# In a nutshell

This page discusses surgery for the treatment of obstetric fistula. An obstetric fistula is an abnormal opening between the vagina and the bladder or rectum, typically caused by tissue death from prolonged obstructed labor. Obstetric fistula can lead to physical complications and poor psychosocial outcomes.

Our preliminary estimate suggests that surgery to treat obstetric fistula has the potential to be as cost-effective as our priority programs. However, several major unanswered questions remain, especially regarding the total costs of fistula surgery and the long-term outcomes of fistula surgery.

Our investigation of fistula surgery is ongoing. GiveWell and IDinsight are currently in discussions with charities that fund fistula surgery about ways in which we might work with them to improve their monitoring and to answer some of our outstanding questions. It is possible that we may review one or more of these charities for top charity status in the future.

Published: June 2017

## What is the problem?

An obstetric (or gynecologic) fistula is an abnormal opening between the vagina and the bladder (vesicovaginal fistula) or rectum (rectovaginal fistula), typically caused by prolonged obstructed labor.1 A fistula forms when the sustained pressure of a fetus's presenting part (usually its head) against the mother's pelvic bone cuts off blood flow to soft tissues, which necrotize and form a hole between body cavities. Obstetric fistula causes continuous and uncontrollable leakage of urine and/or feces through the vagina, which can lead to physical complications and poor psychosocial and economic outcomes.2

• Physical complications of fistula can include:3
• Dermatological conditions
• Unpleasant odor
• Constipation
• Psychosocial consequences can include:4
• Divorce and ostracism from familial and social activities
• Depression and other psychological complications
• Decreased economic outcomes
• Additional complications associated with obstructed labor but not caused by fistula (and therefore not ameliorated by fistula surgery) can include:5
• Fetal loss and associated psychosocial consequences, such as mourning
• Reproductive organ damage, such as uterine rupture
• Amenorrhea and loss of fertility
• Neurological damage resulting in weakness in the leg, limb contracture, and foot drop
• Renal damage resulting in decreased kidney function
• Vaginal stenosis and painful intercourse

Obstetric fistula from prolonged labor typically does not occur in countries where women have access to obstetric care and emergency obstetric procedures (such as caesarean section to prevent prolonged labor) through developed health systems.6 Obstetric fistula can be considered one symptom of a larger obstructed labor injury complex.7

Our understanding is that living with obstetric fistula is highly detrimental to well-being. The Global Burden of Disease Study 2013 assigned vesicovaginal fistula a disability weight (a measure of the size of the negative impact of a fistula on a woman's life) of 0.342, similar to the disability weight assigned to moderate dementia (0.377) or the amputation of both arms without treatment (0.383).8

## What is the program?

Surgery to repair vesicovaginal or rectovaginal fistula is a complex procedure, and surgical method may vary depending on the characteristics of the injury and the experience of the surgeon.9 Fistula surgery generally involves making an incision in the vaginal mucosa around the fistula and the suture of tissue to cover the fistula in either a single or double layer.10 After surgery for vesicovaginal fistula, a transurethral drainage catheter is used for an average of 14 days and high fluid intake is advised. Patients are advised against sexual contact for three months to allow the tissues to heal.11 Postoperative care may also include social reintegration via counseling and life skills training.12

In some cases, surgery is not the most advisable method of fistula management. Some small vesicovaginal fistulas may close spontaneously if managed with catheter use.13 In some cases, the damage is extensive enough that surgery is unlikely to result in improved function, and fistula symptoms may be managed with urinary diversion.14

Organizations that support surgery to repair obstetric fistula include the Fistula Foundation, EngenderHealth's Fistula Care Plus program, the United Nations Population Fund (UNFPA), Hamlin Fistula Ethiopia, Worldwide Fistula Fund, and Operation Fistula, among others. These organizations conduct the following activities:

• Identifying patients via community outreach efforts and referring and transporting these patients to health facilities for surgery.15
• Funding the training of fistula surgeons.16
• Providing health facilities with equipment needed to perform fistula surgeries,17 for example designing and funding the creation and distribution of fistula repair kits.18
• Funding fistula centers, hospitals, and other partners.19
• Operating fistula centers and hospitals.20
• Providing post-operative support, including physical care, counseling, social reintegration, and life skills training.21
• Preventing fistula by funding training of OB/GYNs and community health advocates, increasing awareness of fistula and access to family planning, and advocating for policy changes.23
• Researching ways to improve the quality of fistula surgery, for example piloting a pay-for-performance model of fistula surgery.24
• Improving the monitoring and evaluation of fistula surgery, for example by developing a tool to allow surgeons to centrally report data on patients and outcomes.25

