Measuring the cost-effectiveness of treating rectovaginal and vesicovaginal fistulas: A multicenter global study by the Fistula Foundation

Abstract

Objective

Surgery for obstetric fistula is a highly effective treatment to restore continence and improve quality of life. However, a lack of data on the cost-effectiveness of this procedure limits prioritization of this essential treatment. This study measures the effectiveness of fistula surgeries using disability-adjusted life years (DALYs) averted.

Methods

In 2021 and 2022, the Fistula Foundation funded 20 179 fistula surgeries and related procedures at 143 hospitals among 27 countries. We calculated DALYs averted specifically for vesicovaginal fistula and rectovaginal fistula procedure types (n = 13 235 surgeries) by using disability weights from the 2019 Global Burden of Disease study. We based cost calculations on direct treatment expenses, including medical supplies, health provider fees, and preoperative and postoperative care. We measured effectiveness using data on the risk of permanent disability, country-specific average life spans, and treatment outcomes.

Results

The total treatment cost was $7.6 million, and a total of 131 433 DALYs were averted. Thus, the cost per DALY averted—the cost to restore 1 year of healthy life—was $58. For this analysis, we took a cautious approach and weighted only surgeries that resulted in a closed fistula with restored continence. We calculated DALYs averted by country. Limitations of the study include data entry errors inherent in patient logs and lack of long-term outcomes.

Conclusion

The current study demonstrates that obstetric fistula surgery, along with having a significant positive impact on maternal health outcomes, is highly cost-effective in comparison with other interventions. The study therefore highlights the benefits of prioritizing fistula treatment as part of the global agenda for maternal health care.

1 INTRODUCTION

Obstetric fistula is a devastating childbirth injury that is primarily caused by prolonged, obstructed labor. A fistula is characterized by an abnormal hole between two organs or vessels. The most prevalent types of obstetric fistula are vesicovaginal fistula (VVF), which occurs between the bladder and vagina and results in continuous leakage of urine through the vagina, and rectovaginal fistula (RVF), which occurs between the rectum and vagina and results in leakage of feces or gas.^1-3 The health consequences associated with VVF and RVF include increased risks of infertility, stillbirth, urethral loss, skin excoriation, vaginal stenosis, amenorrhea, orthopedic injuries, and neurological disorders. Apart from its devastating physical impact, obstetric fistulas also have profound social, psychological, and economic effects on affected women.⁴

The prevalence of obstetric fistula is particularly high in low-income settings where barriers to adequate care and limited access to maternal health services persist.⁴ An estimated 50 000–100 000 new cases occur globally each year, and one million women—concentrated in sub-Saharan Africa and south Asia—live with untreated cases.⁵

Surgery is the primary treatment for fistulas, and it has been shown to be highly successful in improving the physical and psychological well-being of affected women.⁵ However, many women lack access to quality surgical treatment, leaving them to endure a life of continued suffering and acute social isolation. The devastating impact of fistula on women and their communities calls for urgent action.

The Fistula Foundation, a nonprofit organization based in San Jose, CA, is the largest private funder of fistula surgery and related procedures.⁶ From 2009 to 2022, the foundation worked with 126 partners, including hospitals, surgical teams, and community-based organizations, among 33 countries to enable more than 75 000 surgeries. In 2022, more than 87% of repair surgeries conducted across the foundation's global network resulted in full continence for treated women. The organization provides comprehensive support for fistula care and treatment by covering the direct costs of fistula surgery, facilitating training for healthcare providers, providing medical supplies and equipment, mobilizing community health workers to identify and refer patients, and organizing support groups and job training to enable patients with fistulas to reintegrate into society.⁷ The establishment of Fistula Foundation Treatment Networks has further streamlined treatment, outreach, training, and reintegration services. These networks aim to reduce the time between fistula occurrence and repair by delivering countrywide access to care to all women in need of treatment.⁷

The literature on the cost-effectiveness of fistula repair surgery remains limited. To our knowledge, there is one study to date that focuses exclusively on Uganda.⁸ While the benefits of fistula repair surgery in restoring health are widely recognized, the lack of published cost-effectiveness evidence has limited the funding potential of this intervention. Cost-effectiveness analysis provides a systematic framework to compare different interventions and treatments. It is compelling in settings where, because of limited resources, surgical interventions may seem prohibitively expensive. By showing that fistula repair surgery is highly cost-effective, disability-adjusted life-years (DALYs) averted analysis can help raise the profile of this important maternal health intervention.

