Initiatives taken at the global, regional and national levels.

 A. Major global initiatives 

The implementation of the Programme of Action of the International Conference on Population and Development, adopted in 1994, contributes to the achievement of the 2030 Agenda for Sustainable Development. It is stated in the Programme that “the human rights of women and the girl child are an inalienable, integral and indivisible part of universal human rights”, as well as the right to attain the highest standard of sexual and reproductive health. It calls for the elimination of all practices that discriminate against women and the advancement of gender equality and equity and the empowerment of women. Achieving universal access to sexual and reproductive health care and fulfilling the reproductive rights of individuals remain an unmet goal, with millions left behind. In 2021, the High-level Commission for the 25-year review of the implementation of the Programme of Action assessed progress made with regard to 12 global commitments made at the 25-year review in Nairobi, in 2019, by Governments, individual and organizations, including a commitment to zero preventable maternal deaths and morbidity. The commission reported slow progress on quality, accessible sexual and reproductive health care, exacerbated by the COVID-19 pandemic, and recommended a deliberate and comprehensive agenda for sexual and reproductive justice.

In 2022, at its fifty-fifth session, the Commission on Population and Development called upon Member States to ensure universal access to sexual and reproductive health-care services, including for family planning, and to ensure the full and effective implementation of the Beijing Declaration and Platform for Action and the Programme of Action of the International Conference on Population and Development, and to ensure universal access to sexual and reproductive health and reproductive rights. The Commission also urged Member States to mainstream a gender perspective into all development and humanitarian efforts, acknowledging that achieving gender equality and the empowerment of all women and girls and the elimination of all forms of violence and discrimination against them were crucial to the full implementation of the 2030 Agenda. 

 In 2022, at its sixty-sixth session, the Commission on the Status of Women called upon Governments to integrate reproductive health into national strategies and programmes, recognizing that the human rights of women include their right to have control over and decide freely and responsibly on all matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence, as a contribution to the achievement of gender equality and the empowerment of women and the realization of their human rights, including in the context of climate change and environmental and disaster risk reduction policies and programmes. 

 In 2021, the Generation Equality Forum launched a five-year action journey to achieve irreversible progress towards gender equality, through concrete, ambitious and transformative actions, including $40 billion in financial commitments. 

 In its resolution 47/25, adopted in 2021, the Human Rights Council called upon States to promote a human rights-based and gender-responsive multisectoral and cross-disciplinary coordination of policies, programmes, budgets and services designed to prevent and treat maternal morbidities with the active participation of all relevant stakeholders, and especially the full, equal and meaningful participation of women and girls at the national, local and community levels; and to promote social accountability mechanisms in order to accelerate the elimination of maternal mortality and morbidity and the achievement of universal access to sexual and reproductive health. 

 The commitments made in the 2030 Agenda include eliminating poverty, achieving gender equality and securing health and well-being for all through the achievement of the 17 Sustainable Development Goals. According to a report of the Secretary-General on progress towards the Goals issued in 2022 (E/2022/55), the COVID-19 pandemic led to the first increase in extreme poverty (a root cause of fistula) in years, adversely affecting progress towards gender equality and worsening the unevenness in overall progress towards reaching the Goals. Improvements in essential health services remain lowest in sub-Saharan Africa. In the same report, the Secretary-General warns of a possible reversal of two decades of progress in reproductive, maternal and child health, calls for a scale-up of investments into universal health coverage and notes the importance of social protection systems to protect health, as well as the consequences of large coverage gaps. International solidarity will require a transformative recovery, specifically focused on the 2030 Agenda and the Paris Agreement on climate change. 

Global initiatives led by the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA) or the United Nations Entity for Gender Equality and the Empowerment of Women (UN-Women), such as the Global Programme to End Child Marriage and the Spotlight Initiative, in partnership with the European Union and Member States, are aimed at achieving gender equality, ending child marriage and adolescent pregnancy and preventing maternal and newborn deaths and disabilities by addressing the underlying social determinants of fistula.