## Does the program work?

Success of fistula surgery consists of two components:

1. Physical surgical success, measured by fistula closure as reported by the surgeon, continence at discharge from the hospital (for example, as measured by a dye test), and long-term continence. The limited available literature on surgical outcomes suggests average surgical success rates of approximately 86% for fistula closure and 70% for continence at discharge.26 We have found insufficient follow-up data to determine long-term continence rates and are uncertain about the degree to which continence at discharge is predictive of long-term continence.
2. Psychosocial life outcomes. We have not seen strong evidence that life outcomes are improved post-surgery, in part due to a lack of follow-up data in this area. Some weak evidence suggests that psychosocial life outcomes may not be entirely dependent on the physical outcome of the surgery.27 Some fistula centers provide post-surgical psychological care or reintegration training; we are uncertain about the effect of these programs on life outcomes of patients.

As part of an evaluation of a fistula organization, we would examine monitoring of patient outcomes, including physical outcomes at discharge and other outcomes if available. Due to paucity of data on long-term continence and psychosocial life outcomes, we find it likely that even after further investigation and engagement with fistula organizations, we would remain more uncertain about the outcomes of fistula surgery than we are about the outcomes of our current priority programs.

In a 2012 letter to GiveWell, which is cited in the DCP3: Essential Surgery, 2015 as its source for fistula cost data, the Fistula Foundation estimated the cost per surgery at $1,000.28 We are uncertain about the accuracy of this estimate, though it seems to be supported by a small amount of additional cost data of uncertain quality.29 In order to more accurately estimate the cost per surgery, we would want to see estimates based on data from hospitals and centers where fistula surgery is performed. ## Is there room for more funding? It seems plausible to us that there is room for more funding for fistula surgery globally. Given an estimated 1 million existing cases of obstetric fistula30 and the rough cost estimate of$1,000 per surgery, we estimate global capacity for fistula surgery funding on the order of $1 billion. While we do not have a comprehensive sense of the available global funding for fistula repair, it is our impression that the annual budgets of major funders of this work represent a small portion of this global funding need.31 However, it is plausible that funding is not the only constraint to providing more fistula surgeries, and that additional funding would therefore not necessarily lead to additional surgeries. Additionally, we expect that as fistula identification and management improves, remaining cases are increasingly the most difficult or expensive to identify and treat. ## Cost-effectiveness We are highly uncertain about whether the cost-effectiveness of fistula surgery is competitive with that of our priority programs. We are highly uncertain about the full costs of fistula surgery, and about the effect of fistula surgery on life outcomes We very roughly estimate the cost of a physically successful fistula surgery at$1,400.32 If this estimate is roughly accurate, it is possible that fistula surgery could be competitively cost-effective with our priority programs. Our very preliminary cost-effectiveness model of fistula surgery illustrates the effect of individuals' moral valuation of the benefit of averting fistula burden compared to the benefits of other GiveWell top charities.33

Additional questions that may impact our cost-effectiveness estimate include the rate at which fistulas reopen after surgery, the rate of residual incontinence and its impact on life outcomes, and the rate of adverse effects of fistula surgery.

## Our process

We have spoken with representatives of several organizations that support fistula surgery, including the Fistula Foundation, EngenderHealth, Operation Fistula, and Hamlin Fistula.34 As part of our Incubation Grants program, GiveWell is partnering with IDinsight to support the identification or development of a GiveWell top charity focused on fistula surgery.

## Questions for further investigation

There are several major questions that we were not able to resolve in our review of the academic literature:

• How much does a fistula program cost per patient treated?
• Is there room for more funding to cause additional fistula surgeries?
• What monitoring and evaluation is collected by fistula programs?
• How much does fistula closure and lack of incontinence impact a woman's life? In what percentage of cases, and to what extent, does fistula surgery reduce ostracization or otherwise cause major reductions in psychological distress?
• Is fistula surgery successful at closing fistula and reducing incontinence in the long term?

