Actions taken by the international community: progress made and challenges ahead.

A. Prevention strategies and interventions to achieve maternal and newborn health and eliminate obstetric fistula.

The global Campaign to End Fistula, launched in 2003 by UNFPA and partners, focuses on four key strategies: prevention, treatment, social reintegration and advocacy. The Campaign is active in more than 55 countries and brings together nearly 100 partners with the aim of eradicating fistula globally. UNFPA leads the Campaign and serves as the secretariat of the International Obstetric Fistula Working Group, the main decision-making body of the Campaign. Since 2003, UNFPA has provided direct support for over 129,000 fistula repairs, and partners, such as EngenderHealth, the Fistula Foundation, the Freedom from Fistula Foundation, Direct Relief, the United Nations Federal Credit Union Foundation, Focus Fistula, Women and Health Alliance International and the Kupona Foundation, have provided support for thousands more. UNFPA and the Campaign to End Fistula were awarded the United Nations Federal Credit Union Foundation Women’s Empowerment Award, in appreciation for the global leadership of UNFPA and the transformative impact of the Campaign on reducing inequities and its action for a new global agenda grounded in the principles of rights, inclusiveness, and equality.  In its new strategic plan (2022–2025), UNFPA affirmed its commitment to leading the Campaign to End Fistula by 2030. 

Midwives represent the key health workforce that provide the full continuum of care from pre-pregnancy to childbirth and the postnatal period, including obstetric fistula prevention. In The State of the World’s Midwifery Report 2021, it is stated that midwives who are educated, supported and regulated according to international standards can provide 90 per cent of the essential sexual, reproductive, maternal, newborn and adolescent health interventions needed. The UNFPA Global Midwifery programme has helped to educate and train over 200,000 midwives in more than 140 countries. By 2021, over 85 countries had aligned their midwifery curriculum with international standards. The World Health Organization (WHO), UNFPA, the International Confederation of Midwives and other partners have developed the Framework for Action for Strengthening Quality Midwifery Education for Universal Health Coverage 2030. UNFPA is updating its global midwifery strategy to include new megatrends, maternal mental health and a humanitarian segment to better address the sexual and reproductive health needs of women and the health needs of their newborns. 

 Universal, accessible, high-quality health care has helped to eliminate obstetric fistula in developed countries. In the action plan “Every Newborn: an Action Plan to End Preventable Deaths”, WHO, UNICEF and partners called for universal coverage of high-quality care, to be achieved through: innovation, accountability and data; leadership, governance, partnerships and financing; and a review of global and national goals, targets and milestones for the period 2014–2035. Ninety countries have adopted the Every Newborn Tracking Tool, showing an overall improvement across all national milestones and demonstrating country-level commitment to achieving planned milestones.

 Ensuring that all women have access to high-quality health care is critical to ending fistula. The Network for Improving Quality of Care for Maternal, Newborn and Child Health was launched in 2017 by WHO, UNICEF, UNFPA and partners. The Network is a country-led initiative, active in 10 countries and supported by a high quality of care framework, with the aim of halving rates of maternal and newborn deaths and stillbirths in targeted health-care facilities by 2022. All participating countries are implementing road maps for high quality of care. Ghana, Nigeria and Sierra Leone have, in addition, developed national high-quality policies and strategies. 

 To better support countries in achieving the health-related Sustainable Development Goals, the Global Action Plan for Healthy Lives and Well-Being for All was launched by 12 agencies before the General Assembly in 2019. Implementation of the plan at the country-level had scaled up from 5 countries in 2020 to 37 in 2021. The plan features four commitments (engage, accelerate, align and account) and seven accelerator themes (primary health care; sustainable financing for health; community and civil society engagement; determinants of health; innovative programming in fragile and vulnerable settings and disease outbreak responses; research and development, innovation and access; and data and digital health). The H6 partnership is a transformative mechanism that harnesses the collective strengths of UNFPA, UNICEF, UN-Women, WHO, the Joint United Nations Programme on HIV/AIDS and the World Bank Group to build equitable and resilient national systems for health. H6 plays a key role in countries by ensuring agency coordination and collaboration, supporting country leadership and action for the health of women, children and adolescents. 

Ensuring access to family planning contributes to the prevention of unintended pregnancies and the reduction in deaths and disabilities related to complications with pregnancy and childbirth, including fistula. Access to voluntary family planning information, high-quality counselling and a range of contraceptive methods is critical for delaying early childbearing. However, more than 257 million women and girls who want to avoid pregnancy are not using safe, modern methods of contraception. In 2021, UNFPA programmes contributed to averting 5.4 million unintended pregnancies and 14,500 maternal deaths. The new phase of the global partnership Family Planning FP2030 builds on the strengths and successes of Family Planning 2020 and is aimed at accelerating progress towards universal access to family planning. 