 Additional global initiatives, such as the Every Woman, Every Child initiative of the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016 – 2030), the UNFPA Maternal and Newborn Health Thematic Fund, the Partnership for Maternal, Newborn and Child Health, the Global Financing Facility for Women, Children and Adolescents, the H6 partnership and the strategies towards ending preventable maternal mortality, remain significant in the fight to end fistula. The initiatives are aimed at ending preventable maternal and newborn mortality and morbidities and supporting countries in implementing the Sustainable Development Goals. They place emphasis on country leadership and strengthening accountability, as well as on developing a sustainable evidence-informed health financing strategy, strengthening health systems and building strategic, multi-sectoral partnerships. 

In its resolution on strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage, the World Health Assembly called for access to emergency and essential surgery for all. For fistula survivors, this global commitment to strengthening surgical and anaesthesia care could help to accelerate a reduction in disparities, morbidity and mortality through improved access to surgical treatments. Nigeria, Pakistan, Rwanda, the United Republic of Tanzania and Zambia have integrated national surgical obstetrics and anaesthesia plans into their national health strategic plans.

Fistula was first acknowledged by the General Assembly in 2007 as a major women’s health issue, with the adoption of resolution 62/138. In 2020, the Assembly adopted resolution 75/159, in which it called for greater investments and accelerated action to end fistula within a decade, as part of the United Nations agenda for the advancement of women. Resolution 75/159 builds on six previous resolutions (adopted between 2007 and 2020) in which Member States reaffirmed their obligation to promote and protect the rights of all women and girls and to strive to end fistula, including by supporting the Campaign to End Fistula. 

The International Day to End Obstetric Fistula is commemorated annually, on 23 May, to raise awareness, strengthen partnerships and foster commitment, national leadership and ownership to end fistula.

B. Major regional initiatives

 A number of regional initiatives have been developed, assessed and strengthened to respond to commitments to ending obstetric fistula as part of the broader maternal and newborn health, development and human rights agenda. 

The Campaign on Accelerated Reduction of Maternal, Newborn and Child Mortality in Africa (extended to 2030), promotes the implementation of the Maputo Plan of Action 2016–2030 for the Operationalization of the Continental Policy Framework for Sexual and Reproductive Health and Rights and the Africa Health Strategy 2016–2030. Fifty countries in the region have launched the Campaign and implemented it within their national road maps to accelerate the reduction in maternal mortality and within their poverty reduction strategies and health plans. Four successful strategies of the Campaign are: (a) the use of existing structures; (b) the use of innovations to implement low-cost interventions; (c) the engagement of high-profile and high-level personalities; and (d) strengthened partnerships to support activities and prioritize maternal and newborn and child health. 

At a high-level meeting held in 2021, the First Ladies in West and Central Africa, under the patronage of the First Lady of the Niger, and UNFPA launched a regional strategy entitled “Helping Women Regain Their Dignity” aimed at ending obstetric fistula in West and Central Africa. The meeting offered an opportunity to leverage partnerships in order to mobilize resources and support to eliminate obstetric fistula in the region, with reiterated financial and technical commitments from the Korea International Cooperation Agency, Germany, Iceland, the Islamic Development Bank and the United States Agency for International Development. This follows a resolution adopted in 2018 by health ministers of the Economic Community of West African States (ECOWAS) aimed at eliminating obstetric fistula from the ECOWAS region and the 2019 Niamey Declaration of ECOWAS First Ladies calling for an end to child marriage and the promotion of the education and empowerment of girls. 

 The Sahel Women’s Empowerment and Demographic Dividend Project is a joint response by the United Nations and the World Bank Group active in West Africa. Since 2015, the project has strengthened national programmes that promote fistula prevention, such as those focusing on generating demand for maternal and newborn health, empowering women and girls, preventing early marriages and increasing the availability of trained health workers, including midwives. With a total investment of $680 million by 2020, the project is also aimed at strengthening legal frameworks that promote women’s rights to health and education. 

Key regional initiatives, including the Agenda 2063: The Africa We Want, the African Union Campaign to End Child Marriage, the African Charter on Human and People’s Rights and the African Charter on the Rights and Welfare of the Child, address the underlying determinants of fistula. In Eastern and Southern Africa, 17 countries have put in place national strategies to end fistula. UNFPA and Campaign to End Fistula partners have supported national initiatives to end fistula in the region.

The Asia-Pacific region continues to battle both obstetric and iatrogenic fistulas. Twelve countries in the region have developed road maps to reduce maternal mortality and morbidity, including fistula. 