In the current study, we aim to quantify the impact and cost-effectiveness of surgeries supported by the Fistula Foundation in 2021 and 2022 among 27 countries using the Institute for Health Metrics and Evaluation's (IHME's) most recent GBD (Global Burden of Disease) study results. We hypothesize that the cost-effectiveness of fistula repair surgery, as measured by DALYs averted, demonstrates the significant value of these interventions in improving global maternal health outcomes.

2 MATERIALS AND METHODS

2.1 Data collection: Patient and surgery data

The current study employed a retrospective observational research approach. Data for the analysis were extracted from the Fistula Foundation Patient Log, a standardized data collection instrument submitted to the foundation by its surgical partners on a quarterly basis. We used data from procedures funded from January 2021 to December 2022. The patient logs provided comprehensive information on variables including patient age, type of procedure, and surgical outcomes observed at discharge. Ethical approval was not required for this study as only deidentified data were used for analysis. The data used for this study were collected as part of the Fistula Foundation's grant management protocols, which mandate the collection of information for patients who receive surgical support. All patient identifiers have been meticulously removed to ensure confidentiality and privacy. The results reported in this study are based on aggregated and deidentified information, ensuring that individuald cannot be identified or linked to the study outcomes.

2.2 Data collection: Cost data

This study used each surgical partner's average fistula repair cost, comprising direct costs associated with hospital admission fees, operating room fees, health provider fees, bed rates, patient food and medications, laboratory investigations, and medical supplies. Direct costs refer to expenses directly attributed to the surgical procedures. Indirect costs, on the other hand, encompass expenses not directly related to the surgical procedures themselves but are incurred as a result of the overall program activities. It is important to note that the cost analysis focused solely on direct costs and excluded other activities funded by the foundation which contribute to connecting women to care, such as health provider training, community outreach, patient reintegration, and overhead costs. The cost per DALY averted was determined by dividing the total cost of the fistula surgeries by the number of DALYs averted. We established a significance threshold of P < 0.05 to evaluate the statistical significance of our results. Microsoft Excel version 2308 was used for data processing and hypothesis testing.

2.3 Inclusion criteria

During the years 2021 and 2022, the Fistula Foundation supported a total of 20 179 surgeries, encompassing various procedures such as VVF repair, RVF repair, ureteric fistula repair, urethral fistula repair/replacement, third-/fourth-degree perineal tear repair, sling or urethroplasty, vaginoplasty, urinary diversion, bladder stone removal, catheterization, colostomy opening, colostomy closing, and examinations under anesthesia. However, because the IHME's GBD study only includes disability weights for VVF and RVF procedures, we focused solely on these procedures. Thus, our cost-effectiveness analysis was restricted to 13 235 VVF and RVF repair surgeries.

2.4 Calculation of DALYs

The burden of VVFs and RVFs was calculated according to the GBD study, using DALYs as the unit of measurement. DALYs for a disease or health condition are the sum of the years of life lost due to premature mortality (YLLs) and the years lived with a disability (YLDs) due to prevalent cases of the disease or health condition in a population. Disability weights, which represent the magnitude of health loss associated with specific health problems, were used to calculate YLDs. All DALYs were attributable to YLDs, as it was assumed that fistula surgeries were not life-saving (YLLs = 0).

The number of Fistula Foundation–funded RVF and VVF surgeries in 2021 and 2022 and their corresponding disability weights is displayed in Table 1. A weight of 0 represents perfect health and a weight of 1 represents death.

TABLE 1. Procedure counts and disability weights.

Procedure type	2021	2022	Disability weight
RVF repair	825	1029	0.501 (0.339–0.657)
VVF repair	5495	5886	0.342 (0.227–0.478)
Total RVF and VVF repairs	6320	6915

• Abbreviations: RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

Cost per DALY averted has gained traction as an approach to assessing the efficiency of health interventions.⁹ This measure is frequently used in the Disease Control Priorities report¹⁰ to quantify maternal conditions that are “surgically avertable” through access to high-quality obstetric surgical procedures. We calculated DALYs averted for each fistula case treated in the hospital using the method originally developed by McCord and Chowdhury¹¹ and leveraged by other researchers, using minimal assumptions around estimates of risk of death and disability and effectiveness of treatment.^11-15 By employing this approach, our study quantified the prospective impact of fistula surgery, providing insight into years of symptom (incontinence) averted and the associated cost for achieving a unit of health outcome (life-year).

