development goals were adopted after the united nations millennium summit to be achieved by 2015. the fifth goal of improving maternal health is directly related to obstetric fistula. since 2003, obstetric fistula has been gaining awareness amongst the general public and has received critical attention from unfpa, who has organized a global "campaign to end fistula". new york times columnist nicholas kristof, a pulitzer prize–winning writer, wrote several columns in 2003, 2005, and 2006 focusing on fistula and particularly treatment provided by catherine hamlin at the fistula hospital in ethiopia. in 2007, fistula foundation, engel entertainment, and a number of other organizations including pbs nova released the documentary film, a walk to beautiful, which traced the journey of five women from ethiopia who sought treatment for their obstetric fistulae at the addis ababa fistula hospital in ethiopia. the film still airs frequently on pbs in the u.s. and is credited with increasing awareness of obstetric fistulae greatly. increased public awareness and corresponding political pressure have helped fund the unfpa's campaign to end fistula, and helped motivate the united states agency for international development to dramatically increase funding for the prevention and treatment of obstetric fistulae. countries that signed the united nations millennium declaration have begun adopting policies and creating task forces to address issues of maternal morbidity and infant mortality, including tanzania, democratic republic of congo, sudan, pakistan, bangladesh, burkina faso, chad, mali, uganda, eritrea, niger, and kenya. laws to increase the minimum age for marriage have also been enacted in bangladesh, nigeria, and kenya. to monitor these countries and hold them accountable, the un has developed six "process indicators", a benchmark tool with minimum acceptable levels that measures whether or not women receive the services they need. the unfpa set out several strategies to address fistulae, including "postponing marriage and pregnancy for young girls, increasing access to education and family planning services for women and men, provide access to adequate medical care for all pregnant women and emergency obstetric care for all who develop complications, and repairing physical damage through medical intervention and emotional damage through counselling." one of the unfpa's initiatives to reduce the cost of transportation in accessing medical care provided ambulances and motorcycles for women in benin, chad, guinea, guinea-bissau, kenya, rwanda, senegal, tanzania, uganda, and zambia. campaign to end fistula the addis ababa fistula hospital in ethiopia successfully treats women with obstetric fistulae, even in less than desirable environments. as a result, the unfpa gathered partners in london in 2001, and officially launched an international initiative to address obstetric fistulae later in 2003. partners in this initiative include columbia university's averting maternal death and disability program, the international federation of gynecology and obstetrics, and the world health organization. the official international partnership formed by the campaign to end fistula is named the obstetric fistula working group (ofwg) and its purpose is to coordinate and collaborate global efforts to eliminate obstetric fistulae. the initiative's first action was to quantitatively assess the issue in countries where the prevalence is suspected to be high, including nine countries in sub-saharan africa. the studies found that fistula patients are mostly illiterate, young, and poor women. moreover, local legislators and government officials' lack of awareness exacerbate the problem. the ofwg improves awareness for prenatal and neonatal care and develops strategies for clinically managing obstetric fistula cases. to date, the campaign to end fistula has involved more than 30 countries in sub-saharan africa, south asia, and the middle east, and completed rapid needs assessments in many of those countries to continually assess the needs in each country. the strategies that the campaign helps each nation to develop are three-fold: prevention of new cases, treatment for patients, and support for reintegration into society after the operation. prevention efforts include access to maternal health services and mobilizing communities and legislators to increase awareness of maternal health problems. training health providers and ensuring affordable treatment services, as well as providing social services such as health education and mental health services, help treat and reintegrate women into their communities. other tasks undertaken by the campaign include fundraising and introducing new donors and gathering new partners of all perspectives, such as faith-based organizations, ngos, and private-sector companies. fistula fortnight the fistula fortnight was a two-week initiative that took place from february 21 to march 6, 2005, where fistula experts treated fistula patients for free at four surgical camps in the northern nigerian states of kano, katsina, kebbi, and sokoto. the initiative was collaborated by many partners such as the federal and state governments of nigeria, 13 nigerian fistula surgeons, the nigerian red cross, and unfpa. during the nine-month preparation period, facilities were renovated, equipment were provided, and staff were extensively trained to treat fistula. the goals of this initiative were to alleviate the backlog of patients waiting for surgery, provide treatment services at host sites, and to raise awareness for maternal health. the fistula fortnight treated 569 women at no cost, with an 87.8% rate of successful closures. follow-up treatments and services were provided, such as bed rest, analgesics, oral fluids, visual monitoring of urination by nurses, a catheter, catheter removal, and an examination and discharge from the hospital at a minimum of four weeks, with instruction to avoid sexual intercourse. the fistula fortnight also had preoperative and postoperative counseling provided by nurses and social workers and held health education workshops for fistula patients and their families. community organizations people recovering from a fistula in the postoperative period need support to fully reintegrate into society. in particular, physical labor is limited in the first year of recovery, so women need alternative ways to earn an income. since poverty is an indirect cause of obstetric fistulae, some community organizations aim to provide postoperative services to enhance the women's socioeconomic situation. delta survie, located in mopti, mali, is a community center that provides skills training and helps women to produce hand-made jewelry to generate income and meet other women while they recover. another organization, iamaneh suisse, identifies malian fistula patients, facilitates operations for those without the financial means, and helps them access follow-up services to prevent recurrence of fistulae in their subsequent pregnancies. other organizations also help to arrange mission trips for medical personnel to visit countries with women affected by fistulae, perform surgeries, and train local doctors to give medical assistance for fistula patients. the international organization for women and development (iowd) is one such nonprofit organization. the iowd hosts four to five mission trips per year to provide relief to obstetric fistula patients in west africa. iowd mission trip members have evaluated thousands of patients at no cost and performed surgeries for over a thousand women. treatment centers a complete fistula treatment center includes investigative services like laboratory work, radiology, and a blood bank, to ensure that the medical history of patients is clearly understood before treatment options are evaluated. the surgical services would include operating theaters, postoperative wards, and anesthetic services. physiotherapy and social-reintegration services are also necessary to arm women affected by obstetric fistula with the tools necessary to re-enter a society from which they have been ostracised. the size of the facility should be tailored to the need in the area, and the most successful centers work in collaboration with other treatment centers and organizations, forming a larger network of resources. the cost of salaries, single-use medical equipment, up to date technology and equipment, and maintenance of infrastructure, collectively provide large economic burdens to treatment centers. a barrier also arises when governments and local authorities require that approval be obtained prior to the construction of centers. there is an uneven distribution of specialized health care providers due to the below optimal training and supervision of health works and the low wages of fistula surgeons. most fistula surgeons come from developed countries and are brought to developing countries, the nations more often affected by fistula, by a variety of organizations. an example of a well functioning treatment center is in bangladesh where a facility has been created in association with the dhaka medical college hospital with support from the united nations population fund. here, 46 doctors and 30 nurses have been trained and have successfully doubled the number of fistula cases addressed and operated on. another example is a fistula unit in n'djamena, chad, which has a mobile clinic that travels to rural, hard-to-reach areas, to provide services, and works in association with liberty hospital. the world health organization has created a manual articulating necessary principles for surgical and pre- and post- operative care regarding obstetric fistula, providing a beneficial outline for affected nations. treatment centers are crucial for the survival of obstetric fistula patients and well-equipped centers help the emotional, physical, and psychological aspects of their lives.