## Sources

Document Source
Adler et al. 2013 Key Informant Method Source (archive)
Adler et al. 2013 Prevalence Review Source (archive)
Ahmed and Holtz 2007 Source (archive)
Arrowsmith, Barone, and Ruminjo 2013 Source (archive)
Arrowsmith, Hamlin, and Wall 1996 Source (archive)
AusAID/USAID Review of Support to Hamlin Fistula Ethiopia 2013 Source (archive)
DCP3: Essential Surgery, 2015 Source (archive)
EngenderHealth 2012 "Estimating Costs to Provide Fistula Services in Nigeria and Ethiopia" Source (archive)
EngenderHealth website, Fistula Source (archive)
Fistula Foundation Annual Report 2015 Source (archive)
Fistula Foundation, Letter to GiveWell 2012 Source
GiveWell's non-verbatim summary of a conversation with Operation Fistula, May 3, 2016 Source
GiveWell's preliminary cost-effectiveness model of fistula surgery Source
Hamlin Fistula Ethiopia website, About Us Source (archive)
Hancock 2009 Source (archive)
Lombard et al. 2015 Source (archive)
Operation Fistula website, GOFER Source (archive)
Operation Fistula website, Pay-for-Performance to the Point-of-Care Source (archive)
Salomon et al. 2015 Source (archive)
UNFPA MHTF Annual Report 2015 Source (archive)
UNFPA/EngenderHealth Obstetric Fistula Needs Assessment Report 2003 Source (archive)
USAID 2017 Midterm evaluation of Fistula Care Plus Source (archive)
Worldwide Fistula Fund website, Our Programs Source (archive)
• 1.

"A gynecologic fistula refers to an abnormal communication between the urinary tract or the gastrointestinal tract and the genital tract, produced by obstetric causes, usually prolonged and obstructed labor." DCP3: Essential Surgery, 2015, p. 95.

• 2.

"In prolonged labor, which frequently results in delivery of a stillborn, the bladder and/or rectal tissue is compressed between the pelvic bones and the fetal head, cutting off blood flow and causing ischemic pressure necrosis (Husain and others 2005). In the hours or days following such a prolonged labor, the fistula forms and leakage of urine, stool, or both appears." DCP3: Essential Surgery, 2015, p. 95.

• 3.

"Additional major complications can include reproductive organ damage, such as uterine rupture, amenorrhea, and uterine scarring resulting in secondary infertility; dermatological conditions, resulting in excoriations and infections; neurological damage, resulting in weakness in the leg and foot drop (Arrowsmith, Hamlin, and Wall 1996); and renal damage, resulting in decreased kidney function. Women also report genital soreness; painful intercourse; constipation; and unpleasant odor, despite frequent washing and pad changes (Turan, Johnson, and Polan 2007)." DCP3: Essential Surgery, 2015, p. 96. Some complications listed above are complications of the obstetric event that causes the fistula, whereas others are reversible physical complications of the fistula itself.

• 4.

"...the woman may be abandoned by her husband and family to live as a social outcast without the ability to earn a living (Wall and others 2002). In many cultures, the woman either blames herself or is blamed by the community for the fistula, which is seen as a mark of punishment for some wrong-doing (Johnson and others 2010). She endures social isolation, economic deprivation, and depression (Turan, Johnson, and Polan 2007; Weston and others 2011)." DCP3: Essential Surgery, 2015, p. 97.

• 5.
• "Additional major complications can include reproductive organ damage, such as uterine rupture, amenorrhea, and uterine scarring resulting in secondary infertility; dermatological conditions, resulting in excoriations and infections; neurological damage, resulting in weakness in the leg and foot drop (Arrowsmith, Hamlin, and Wall 1996); and renal damage, resulting in decreased kidney function. Women also report genital soreness; painful intercourse; constipation; and unpleasant odor, despite frequent washing and pad changes (Turan, Johnson, and Polan 2007)." DCP3: Essential Surgery, 2015, p. 96. Some complications listed above are complications of the obstetric event that causes the fistula, whereas others are reversible physical complications of the fistula itself.
• See also Figure 6.1, DCP3: Essential Surgery, 2015, p. 96 which lists possible consequences of “Obstructed labor injury complex” including: fetal death, fistula formation, complex urological injury, vaginal scarring and stenosis, secondary infertility, musculoskeletal injury, foot drop, chronic skin irritation, offensive odor.
• 6.

