"An obstetric (or gynecologic) fistula is an abnormal opening between the vagina and the bladder (vesicovaginal fistula) or rectum (rectovaginal fistula)... 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." (GiveWell, Surgery to Repair Obstetric Fistula, June 2017)
 I have shortened "obstetric fistula" to "fistula" for brevity throughout this post, although there are also non-obstetric fistulas. This post only refers to obstetric fistulas.
 "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. 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." (GiveWell, Surgery to Repair Obstetric Fistula, June 2017)
 "Physical complications of fistula can include:
- "Dermatological conditions
- "Unpleasant odor
"Psychosocial consequences can include:
- "Divorce and ostracism from familial and social activities
- "Depression and other psychological complications
- "Decreased economic outcomes"
(GiveWell, Surgery to Repair Obstetric Fistula, June 2017)
Comments relating fistula odor to negative employment outcomes, divorce, and isolation were made by Kate Grant, Chief Executive Officer at the Fistula Foundation, in response to this write-up, November 13, 2019.
 The New York Times, Nicholas Kristof, "The World's Modern-Day Lepers: Women with Fistulas," March 19, 2016
 "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. 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." (GiveWell, Surgery to Repair Obstetric Fistula, June 2017)
 "Fistula Foundation supports the treatment of obstetric fistula by providing funding to hospitals that perform surgeries, providing funding to train new surgeons, conducting community outreach, reintegrating patients into their communities after surgery, constructing new hospitals, and providing surgical equipment." (GiveWell, Fistula Foundation review, August 2019)
 "Previous to 2009, the Fistula Foundation provided funding to only the Hamlin Fistula Hospitals in Ethiopia. In 2009 the Fistula Foundation began funding other hospitals performing fistula surgeries throughout the developing world." (GiveWell, Fistula Foundation review, 2011)
 "We reviewed the Fistula Foundation's website and spoke to Kate Grant, Executive Director of the Fistula Foundation, three times over the phone as well as exchanging emails. Ms. Grant provided us with applications submitted by the organizations that have received funding from the Fistula Foundation (aside from the Addis Ababa hospital) and other supporting documentation. In reviewing these materials, we focused on the following questions, based on our questions for surgery charities:
- "Do Fistula Foundation grants cause additional surgeries to take place that would not have taken place otherwise?
- "Are these surgeries successful? Has this information been checked for accuracy?
"Based on what we have seen, we cannot answer the above questions with confidence." (GiveWell, Fistula Foundation review, 2011)
 "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." (GiveWell, Surgery to Repair Obstetric Fistula, June 2017)
 "It may be challenging to identify and diagnose potential fistula cases. Fistula most often occurs in women who are located in very geographically remote areas or who are too poor to access health systems for delivery care in the event of prolonged obstructed labor. Women located in very remote areas may be hard to reach in general; women with obstetric fistula may be very hard to reach in particular, because they may be more likely to be socially disconnected or unreachable through regular community health systems…
"We’re unsure how the above outreach contributes to the overall cost per patient of fistula treatment. In addition to outreach activities, our impression is that fistula surgery programs often involve training surgeons and the purchase of equipment. We remain very unsure about the costs and benefits of these activities. (GiveWell blog, Deciding whether to recommend fistula management charities, July 6, 2017)
 "IDInsight [sic] has estimated the total cost of identifying and treating a fistula patient through Fistula Foundation's Action on Fistula (AOF) program in Kenya. To do so, it uses annual financial statements for the first phase of the AOF program (May 2014-April 2017) and annual projections for the second phase of the program (May 2017 - April 2020). This cost figure includes both the direct costs of the program (community outreach, fistula surgery and reintegration) and the indirect costs (e.g. doctor and nurse training, program management, administration)." (GiveWell Fistula Foundation CEA, August 2019, cell W6)
 "After a candidate organization signs off on our publishing the interim review, GiveWell will make a $100,000 'participation grant' to it." (GiveWell, Charity Application Process, Updated October 2017)
 "What are GiveWell's next steps? We hope to continue our assessment of Fistula Foundation in the future, focusing on the following questions, which are discussed in more detail below:
- "We would like to understand in more detail the exact nature of Fistula Foundation's role in supporting fistula surgeries. Who does it provide funding to? Does it directly perform any activities that lead to additional surgeries? How is the Countrywide Treatment Program distinct from Fistula Foundation's activities in other countries?
- "Does Fistula Foundation increase the number of fistula surgeries relative to the number that would have occurred in its absence?
- "What are the long-term outcomes of these surgeries?
- "What are the opportunity costs of the capacity that Fistula Foundation draws into working on fistula? For example, if it supports surgeons, what would these surgeons have done in its absence?...
"Key remaining questions
- "What steps were taken to verify the accuracy of the data collected at the Fistula Foundation-supported facilities? How was this data collected?
- "Over time, how many fistula surgeries have taken place at all facilities (both those supported and not supported by Fistula Foundation) in the regions in which Fistula Foundation operates?
- "Is there evidence of an upward trend in fistula surgeries before Fistula Foundation's intervention?
- "Do other actors provide funding for fistula surgeries in these regions – for example, the local government, private funders, or other donors?" (GiveWell, Fistula Foundation review, August 2019)