Fistula may recur in women whose fistula has been surgically treated but who receive little or no medical follow-up and become pregnant again. In its resolution 73/147, the General Assembly called upon States to acknowledge obstetric fistula as a nationally notifiable condition, triggering immediate reporting, tracking and follow-up. Developing and strengthening systematic registration and tracking mechanisms for fistula, with a human rights-based approach, at the community, facility and national levels are crucial to help to prevent the recurrence of fistula, ensure the survival and well-being of mothers and their newborns in subsequent pregnancies and strengthen the integration of data-driven fistula programmes into maternal health systems. 

Community empowerment, participation and awareness-raising are essential to addressing the determinants of maternal mortality and morbidity. Fistula survivors are key advocates and champions in that effort. Many organizations train former fistula patients as safe motherhood ambassadors who educate women and communities about maternal and newborn care and safe delivery, identify and refer fistula survivors for treatment and provide psychosocial support, thereby breaking the cycle of isolation and suffering. 

B. Treatment strategies and interventions 

 While much progress has been made, as evidenced by the significantly decreased prevalence of fistula, there is still much to be done in the area of treatment. Through the effort of the United Nations and a large range of partners (e.g. EngenderHealth, the International Federation of Gynaecology and Obstetrics, Freedom from Fistula, the Fistula Foundation, Hamlin Fistula Ethiopia, Mercy Ships and Médecins sans frontières), many surgeons have been trained and fistula repairs are being provided globally. There is evidence that the COVID-19 pandemic has reduced the number of surgical interventions in locations where surgical repairs rely on non-local surgeons (e.g. Zimbabwe). Afghanistan and Ethiopia experienced significant disruptions in fistula care owing to political changes, and many fistula surgeons and trained health workers left the country. Training programmes have continued to focus on increasing and sustaining local surgical capacity while ensuring the quality of surgery. UNFPA partnered with Operation Fistula to scale up a performance-based funding model for the treatment of fistula patients in Burkina Faso, Cameroon, Madagascar and Nigeria with the aim of expanding access to high - quality fistula treatment and care.

In 2021, a new manual on principles for clinical management and programme development for obstetric fistula and other female genital fistula developed by UNFPA, the Campaign to End Fistula and partners (e.g. Direct Relief, the Fistula Foundation and the International Society of Obstetric Fistula Surgeons) was launched and disseminated. The manual provides guidance regarding holistic, comprehensive and strategic aspects of the response for eliminating obstetric fistula by 2030, with evidence-based approaches. It reiterates the quality of care and the consolidation of resources as significant factors for improving maternal health-care outcomes. 

Mental health concerns should be incorporated in fistula care in view of the high prevalence of depression noted in research. A study carried out in Mali demonstrates the benefits of integrating mental health care with obstetric fistula surgery.

The International Society of Obstetric Fistula Surgeons and UNFPA developed fistula repair kits with the supplies necessary to perform fistula repair surgery, thereby promoting access to high-quality fistula care. Between 2020 and 2021, UNFPA procured 759 kits for use at facilities in 12 countries. 

C. Reintegration strategies and interventions for holistic fistula care 

Increased financing for holistic fistula care is critical. A holistic approach that addresses the psychological and socioeconomic needs of fistula survivors is required to ensure full recovery and healing. The follow-up of fistula patients and the social reintegration of survivors (including for women and girls deemed to be inoperable or incurable) are major gaps in the continuum of care. Furthermore, when surgery fails, women struggle to reintegrate into society. Ideally, each woman should be repaired only once and paired with a surgeon with the appropriate skill to achieve successful closure the first time. Psychological support is necessary for all fistula patients, especially if they are not fully healed. Providing social, educational and economic opportunities tailored to their needs is key to helping survivors to rebuild their lives and livelihoods and reclaim their dignity and agency. 

D. Research, data collection and analysis 

 A human rights-based approach helps to uncover the underlying inequalities and discrimination that lead to obstetric fistula through multiple intersecting factors. Fistula primarily affects poor women in remote areas where health services are scarce. Such barriers to life-saving obstetric care, including for preventing fistula, are at the intersection of multiple human rights, such as the right to equality and non-discrimination and the right to health. Human rights accountability goes beyond data monitoring and extends to putting in place redress mechanisms (e.g. issues of obstetric violence and fistula can be investigated by national human rights institutions and tried by courts) and social accountability mechanisms, whereby affected women and girls, civil society organizations and human rights groups can monitor how programmes, services and budgets related to maternal health and fistula care are being implemented. 