"The advent of anesthesia and safe, effective surgical procedures for cesarean sections have made the occurrence of obstetric fistula a rare event in the developed world; when they do occur, they are typically due to a congenital anomaly, surgical complication, malignancy, or radiation damage." DCP3: Essential Surgery, 2015, p. 95.

• 7.
• "Arrowsmith and colleagues coined the phrase 'obstructed labor injury complex' to encompass the extent of physical and social injury caused by fistulas." Ahmed and Holtz 2007, p. S11, referring to Arrowsmith, Hamlin, and Wall 1996.
• "The field injury that is produced by prolonged obstructed labor may result in multiple birth-related injuries in addition to (or instead of) a vesicovaginal fistula. Focusing simply on the 'hole' between the bladder and the vagina ignores the multifaceted nature of the injury that many of these patients have sustained. These injuries may include total urethral loss, stress incontinence, hydroureteronephrosis, renal failure, rectovaginal fistula formation, rectal atresia, anal sphincter incompetence, cervical destruction, amenorrhea, pelvic inflammatory disease, secondary infertility, vaginal stenosis, osteitis pubis, and foot-drop. In addition to their physical injuries, women who have experienced prolonged obstructed labor often develop serious social problems, including divorce, exclusion from religious activities, separation from their families, worsening poverty, malnutrition, and almost unendurable suffering." Arrowsmith, Hamlin, and Wall 1996, p. 568.
• 8.

Salomon et al. 2015, pp. e717, e718, e720.

• 9.

"The surgical approach can be vaginal, abdominal, or combined, based on the location of the fistula and the preference and experience of the surgeon. The vaginal route seems to be associated with less blood loss and pain (Chigbu and others 2006). However, the evidence on the difference in operative complications and speed of recovery is limited." DCP3: Essential Surgery, 2015, p. 102.

• 10.

"An incision is made over the vaginal mucosa all around the fistula about 3 millimeters away from the junction of the bladder (rectum in RVF [rectovaginal fistula]) and vaginal skin (epithelium). Lateral extension of the incision, at the 3:00 and 9:00 o’clock positions, is made bilaterally. These incisions over the vaginal mucosa should be just deep enough to cut only the vaginal mucosa. The bladder (rectum in RVF) should be mobilized adequately to avoid tension on the closure of the defect.

Bladder or rectal muscle should be approximated, avoiding the bladder or rectal mucosa. The closure of bladder fistulas can be in either a single or a double layer based on individual preference. Closure of rectal fistula is preferable in two layers, to avoid rectal mucosal interposition between the sutures. In patients who had had a diverting colostomy and repair of an RVF, a dye test must be done to confirm success of repair before planning for colostomy closure." DCP3: Essential Surgery, 2015, p. 102.

For details of surgical technique, see the textbook "Practical Obstetric Fistula Surgery", Hancock 2009, especially Chapter 6.

• 11.

"The main concern in VVF [vesicovaginal] patients in the postoperative period is the maintenance of free and continuous bladder drainage. High fluid intake is widely advised; women should be encouraged to drink four to five liters a day (Hancock 2009b) and the color of the urine should be watched as the indicator of the adequacy of hydration. A blocked catheter signals an emergency. Transurethral drainage catheters are generally kept for an average of 14 days (up to 21 days following new urethral reconstruction) and should be removed without clamping. Some suggest that postoperative catheterization for 10 days may be sufficient for less complicated cases of VVF repair (Nardos, Browning, and Member 2008). Women are advised not to resume sexual contact for three months to give adequate time for the tissues to heal." DCP3: Essential Surgery, 2015, p. 102.

• 12.

"For women who have lived with fistula for many years, reintegration into society involves redefinition of self and transition from being identified as filthy, dependent, and unworthy to being seen as clean, feminine, and active in family and community life. Thus, reintegration into family and community life is a major adjustment and goal after surgery. This need for reintegration requires that surgical programs dedicated to fistula repair consider and implement counseling for social integration and training in life skills to help these women return to gainful employment after repair.

