Ending fistula: a cost-effective, restorative surgery

Imagine you are in labour, giving birth at home with no medical support. You are praying things will go well. They don’t. After four long days of excruciating obstructed labour, you give birth to a still born baby. On top of this grief, you find yourself unable to control your own body waste.

This is the tragic reality for too many Ethiopian women. Obstetric fistula is a nightmare.

Every woman matters

In 2024, no woman should suffer the indignity of an obstetric fistula, however it is estimated that a staggering 500,000 women in Sub Saharan Africa and Asia are living with untreated fistula and each year a further 50,000 – 100,000 women develop a fistula[1].

Survivors, often voiceless and marginalised, tend to live in impoverished countries, with the common thread of being poor, rural and female.

As well as suffering incontinence that can lead to severe infections, some women, even more devastatingly, suffer from paralysis caused by nerve damage. Survivors are often subject to severe social stigma and isolation, outcast by their communities. Many women report psychological issues and many marriages do not survive, unable to cope with the ongoing physical and emotional trauma.

In fact, the burden of living with obstetric fistula was reported by the Institute for Health Metrics and Evaluation in 2017 as comparable to living with terminal cancer and double the burden of blindness[2].

Map of fistula prevalence in the world

Fistula is virtually non-existent in Europe and North America thanks to access to health care.

However, in poor, rural communities across up to 60 low-income countries including Ethiopia, limited access to maternal health services and poor infrastructure result in thousands of women suffering the pain and devastation of fistula.

Although achieving UN Sustainable Development Goal 3 – Good Health and Well-being – will only be possible if fistula is ended for good, too often women’s health is not at the forefront of international policy making.

Fistula surgery: A cost-effective intervention

However, obstetric fistula can mostly be repaired with a single life-changing fistula treatment surgery. For some, this can take no more than two hours.

The global success rate for fistula repair surgeries is approximately 86%[3], and following specialist surgery, most patients can return to their previous lives, armed with restored health and dignity.

Nurse with patient

One standard fistula surgery at Hamlin Fistula Ethiopia costs £750 and gives a woman her life back.

The Life You Can Save, an organisation focused on identifying the most cost-effective interventions to tackle global poverty describes the suffering and health burden averted by fistula surgery as “comparable to the most cost-effective health interventions, such as vaccines and bed nets[4].

Founder of The Life You Can Save, Australian academic and global poverty expert Peter Singer, in his book of the same name, highlights obstetric fistula surgery as an example of an intervention that is cost-effective and clearly provides profound benefits at a modest cost:

“Both Hamlin and Fistula Foundation estimate the cost for full fistula surgery and rehabilitation services to be around $650–$700 per woman. Just for comparison, as I was writing this account, I checked on the cost of tickets for Lady Gaga’s next concert, which happened to be in Las Vegas in May 2019. They started at $762 and went up from there. So what is more important to you: seeing Lady Gaga perform for a couple of hours, or giving a young woman her life back?”

Peter Singer, The Life You Can Save [5]

New research highlights high impact at low cost

New peer-reviewed research conducted by the US-based Fistula Foundation, has also highlighted just how far each pound invested in tackling obstetric fistula goes in improving the quality of a woman’s life.

The Fistula Foundation analysed the cost-effectiveness of fistula repair surgery across 143 hospital sites in 27 countries, including EthiopiaThey found fistula surgery has a cost per disability adjusted life year averted of US$ 58 – highlighting the enormous value of investing in fistula surgery on a woman’s life.

Disability Adjusted Life Years are a time-based measure that combine years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health or disabililty, to assess the relative burden of a health condition.

When assessing the impact of fistula repair surgery, the relevant metric is DALYs averted—the number of years of healthy life that the intervention will save or restore. The Fistula Foundation highlight in their research “Quantifying impact in this way enables researchers to assess the improvement in quality of life per dollar spent on the intervention”. The lower the cost to avert a single DALY, the more cost-effective an intervention is.

“We already know that fistula surgery is one of the best bargains in the field of global health…with this newly released study, we now have precise data on the incredible ‘bang for the buck’”.

Kate Grant, CEO, Fistula Foundation

Read the research in the International Journal of Gynecology and Obstetrics

Our impact in Ethiopia

Each year, Hamlin Fistula Ethiopia provides over 3,500 surgeries for women, free of charge.

Hamlin Fistula Ethiopia is globally renowned for its pioneering surgical technique, which was developed by our founder Dr Catherine Hamlin, and has been recognised as a best practice in global health by leading organisations like the American College of Obstetricians and Gynecologists.

Surgeons from around the globe visit and train at Hamlin’s hospitals to learn this acclaimed, world-best treatment.

“Working with her [Catherine Hamlin] was a blessing. She made me look beyond surgical techniques and created an outstanding model on how to provide holistic and patient-centred care for these poor women.”

Dr Yeshineh Demerew, Medical Director at Hamlin Fistula Ethiopia

Hamlin takes a total care approach: One that seeks to repair, mend and heal all the scars – emotional and physical that come with this heart-breaking injury.

Hamlin Fistula Ethiopia’s six hospitals are fully staffed by over 550 Ethiopians who continue Catherine’s dream of transforming women’s care throughout Ethiopia and ending fistula, forever.

[1] https://www.who.int/news-room/facts-in-pictures/detail/10-facts-on-obstetric-fistula

[2] The Life You Can Save and Institute for Health Metrics and Evaluation https://ghdx.healthdata.org/record/ihme-data/gbd-2017-disability-weights


[4] The Life You Can Save and Institute for Health Metrics and Evaluation https://ghdx.healthdata.org/record/ihme-data/gbd-2017-disability-weights

[5] The Fistula Foundation was founded in the USA in 2000 to support Hamlin Fistula Ethiopia. Following Dr Catherine Hamlin’s appearance on the Oprah Winfrey show, from 2005 – 2013 the Foundation donated funds raised from US supporters. Hamlin was the key programme delivery partner of the Fistula Foundation in that first decade and together they worked to raise awareness of fistula surgery as a cost effective health intervention. The Fistula Foundation’s strategy today is to support training of fistula surgeons and surgical treatment outside of Ethiopia.