 The League of Arab States, in partnership with UNFPA, has developed a regional strategy for reproductive, maternal, newborn, child and adolescent health that gives its member States a strategic framework for informing national plans until 2030. The strategy provides a comprehensive approach to reducing maternal mortality and obstetric fistula in four priority States: Djibouti, Somalia, the Sudan and Yemen. 

South-South cooperation is an essential part of the strategy to end obstetric fistula. In order to build national capacity and sustainability for fistula management, UNFPA and Campaign to End Fistula partners, including the International Federation of Gynaecology and Obstetrics and the Comprehensive Community-based Rehabilitation in the Tanzania, have supported highly skilled fistula surgeons from all regions of the world to provide fistula training, mentoring and treatment in the highest-burdened fistula countries.

C. Major national initiatives 

The global maternal mortality ratio decreased by 38 per cent between 2000 and 2017, and the number of maternal deaths fell from 451,000 per year to 295,000; yet thousands of new cases of fistula occur every year. 

Government ownership and leadership coupled with adequate health budgets, as well as additional technical and financial support from the international community, are crucial to solving the problem of fistula. Data indicate that 21 countries with a high prevalence of fistula have national strategies for eliminating obstetric fistula, and 18 countries (Bangladesh, Benin, Burkina Faso, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Guinea-Bissau, Madagascar, Mauritania, Nigeria, Senegal, Somalia, Togo and Uganda) have costed and time-bound operational plans to end fistula. Most of the strategies and plans are, however, not fully funded. Twenty-three countries have established national fistula task forces, which serve as coordinating and monitoring mechanisms for government and partner activities.

Partnerships are key to sustaining efforts to end fistula. The Fistula Foundation improved the care pathway for fistula patients in Kenya by linking rural patients to surgeons throughout the country and raising awareness of fistula in communities. The United Nations Federal Credit Union Foundation supported empowerment and social reintegration of fistula survivors in Nigeria. Together with partners, the Government of Nigeria developed a national protocol for the rehabilitation and social reintegration of fistula survivors to guide programmes. Mauritania has initiated the development of an emergency obstetric newborn care facility network to improve timely access to obstetric care. 

In Haiti, the capacities of health professionals and community stakeholders with regard to fistula surveillance, prevention, referral and screening were strengthened. Awareness-raising campaigns conducted in partnership with the Haitian Society of Obstetrics and Gynecology and midwives enabled the identification of 40 fistula survivors for treatment. 

The Government of Bangladesh has introduced a fistula elimination approach in four divisions in the country. Amid the COVID-19 pandemic, 801 fistula survivors received surgical treatment with a success rate of over 92 per cent, and 85 per cent of the women concerned received needs-based rehabilitation and reintegration support including training to make three-layer cloth masks and jute handicrafts, and psychosocial counselling through telemedicine. In 2021, Panchagarh was declared the first fistula-free district in Bangladesh. In Nepal, obstetric fistula-related indicators have been integrated into the national health management information system, and the detection and early management of fistula are included in the pre-service curriculum of midwives. 

 One in 20 women die in childbirth in Somalia and thousands are affected with morbidities, including obstetric fistula. UNFPA supports 55 emergency obstetric and newborn care facilities, midwifery schools and human rights-based family planning services across the country, which contribute to preventing those avoidable maternal deaths and morbidities. 38. The International Federation of Gynaecology and Obstetrics training programme has built the capacity of 75 fellows from 24 countries with skills in fistula surgery. In addition, the programme is training fistula care teams on holistic fistula care to enhance the quality of treatment. In April 2022, the training programme reached a milestone of 15,000 fistula repairs performed by fellows. Another training centre was established in Soroti, Uganda, in collaboration with TERREWODE, the Association for the Rehabilitation and Re-Orientation of Women for Development. 

 Since 2009, the Fistula Foundation has provided support for 60,000 fistula surgical interventions and carried out social reintegration in 33 countries in Africa and the Arab States region. The Foundation has formed new partnerships in Burkina Faso, the Democratic Republic of the Congo and the United Republic of Tanzania to end fistula. Healing Hands of Joy, a non-governmental organization, has trained more than 2,000 fistula survivors in Ethiopia as safe motherhood ambassadors, reaching over 1 million community members with information on fistula prevention, treatment and maternal health.