and gender inequality as root causes of obstetric fistula, and that poverty remains the main social risk factor, Stressing also that obstetric fistula can be a cause of devastating lifelong morbidity if left untreated, with severe medical, social, psychological and economic consequences, that approximately 90 per cent of women who develop fistula deliver stillborn babies and that misperceptions about its cause often result in stigma and ostracism, Recognizing that the difficult socioeconomic conditions that exist in many developing countries, in particular the least developed countries, have resulted in the acceleration of the feminization of poverty, Recognizing also that early childbearing increases the risk of complications during pregnancy and delivery and entails a much higher risk of maternal mortality and morbidity, and deeply concerned that early childbearing and limited access to the highest attainable standard of mental and physical health, including sexual and reproductive health, specifically timely access to high-quality emergency obstetric care, cause high levels of obstetric fistula and other maternal morbidities, as well as maternal mortality, Recognizing further that adolescent girls, in particular those who live in poverty or who are marginalized, are at particular risk of maternal death and morbidity, including obstetric fistula, and concerned that the leading cause of death among girls aged 15 to 19 in many low- and middle-income countries is complications from pregnancy and childbirth and that women aged 30 and older are at increased risk of developing complications and of dying during childbirth, Recognizing that lack of access to sexual and reproductive health, especially emergency obstetric, services, including in humanitarian settings, remains among the leading causes of obstetric fistula, leading to ill health and death for women and girls __________________ 8 Resolution 217 A (III). 9 United Nations, Treaty Series, vol. 1249, No. 20378. 10 Ibid., vol. 1577, No. 27531. 11 See resolution 2200 A (XXI), annex. 12 United Nations, Treaty Series, vol. 2131, No. 20378; ibid., vols. 2171 and 2173, No. 27531; resolution 66/138, annex; and resolution 63/117, annex. 13 A/73/285. Intensification of efforts to end obstetric fistula A/RES/73/147 18-22184 3/8 of childbearing age in many regions of the world, and that a dramatic and sustainable scaling-up of quality treatment and health-care services, including high-quality emergency obstetric services, and of the number of trained, competent fistula surgeons and midwives is needed to significantly reduce maternal and newborn mortality and to eradicate obstetric fistula, Noting that a human rights-based approach to eliminating obstetric fistula and efforts to eliminate obstetric fistula should be underpinned by, inter alia, accountability, participation, transparency, empowerment, sustainability, non-discrimination and international cooperation, Deeply concerned about discrimination against and marginalization of women and girls, in particular those who are facing multiple and intersecting forms of discrimination, which often result in reduced access to education and nutrition, compromising their physical and mental health and well-being and the enjoyment of their human rights and the opportunities and benefits of childhood and adolescence compared with boys, and often in their being subjected to various forms of cultural, social, sexual and economic exploitation and abuse, violence and harmful practices, which can increase the risk of obstetric fistula, Deeply concerned also about the situation of women and girls living with or recovering from obstetric fistula, who are often neglected and stigmatized, which may lead to negative effects on their mental health, resulting in depression and suicide, and are driven deeper into poverty and marginalization, Recognizing the need to raise awareness among men and adolescent boys and, in this context, to fully engage men and community leaders as strategic partners and allies in the efforts to address and eliminate obstetric fistula, Welcoming the contribution by Member States, the international community, the private sector and civil society to the global Campaign to End Fistula led by the United Nations Population Fund, bearing in mind that a people -centred approach to social and economic development is fundamental for protecting and empowering individuals and communities, Deeply concerned that, as the global Campaign to End Fistula completes its fifteenth anniversary, while some progress has been made, significant challenges remain that require the intensification of efforts at all levels to end obstetric fistula, Deeply concerned also about the insufficient resources for addressing obstetric fistula in high-burden countries, compounded by the low levels of development assistance for maternal and newborn health, which have declined in recent years, and the substantial need for additional resources and support for the global Campaign to End Fistula and for national and regional initiatives dedicated to improving maternal health and eliminating obstetric fistula, Noting the Secretary-General’s revised Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), undertaken by a broad coalition of partners, in support of national plans and strategies that aim for the highest attainable standards of health and well-being, physical, mental and social, at every age, ending maternal and newborn mortality, which is preventable, and noting that this can contribute to the achievement of the Sustainable Development Goals, Welcoming the various national, regional and international initiatives on all the Sustainable Development Goals and the global Campaign to End Fistula, including those undertaken bilaterally and through South-South cooperation, in support of national plans and strategies in sectors such as health, education, finance, gender equality, energy, water and sanitation, poverty eradication and nutrition as a way to