Most women live an agrarian lifestyle, and returning to farming is important to them. One paper identifies the most important factor helping them feel normal again is the ability to return to farming after surgical repair (Pope, Bangser, and Requejo 2011). However, most women felt that they needed more time after surgery to fully recover their strength; the authors recommend having an alternate non-labor-intensive form of income for the first year after repair before most women return to their routine work. The full reintegration of a patient postrepair should also include her sexual and reproductive health needs (Mselle and others 2012). Preoperative and postoperative counseling for 47 Eritrean fistula patients was shown to increase their self-esteem (Johnson and others 2010)." DCP3: Essential Surgery, 2015, pp. 102-103.

• 13.

"Women with bladder fistulas can sometimes be treated conservatively if the injury is recent and the hole is small. Continuous bladder drainage with Foley catheters for four to six weeks has been reported to result in the spontaneous closure of small fistulas with fresh edges in 15 percent to 20 percent of cases (Waaldijk 1994). However, the majority of VVFs [vesicovaginal fistulas] require surgical treatment." DCP3: Essential Surgery, 2015, p. 101.

• 14.

"In some cases, the damage to the urethra and bladder is so severe that conventional repair methods are not successful. In specialized centers, these patients are sometimes offered urinary diversion in which the ureters are implanted in the lower bowel (Morgan and others 2009)." DCP3: Essential Surgery, 2015, p. 102.

• 15.
• "Fistula Foundation funds patient outreach to educate communities about the condition and to help identify, refer, and transport women to life-changing treatment." Fistula Foundation Annual Report 2015, p. 4.
• "WFF [Worldwide Fistula Fund] works to identify women who need fistula treatment and transports them to surgery performed by Expert Fistula Surgeons." Worldwide Fistula Fund website, Our Programs
• "As obstetric fistula largely affects poorer, marginalized women and girls, often living in remote areas, it can be a challenge to identify them, either in health facilities or communities, and then to connect them to treatment. In 2015, UNFPA in Ethiopia supported the training of 240 health extension workers and 129 nurses, midwives and doctors in fistula case identification to strengthen referrals to surgical treatment. Other assistance helped the Ghana Health Services to develop a good practice document on fistula case identification and referral. It catalogues existing practices that have yielded promising results and will inform the establishment of a national fistula identification mechanism.

In the Democratic Republic of the Congo, UNFPA partners with local public, private and civil society entities to raise awareness on fistula and connect women to treatment. Fistula survivors who have undergone treatment help identify other women with fistula in their communities, and assist them to seek medical care. Media and community outreach campaigns spread prevention and treatment messages, and in 2015 reached an estimated 100,000 people in one province." UNFPA MHTF Annual Report 2015, p. 44.
• 16.
• "A lack of trained surgeons throughout sub-Saharan Africa and Southeast Asia means that capacity to treat the growing backlog of fistula patients is limited. Compounding this challenge, no two fistulas are identical—it can take years of training for a single surgeon to be sufficiently prepared to treat a complex injury. To meet this need, Fistula Foundation funds a comprehensive fistula surgeon training program, directed by the International Federation of Gynecology and Obstetrics (FIGO)." Fistula Foundation Annual Report 2015, p. 4.
• "At global, regional and national levels, UNFPA works with several partner organizations, such as EngenderHealth/Fistula Care Plus, Fistula Foundation, Freedom From Fistula Foundation, the International Society of Obstetric Fistula Surgeons, the International Federation of Gynecology and Obstetrics, and Operation Fistula to promote high-quality training in fistula surgical repair. At the national level, the MHTF endorses the training of surgeons in a standardized curriculum for fistula repair developed by the International Federation of Gynecology and Obstetrics, the International Society of Obstetric Fistula Surgeons, UNFPA, EngenderHealth, and the Royal College of Obstetricians and Gynecologists." UNFPA MHTF Annual Report 2015, p. 45.
• 17.

"Many facilities lack even the most basic equipment. Our partners have become accustomed to working in conditions that are less than ideal, performing surgery with aging equipment, or making do with tools that may not be the most appropriate for fistula surgery. We listen and respond to the needs of our partners and help provide support that will enable them to perform surgery in the safest environment possible." Fistula Foundation Annual Report 2015, p. 4.