 The lack of robust data and research on fistula remains a challenge. The period from 2020 to mid-2022 has seen the smallest number of research papers on fistula captures locations and capacity for fistula treatment worldwide with data visualizations. Up-to-date surgical data are however lacking, especially as the production of all maternal health data has been hampered by the pandemic. The integration of routine surveillance and of the monitoring of fistula into national health systems is recommended to help to address the data gap. 

The availability of estimates of the global burden of fistula based on a model developed by the Johns Hopkins Bloomberg School of Public Health in collaboration with UNFPA and WHO is a welcome endeavour to inform fistula programmes. However, the ongoing collection of accurate data on successful fistula repairs and the number of new cases to assess fistula prevalence and treatment at the country level is severely lacking. 

 Data-driven and evidence-driven health workforce planning is vital to ending fistula and a cost-effective contribution to improving sexual and reproductive, maternal, neonatal and adolescent health-care outcomes. There is, however, a need for 900,000 additional midwives (500,000 in Africa alone). The WHO Global Strategy on Human Resources for Health: Workforce 2030 is aimed at optimizing the performance, quality and impact of the health workforce through evidence -informed policies on human resources for health.

To prevent the occurrence of obstetric fistula, timely access to high-quality health care is crucial. Twelve countries have successfully completed a geographical analysis to manage their national emergency obstetric and newborn care facility network and estimate their population coverage. In 10 countries, however, the population coverage remains low, as a result of poor road conditions, lack of skilled obstetric staff and financial barriers to referrals. Road conditions are likely worsening as a result of climate change, the effects of which include erosion and flooding. Such environmental changes have a direct impact on maternal and newborn health when a woman must travel long distances to reach a facility with a functioning operating room and surgical staff. UNFPA, WHO and UNICEF will continue to develop emergency obstetric and newborn care facility networks at the national scale and support high-quality interventions for obstetric and neonatal care. 

Maternal and perinatal death surveillance and response systems are being increasingly promoted and institutionalized in several countries, with support from UNFPA and WHO. Thirty countries have developed maternal and perinatal death surveillance and response programmes, generate maternal death notification rates and maternal death review rates to monitor the implementation of their national programmes, and 12 generate annual reports on such implementation. 

E. Advocacy and awareness-raising 

The annual commemoration, on 23 May, of the International Day to End Obstetric Fistula; highlighting powerful stories of fistula survivors in the media showing the human face of fistula; influential champions and fistula advocates speaking out; and enhancing collaboration and coordination with partners have all helped to ensure that fistula does not become a forgotten issue. The Campaign to End Fistula continues to spread its strong message and undertakes significant communication activities, raising awareness and support in high-burden fistula countries and around the world. During the COVID-19 pandemic, webinars and social media were used to enhance awareness around fistula.

The West Africa Regional Fistula Dialogue organized in 2021 by the Government of Côte d’Ivoire, the Korea International Cooperation Agency and UNFPA raised awareness on fistula and brought together policymakers, programme managers, development partners, the private sector, civil society, academia and health service providers from around the globe to discuss innovations, partnerships and research for successful fistula programmes. 

To accelerate global commitment and action towards ending fistula, Member States issued a call to action to develop a global road map to end fistula within a decade, in line with General Assembly resolution 73/147. Innovations are needed in community-based prevention and management of obstetric fistula, investment cases and partnerships for fistula treatment, as well as the translation of research into policy to prevent maternal mortality and morbidity. F. Global need to strengthen financial support 

A major challenge faced by many countries is the insufficient level of national financial resources for promoting maternal health and addressing obstetric fistula. Increased investments and intensified resource mobilization (including domestic resources) are required at the national level to support prevention, treatment and social reintegration and the acceleration needed to improve maternal and newborn health to end fistula by 2030. 

Efforts to end fistula are integrated into and supported by broader maternal and newborn health initiatives, including the Every Woman, Every Child initiative of the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), the H6 Partnership, the Muskoka Initiative on Maternal, Newborn and Child Health, the Partnership for Maternal, Newborn and Child Health, the UNFPA Maternal and Newborn Health Thematic Fund, the Quality of Care Network and the Global Financing Facility. 

 In 2020–2021, contributions to the Campaign to End Fistula at the global and national levels included financial commitments from the Governments of Canada, Germany, Iceland, Luxembourg, Poland, the Republic of Korea and Sweden and from the Spotlight Initiative. Additional funds were donated by private sector partners and philanthropic foundations, including Johnson and Johnson, Friends of UNFPA and the United Nations Federal Credit Union Foundation.