reduce the number of maternal, newborn and under-5 child deaths, Welcoming also ongoing partnerships between stakeholders at all levels to address the multifaceted determinants of maternal, newborn and child health, in close coordination with Member States, based on their needs and priorities, and in this regard welcoming further the commitments to accelerate progress on the health-related Sustainable Development Goals by 2030, 1. Reaffirms the commitments made by Member States to achieve the Sustainable Development Goals by 2030, and recognizes that the efforts to end obstetric fistula within a decade will contribute to the achievement of the Goals by 2030; 2. Stresses the need to address the interlinkages between poverty, lack of or inadequate education for women and girls, gender inequality, lack of or inadequate access to health-care services, including sexual and reproductive health-care services, early childbearing and child, early and forced marriage as root causes of obstetric fistula, and calls upon States, in collaboration with the international community, to take accelerated action to address the situation; 3. Calls upon States to take all measures necessary to ensure the right of women and girls to the enjoyment of the highest attainable standard of health, including sexual and reproductive health, and reproductive rights, in accordance with the Programme of Action of the International Conference on Population and Development,3 the Beijing Platform for Action and the outcome documents of their review conferences, and to develop sustainable health systems and social services, with a view to ensuring universal access to such systems and services without discrimination, while paying special attention to adequate food and nutrition, water and sanitation, family planning information, increasing women’s empowerment, knowledge and awareness and ensuring equitable access to high-quality appropriate prenatal and delivery care for the prevention of obstetric fistula and the reduction of health inequities, as well as postnatal care for the detection and early management of fistula cases; 4. Also calls upon States to ensure equitable coverage and timely access, by means of national plans, policies and programmes, to health-care services, in particular emergency obstetric and newborn care, skilled birth attendance, obstetric fistula treatment and family planning, that are financially affordable, accessible and culturally sensitive, especially in rural and the most-remote areas; 5. Further calls upon States to ensure the right to education of good quality for women and girls, on an equal basis with men and boys, and to ensure that they complete a full course of primary education, and to renew their efforts to improve and expand girls’ and women’s education at all levels, including at the secondary and higher levels, including age-appropriate sex education, as well as vocational education and technical training, in order to, inter alia, achieve gender equality, the empowerment of women and girls and poverty eradication; 6. Urges States to enact and strictly enforce laws to ensure that marriage, including in rural and remote areas, is entered into only with the free and full consent of the intending spouses and, in addition, to enact and strictly enforce laws concerning the minimum legal age of consent and the minimum age for marriage and to raise the minimum age for marriage, where necessary; 7. Calls upon the international community to provide intensified technical and financial support, in particular to high-burden countries, to accelerate progress towards the elimination of obstetric fistula within a decade, which can contribute to the achievement of the Sustainable Development Goals by 2030 and leave no one behind; 8. Urges the international community to provide and enhance the necessary resources and capacity-building, upon the request of Member States, in order to treat fistula cases through surgery, leading to the reintegration of affected women and girls into their communities, with appropriate psychosocial, medical and economic support to restore their well-being and dignity; 9. Urges multilateral donors, international financial institutions and regional development banks in the public and private sectors, within their respective mandates, to review and implement policies to support national efforts and institutional capacity-building to end obstetric fistula and to ensure that a higher proportion of resources reach young women and girls, in particular in rural and remote areas and the poorest urban areas, as well as to ensure that needed funding is increased, predictable and sustained; 10. Calls upon the international community to support the activities of the United Nations Population Fund and other partners, including the World Health Organization, in the global Campaign to End Fistula in establishing and financing regional fistula treatment and training centres and, where necessary, national centres, by identifying and supporting health facilities that have the potential to serve as centres for treatment, training and convalescent care; 11. Calls upon States to accelerate progress to improve maternal health by addressing sexual and reproductive, maternal, newborn and child health in a comprehensive manner, inter alia, through the provision of family planning, prenatal care, skilled attendance at birth, including midwives, emergency obstetric and newborn care, postnatal care and methods of prevention and treatment of sexually transmitted diseases and infections, such as HIV, within strengthened health-care systems that provide universal access to affordable, equitable and high-quality integrated health-care services and include community-based preventive and clinical care, towards the achievement of the 2030 Agenda for Sustainable Development; 12. Urges the international community to address the shortage and inequitable distribution of doctors, surgeons, midwives, nurses and other health-care workers