• 18.

"In 2012, UNFPA, in partnership with expert fistula surgeons, designed kits with with all the necessary instruments and medical supplies for performing surgical repairs. In 2015, the MHTF supported the procurement of 568 kits for use at health facilities in 17 countries." UNFPA MHTF Annual Report 2015, p. 42.

• 19.

For example, see Fistula Foundation Annual Report 2015, p.5, "Fistula Foundation 2015 Partners": "The above is a list of all organizations that received 2015 grants from Fistula Foundation, and is not an exhaustive list of current partners."

• 20.

"Hamlin Fistula Ethiopia directs the work of the Addis Ababa Fistula Hospital, its five regional hospitals, the Hamlin College of Midwives and Desta Mender, a farm and training centre for long term patients." Hamlin Fistula Ethiopia website, About Us

• 21.
• "WFF offers Recovery and Ongoing Support to women including safe places to heal, comprehensive post-operative care, meals, group and individual counseling, individual care plans and integrated physical therapy overseen by WFF’s Rehabilitation Advisory Council." Worldwide Fistula Fund website, Our Programs
• "Women are encouraged to participate in Education and Vocational Skills Training in literacy and health classes, as well as embroidery & sewing courses, handcrafting jewelry, and cooking & catering. WFF also launched the Women’s Empowerment Center in Uganda in collaboration with TERREWODE." Worldwide Fistula Fund website, Our Programs
• "The majority of MHTF-assisted countries are supporting social reintegration and the acquisition of income-generating skills critical for fistula survivors to provide for themselves and their families, and rebuild their sense of dignity and agency." UNFPA MHTF Annual Report 2015, p. 42.
• 22.

"We additionally fund research in maternal and reproductive health to assess current treatments, to uncover unmet treatment needs and to improve future care." Worldwide Fistula Fund website, Our Programs

• 23.
• "WFF works to provide Expert OB-GYN Training through our enhanced OB-GYN residency training program, Mekelle Medical Education Collaboration, and our specialized Urogynecology Fellowship training program, both launched in partnership with and at Mekelle University in Ethiopia.

WFF funds Community Health Advocate Training where community members are trained in fistula awareness and risk factors and to encourage local families to give birth in health centers." Worldwide Fistula Fund website, Our Programs
• "Preventing Fistula
• Upgrading emergency obstetric care to prevent obstetric fistula
• Increasing awareness at the community level about fistula prevention and the importance of maternal health care
• Advocating policy changes that tackle the root causes of obstetric fistula, such as delays in accessing emergency obstetric care
• Promoting gender equity and reducing violence against women" EngenderHealth website, Fistula
• "Through the MHTF, UNFPA and the Campaign to End Fistula are strengthening prevention by educating women, families and communities on the importance of delivering with a skilled birth attendant. Sensitizing community leaders and health workers, including midwives, on the risk of developing fistula and its causes is a key component of connecting women to skilled care during pregnancy and delivery." UNFPA MHTF Annual Report 2015, p. 44.
• "UNFPA advocates for fistula-affected countries to develop costed, time-bound national strategies and action plans for eliminating the condition. By the end of 2015, 15 MHTF-supported countries had national strategies in place. Nine had costed operational plans." UNFPA MHTF Annual Report 2015, p. 42.
• "UNFPA helps countries in establishing and successfully operating national task forces for eliminating fistula. In 2015, 28 MHTF-assisted countries had these task forces." UNFPA MHTF Annual Report 2015, p. 42.
• 24.

"As qualified surgeons submitted patient records, we paid out grants directly to them and gave them the flexibility to use the money at their discretion. We piloted this concept in Madagascar, Malawi, Mauritania and Zambia. This pilot program treated 752 women, exceeding all targets, driving quality and capacity-expansion, and delivering unprecedented cost-effectiveness in line with vaccines." Operation Fistula website, Pay-for-Performance to the Point-of-Care

• 25.

"We developed GOFER to improve the accuracy and reliability of data collection and enable a collaborative effort to improve the quality of fistula care globally.

Our vision for GOFER begins by using the platform to unite and improve the fistula sector. With wide adoption, GOFER will introduce visibility into quality of care, improve outcomes of surgery and expand the impact of funding.