The severity of disease, or the probability of a condition causing permanent disability, is assumed to be 1.0 for both RVF and VVF, because without surgical intervention the fistula will continue to be disabling for the rest of the woman's life.¹⁶

The effectiveness of treatment in this study refers to the probability of the intervention preventing permanent disability, as indicated by the outcome of the procedure. The Fistula Foundation's outcome classifications include “Closed, continent (Dry)” when the fistula is closed, and the patient regains continence; “Closed, incontinent” when the fistula is closed, but some degree of incontinence persists; and “Not closed” when the fistula remains open, and continence is not restored. To maintain a cautious approach and avoid overestimating the intervention's effectiveness, our DALYs averted estimate was based only on surgeries resulting in a closed fistula with restored continence.

In summary, the burden of an untreated condition is adjusted by two additional factors: the likelihood of death or permanent disability if left untreated, and the likelihood of success of treatment, as illustrated in Table 2.^11-15

TABLE 2. Scoring system for severity of disease and effectiveness of treatment.^{11, 13-15}

Measure from McCord and Chowdhury	Weight	Application to VVF and RVF repair
Severity of disease
≥95% fatal or disabling without treatment	1.0	Severity of disease score for VVF and RVF is 1.0 because the likelihood of permanent disability caused by fistula if left untreated is always high
<95% and ≥50%	0.7
<50% and ≥5%	0.3
<5%	0.0
Effectiveness of treatment
≥95% chance of survival or cure	1.0	Effectiveness of treatment score is 1.0 if the surgical outcome is “Closed, continent (Dry)”
<95% and ≥50%	0.7
<50% and ≥5%	0.3
<5%	0.0	Effectiveness of treatment score is 0.0 if the surgical outcome is “Closed, incontinent,” “Not closed,” or “Other”

• Note: Years of life preserved = severity of disease.
• Abbreviations: RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

As an example, a woman from Kenya develops RVF at age 30, where the average female life expectancy at birth is 64 years.¹⁷ Women treated by the Fistula Foundation in Kenya live with a fistula for an average of 5 years between fistula onset and repair, due to barriers such as cost and lack of awareness. In this example, the woman received surgery at age 35 and the outcome of her surgery was a closed fistula and restored continence. To determine the DALYs averted in this case, the difference between the life expectancy (64 years) and the woman's age at the time of intervention (35 years) is multiplied by the disability weight (0.501 for RVF), the severity score (1.0 for RVF), and the effectiveness of treatment (1.0 for closed and continent). This results in 14.52 DALYs averted. If the intervention had instead been provided at the time of onset, when the woman was 30 years old, the DALYs averted would be 17.03 (Figure 1).

FIGURE 1

Illustration of disability-adjusted life-years (DALYs) averted.

3 RESULTS

Using the aforementioned methodology, our analysis revealed that between January 2021 and December 2022, an estimated 131 433 DALYs were averted as a result of Fistula Foundation–funded RVF and VVF surgeries (Table 3). To calculate years of life preserved, we used the recorded age of each woman treated in the Patient Log relative to the average life expectancy at birth for that specific country. Patients with no recorded age were excluded (which was negligible). For each case, the years of life preserved was multiplied by the severity of disease (always 1.0), the disability weight (based on the procedure type), and the effectiveness of treatment (based on the outcome).

TABLE 3. DALYs data in 2021 and 2022.

	2021	2022	Total
RVF (n)	825	1029	1854
VVF (n)	5495	5886	11 381
DALYs averted	64 561	66 872	131 433
Total surgery cost (in US$ millions)	$3.58	$4.01	$7.59
Cost-effectiveness (in US$ per DALY averted)	$55.53	$59.99
Average cost per DALY averted	$57.76

• Abbreviations: DALY, disability-adjusted life-year; RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

The total direct cost of all VVF and RVF surgeries was $7.6 million. This includes surgeries that resulted in successful and unsuccessful outcomes, although DALYs averted were based on successful repairs. Therefore, the average cost per DALYs averted was $58, as shown in Table 3.