trained in life-saving obstetric care, and of space and supplies, which limit the capacity of most fistula centres; 13. Commends the commemoration by the international community of 23 May as the International Day to End Obstetric Fistula and the decision to continue to use the International Day each year to significantly raise awareness, intensify actions and mobilize support towards ending obstetric fistula; 14. Calls upon States and/or the relevant funds and programmes, organs and the specialized agencies of the United Nations system, within their respective mandates, and invites the international financial institutions and all relevant actors of civil society, including non-governmental organizations, and the private sector, to end obstetric fistula within a decade by: (a) Redoubling their efforts to meet the internationally agreed goal of improving maternal health by making maternal health-care services and obstetric fistula treatment geographically and financially accessible, including by ensuring universal access to skilled attendance at birth and timely access to high-quality emergency obstetric care and family planning, as well as appropriate prenatal and postnatal care; (b) Making greater investments in strengthening health systems, ensuring adequately trained and skilled human resources, especially midwives, obstetricians, gynaecologists and doctors, and providing support for the development and maintenance of infrastructure, as well as investments in referral mechanisms, equipment and supply chains, to improve maternal and newborn health-care services and ensure that women and girls have access to the full continuum of care, with functional quality control and monitoring mechanisms in place for all areas of service delivery; (c) Supporting the training of doctors and surgeons, nurses and other healthcare workers in life-saving obstetric care, especially midwives, who are the front-line workers in the fight to prevent obstetric fistula and maternal and newborn mortality, including training on fistula prevention, treatment and care as a standard element of the training curricula of health professionals; (d) Ensuring universal access through national policies, plans and programmes that make maternal and newborn health-care services, particularly family planning, skilled attendance at birth, emergency obstetric and newborn care and obstetric fistula treatment, financially accessible and affordable, including in rural and remote areas and among the poorest women and girls through, where appropriate, the establishment and distribution of health-care facilities and trained medical personnel, collaboration with the transport sector for affordable transport options, support for developing and maintaining infrastructure to improve maternal and newborn health-care services and to strengthen the capacity for surgery, the promotion of and support for community-based solutions and the provision of incentives and other means to secure the presence in rural and remote areas of qualified health-care professionals who are able to perform interventions to prevent obstetric fistula; (e) Developing, implementing, following up on and supporting national and international prevention, care and treatment and socioeconomic reintegration and support strategies, policies and plans to eliminate obstetric fistula within a decade by developing further multisectoral, multidisciplinary, comprehensive and integrated action plans in order to bring about lasting solutions and put an end to maternal mortality and morbidity and obstetric fistula, which is preventable and treatable, including by ensuring access to affordable, accessible, comprehensive, high-quality maternal health-care services, and, within countries, incorporating into all sectors of national budgets policy and programmatic approaches to address inequities and reach poor women and girls and those in vulnerable situations; (f) Establishing or strengthening, as appropriate, a national task force for obstetric fistula, with a lead governmental entity, to enhance national coordination and improve partner collaboration to end obstetric fistula, including partnering with in-country efforts, to increase surgical capacity and to promote universal access to essential and life-saving surgery; (g) Strengthening the capacity of health-care systems, in particular public health systems, to provide the essential services needed to prevent obste tric fistula and to treat existing cases by increasing national budgets for health, ensuring that adequate funds are allocated to reproductive health, including for obstetric fistula, ensuring access to fistula treatment through increased availability of trained, expert fistula surgeons and permanent, holistic fistula services integrated into strategically selected hospitals, thereby addressing the significant backlog of women and girls awaiting surgical repair of fistula, and encouraging communication among fistula centres to facilitate training, research, advocacy and fundraising and the application of relevant medical standards, including consideration of the use of the World Health Organization manual entitled Obstetric Fistula: Guiding Principles for Clinical Management and Programme Development, which provides background information Intensification of efforts to end obstetric fistula A/RES/73/147 18-22184 7/8 and principles for developing fistula prevention and treatment programmes, as appropriate; (h) Mobilizing funding to provide free or adequately subsidized maternal health-care and obstetric fistula repair and treatment services, including by encouraging networking among providers and the sharing of new treatment techniques and protocols to protect women’s and children’s well-being and survival and to prevent the recurrence of subsequent fistulas by making post-surgery followup and the tracking of fistula patients a routine and key component of all fistula programmes, and also to ensure access to elective caesarean sections for fistula