We aim to have over 50% of annual spending on fistula care committed to using GOFER by the end of 2016." Operation Fistula website, GOFER

• 26.

We rely on Arrowsmith, Barone, and Ruminjo 2013, the most recent meta-analysis of fistula surgery outcomes that we identified. "The authors reviewed 46 published articles that addressed outcomes in fistula care. Most articles were published between 2006 and 2013." (p. 399) Surgical outcomes in studies identified in this review are not necessarily representative of outcomes of surgeries supported by organizations that GiveWell may evaluate. As part of an evaluation of a fistula organization, we would examine monitoring of patient outcomes, including physical outcomes at discharge and other outcomes if available.

• "The question of continence versus closure has important implications. There are major differences between the expected rates of fistula closure and continence after fistula repair. In the studies reviewed here, closure rates ranged from a low of 53.6% to a high of 97.5%, with most closure rates above 85% and an average of 86%. By contrast, rates of dryness (i.e., no incontinence remaining after closure) are much lower, spanning from 42 to 92%, with most between 50 and 80% and averaging 70%." Arrowsmith, Barone, and Ruminjo 2013, p. 400.
• The authors emphasize a lack of standardized outcome metrics in fistula surgery: "To advance, the fistula care field needs to establish standardized outcome definitions. Professional bodies like the International Continence Society have proven that standardized terminology in other clinical areas related to continence is possible. Routine outcome measurement is essential to maintain quality of care. In addition, reporting on outcomes is unavoidable when considering an individual site’s funding, accreditation, and governmental permission to practice. Commonly agreed upon definitions and outcome measures will help ensure that site reviews are accurate and conducted fairly. To compare technical innovations with existing methods, the field must agree on definitions of success. Furthermore, standardized indicators for mortality and morbidity associated with repair can help improve the evidence base and contribute to quality of care." Arrowsmith, Barone, and Ruminjo 2013, p. 402.
• 27.

Lombard et al. 2015, a literature review, found ten primary qualitative studies of rehabilitation experiences of women in sub-Saharan Africa following obstetric fistula repair, all between 2003-2011.

• "Many women may remain amenorrhoeic, experience intrauterine and/or vaginal scarring and cervical damage that may be associated with pelvic inflammatory disease. Few studies are available on women’s quality of life or their needs post-repair, which would be useful in planning effective interventions and care." p. 555.
• "All ten included studies were conducted in sub-Saharan Africa: three in Tanzania, two in Eritrea, one in Kenya, one in Benin, one in Malawi, one in Ethiopia and one across 20 countries. All research took place in clinical facilities: seven in a rural setting, one in an urban setting and two in mixed settings. Five studies used a mixed-methods approach, whereas the other five used only qualitative methods. The length of research across all studies ranged from 2 months to 2 years between 2003 and 2011. All included studies related to the same target population: rural women affected by fistula (five studies), women and families (four studies) and women, key informants and experts in the field (one study).