survivors who become pregnant again in order to prevent fistula recurrence and to increase the chances of survival of mother and baby in all subsequent pregnancies; (i) Increasing national budgets and harnessing domestic resources for health, ensuring that adequate funds are allocated to prevent obstetric fistula and to treat existing cases, and for strengthening the capacity of health-care systems to provide the essential services needed in this regard; (j) Ensuring that all women and girls who have undergone fistula treatment, including the forgotten women and girls whose conditions are deemed incurable or inoperable, are provided with and have access to comprehensive health-care services, holistic social integration services and careful follow-up, including counselling, education, family planning, socioeconomic empowerment, social protection and psychosocial services, for as long as needed, through, inter alia, skills development, family and community support and income-generating activities, so that they can overcome abandonment, stigma, ostracism and economic and social exclusion, and developing linkages with civil society organizations and women’s and girls’ empowerment programmes so as to help to achieve this goal; (k) Empowering fistula survivors to make informed decisions about their lives and to contribute to community sensitization and mobilization as advocates for fistula elimination, safe motherhood and newborn survival, and supporting the exercise of their voice, agency and leadership; (l) Accelerating efforts to improve the health of women and girls globally, with an increased focus on social determinants that affect their well-being and that include the provision of universal access to quality education for women and girls, economic empowerment, with access to microcredit, savings and microfinancing, legal reforms, the promotion and support of their meaningful participation in decision-making at all levels, and social initiatives, including legal literacy to protect women and girls from violence and discrimination, child, early and forced marriage and early pregnancy; (m) Educating individual women and men, girls and boys, communities, policymakers and health professionals about how obstetric fistula can be prevented and treated, and increasing awareness of the needs of pregnant women and girls, as well as of those who have undergone surgical fistula repair, including their right to the highest attainable standard of mental and physical health, including sexual and reproductive health, by working with community and religious leaders, traditional birth attendants and midwives, women and girls who have suffered from fistula, the media, social workers, civil society, women’s organizations, influential public figures and policymakers; (n) Enhancing the participation of men and adolescent boys in the intensification of efforts to end obstetric fistula and further strengthening their involvement as partners, including in the global Campaign to End Fistula; (o) Strengthening awareness-raising and advocacy, including through the media, to effectively reach families and communities with key messages on fistula prevention and treatment and social reintegration; (p) Strengthening research, monitoring and evaluation systems, including by developing a community- and facility-based mechanism for the systematic notification of obstetric fistula cases and maternal and newborn deaths to ministries of health, and their recording in a national register, and by acknowledging obstetric fistula as a nationally notifiable condition, triggering immediate reporting, tracking and follow-up for the purpose of guiding the development and implementation of maternal health programmes and ending fistula within a decade; (q) Strengthening research, data collection, monitoring and evaluation to guide the planning and implementation of maternal health programmes, including for obstetric fistula, by conducting up-to-date needs assessments on emergency obstetric and newborn care and for fistula and routine reviews of maternal deaths and nearmiss cases as part of a national maternal death surveillance and response system, integrated within national health information systems; (r) Improving data collection, pre- and post-surgery, to measure progress in addressing needs for surgical treatment and the quality of surgery, rehabilitation and socioeconomic reintegration services, including post-surgery prospects for successful subsequent pregnancies, live births and severe health-related complications, so as to address the challenges of improving maternal health; (s) Providing essential health-care services, equipment and supplies, education, skills training and income-generating projects and support to women and girls so that they can break out of the cycle of poverty; 15. Encourages Member States to contribute to efforts to end obstetric fistula, including, in particular, through the global Campaign to End Fistula, to achieve the Sustainable Development Goals by 2030 and to commit themselves to continued efforts to improve maternal and newborn health, with the aim of eliminating obstetric fistula globally within a decade; 16. Requests the global Campaign to End Fistula to develop a road map that will accelerate action to end obstetric fistula within a decade, towards achieving the 2030 Agenda for Sustainable Development, including for enhancing financial resources for interventions at the local, subnational, national, regional and international levels, in order to support countries and relevant United Nations organizations in the prevention, treatment and care of obstetric fistula; 17. Requests the Secretary-General to submit a comprehensive report with specific updated statistics and disaggregated data on obstetric fistula and the challenges faced by Member States in implementing the present resolution to the General Assembly at its seventy-fifth session under the item entitled “Advancement of women”. 

55th plenary meeting 17 December 2018