Most studies used semi-structured interviews as a data collection tool with an average participant population of n = 29 (range 8–61). The average age of women included in the research was 31 years, while the average age at fistula was 24 years. The duration of fistula ranged from 3 months to 30 years." pp. 556-557.
• There is some indication that surgery ameliorates the social effects of fistula even when it does not eliminate the physical effects: "In this review, we were unable to identify the relationship between continence status post-repair and rehabilitation experiences and recommendations due to the qualitative nature of the included studies. Research has shown that a woman who is closed and dry post-repair vs. one who is still incontinent is more likely to live with her husband, eat with others, earn money and attend community gatherings. However, women who are still incontinent demonstrate high percentages of meeting their own needs (75%), ability to work (66%) and staying married (61%). These positive outcomes extend to their families as one sister said: ‘I am very much happy because she wasn’t going to the mosque, was not able to fast during Ramadan, but she is now able to do all that. She is now able to chat with her friends’. Interestingly, for affected women, the surgical repair experience appears to be characterised by a shift in social status rather than physical recovery. Simply receiving the repair can be a positive intervention and even women with only partially successful repairs report improved quality of life. We cannot be sure, however, that these findings would be true for all women with residual incontinence." p. 564.
• 28.
• 29.
• "HFE has estimated the cost per standard repair procedure at the main hospital and Bahir Dar Outreach Centre to range from US$755 to US$1,474 depending on location and severity of the case." AusAID/USAID Review of Support to Hamlin Fistula Ethiopia 2013, p. xiii.
• "The only other organisation supporting comprehensive fistula care in Ethiopia is WAHA, who work in government hospitals, so do not have the same overhead costs. WAHA indicated that with all country level costs (administration, salary, transport etc.) divided by number of cases treated, the cost per OF patient is about US$350, reduced to US$225 when removing costs for prevention." AusAID/USAID Review of Support to Hamlin Fistula Ethiopia 2013, p. 31.
• A 2012 EngenderHealth report estimated the direct costs to institutions of providing fistula repair in Nigeria ($147-$272) and Ethiopia ($161-$229), based on direct observation of a very small number of surgeries. EngenderHealth 2012 "Estimating Costs to Provide Fistula Services in Nigeria and Ethiopia", Table 1, Table 3, pp. 6-7.
• A 2003 assessment estimated the "fully-loaded cost per procedure" for fistula repair based on visits to fistula repair sites in nine African countries. Reported costs ranged from about $10 to$750, with many sites reporting costs in the range of $50-$150. It is not clear what costs are included in these estimates. UNFPA/EngenderHealth Obstetric Fistula Needs Assessment Report 2003
• 30.

"Overall, we estimate that just over one million women may have a fistula in sub-Saharan Africa and South Asia, and that there are over 6000 new cases per year in these two world regions." Adler et al. 2013 Prevalence Review, p. 9. See also Adler et al. 2013 Key Informant Method.

• 31.

It is our understanding that the Fistula Foundation, the United Nations Population Fund (UNFPA), and Engender Health represent major international funders of fistula repair.

• The UNFPA Maternal Health Thematic Fund consists of the Thematic Trust Fund for Maternal Health and the Thematic Fund for Obstetric Fistula, both of which contribute funds to UNFPA's Campaign to End Fistula. In 2015, the Thematic Trust Fund for Maternal Health had an operating budget of $18.4 million and the Thematic Fund for Obstetric Fistula had an operating budget of$610,000. The UNFPA Maternal Health Thematic Fund spent $3 million on UNFPA's Campaign to End Fistula in 2015. UNFPA MHTF Annual Report 2015, pp. 12, 56. • In 2015, the Fistula Foundation had total unrestricted revenues and support of$6.9 million and total expenses of $8.2 million. Fistula Foundation Annual Report 2015, p. 11, “Our Financials”. Due to the partnership between the UNFPA Campaign to End Fistula and the Fistula Foundation, it is possible that summing the fistula budgets of these two organizations double-counts some amount of the funding. • Fistula Care Plus is a five-year project (December 12, 2013 to December 11, 2018) with actual funding through October 2016 of$27.75 million, or an average of approximately $9.61 million per year. USAID 2017 Midterm evaluation of Fistula Care Plus, p. xv. • 32. • The Fistula Foundation estimates the cost per fistula surgery at about$1,000. Fistula Foundation, Letter to GiveWell 2012, p. 2. There is some literature suggesting that this estimate may be roughly accurate (more). We are not sure which costs associated with a fistula surgery program are included or excluded in this estimate. In the past, we have generally found that charity cost estimates are lower than our cost estimates after we review program cost data. We believe that the best way to improve our understanding of the cost per surgery would be to solicit cost data from the Fistula Foundation or other organizations.
• We estimate that roughly 70% of surgeries are physically successful (the patient is continent at discharge), based on: "The question of continence versus closure has important implications. There are major differences between the expected rates of fistula closure and continence after fistula repair. In the studies reviewed here, closure rates ranged from a low of 53.6% to a high of 97.5%, with most closure rates above 85% and an average of 86%. By contrast, rates of dryness (i.e., no incontinence remaining after closure) are much lower, spanning from 42 to 92%, with most between 50 and 80% and averaging 70%." Arrowsmith, Barone, and Ruminjo 2013, p. 400.
• $1,000 per surgery / 70% continence upon discharge =$1,429 per successful surgery
• 33.
• 34.

See GiveWell's non-verbatim summary of a conversation with Operation Fistula, May 3, 2016. We have not made notes from our other conversations available.