It was observed that countries with longer life expectancies experienced a greater number of DALYs averted and demonstrated higher cost-effectiveness. The following table illustrates the allocation of DALYs averted and the count of RVF and VVF repairs facilitated through the Fistula Foundation's partner network, categorized by geography and country for the years 2021 and 2022 (Table 4).

RVF repair surgeries had a higher cost-effectiveness than VVF repair surgeries. This is likely because the disability weight of RVF is 0.501 compared with 0.342 for VVF, leading to a higher number of DALYs averted from each RVF surgical intervention. Among the surgeries analyzed, 14% were RVF repairs (n = 1854) and 86% were VVF repair surgeries (n = 11 381). The age distribution was similar for both procedures during the study period (RVF average age, 32.7 years [SD, 13.0 years]; VVF average age, 32.4 years [SD, 11.8 years]).

TABLE 4. DALYs averted and surgery count by geographic region in 2021 and 2022.

Geographic distribution of partners	Life expectancy at birth, female, 2021 (years)^17	2021		2022
		Sum of DALYS averted	No. of VVF and RVF repairs	Sum of DALYS averted	No. of VVF and RVF repairs
Central Africa		14 250	1588	14 737	1612
Angola	65	3915	493	3561	497
Chad	54	2391	247	1825	192
DRC	62	7944	848	9351	923
Eastern Africa		35 271	2999	36 864	3573
Ethiopia	68	294	26	271	23
Kenya	65	9115	818	11 213	1110
Madagascar	68	9993	796	6703	571
Malawi	67	-	-	2205	224
Mozambique	64	831	99	500	59
Rwanda	69	345	39	621	68
Somalia	57	-	-	165	19
Somaliland	58	3813	334	3412	341
South Sudan	57	607	62	530	61
Tanzania	69	5255	471	6522	586
Uganda	65	1130	117	1156	133
Zambia	65	3128	158	2279	245
Zimbabwe	64	759	79	1289	133
Western Africa		6254	886	5935	828
Benin	61	408	68	191	25
Burkina Faso	62	454	58	643	79
Guinea	60	133	19	83	9
Mali	60	988	117	1516	186
Mauritania	66	2534	243	1685	168
Nigeria	53	1738	381	1816	361
Southern Asia		8786	847	9336	902
Afghanistan	65	661	78	638	74
Bangladesh	74	790	77	892	73
Nepal	71	1013	111	1039	107
Pakistan	69	6321	581	6767	648
Total		64 561	6320	66 872	6915

• Abbreviations: DALY, disability-adjusted life-year; DRC, Democratic Republic of the Congo; RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

4 DISCUSSION

The findings from our study underscore the impressive cost-effectiveness of fistula surgery, yielding an average cost of $58 per DALYs averted. Our results are comparable to those of Epiu et al. in Uganda, who found that the cost per DALYs averted through fistula surgery was $54.⁸ Notably, our study offers a more robust data set encompassing 27 countries.

As previously indicated, our study uses conservative assumptions in our calculations. We assigned a positive weight solely to surgeries that resulted in complete closure of the fistula and fully restored continence. If the fistula was closed but the woman experienced residual incontinence, we assigned a null weight. However, research indicates that even those with residual incontinence experience significant improvements in health and quality of life upon fistula closure.¹⁸ As a result, the calculated DALYs averted can be considered a conservative estimation.

Another example of our cautious approach is that we calculated years of life preserved based on life expectancy at birth for each country. Given that high rates of under-five mortality influence this average, it is reasonable to assume that the life spans of women who develop fistulas are likely to be longer than life expectancy at birth.

In the context of constrained healthcare expenditure in low- and middle-income countries, the challenge of determining worthwhile health interventions is particularly pronounced. To provide a meaningful perspective on our findings, it is essential to situate them within the framework of cost-effectiveness thresholds found in the existing literature. One such threshold, established by the WHO-CHOICE program, designates interventions as highly cost-effective if they fall below 1× the gross domestic product (GDP) per capita.¹⁹ Among the 27 countries in our study, the average GDP per capita²⁰ is $1212 and the lowest GDP per capita is $364 (Afghanistan). Our calculated $58 per DALYs averted falls distinctly below these thresholds.

Furthermore, our results can be compared with the cost per DALYs averted for other public health interventions with similar approaches displayed in Table 5.

TABLE 5. Comparison analysis of cost per DALY averted.^{12, 15, 21}

Study description	Geography	Cost per DALY averted
Doctors Without Borders performs emergency medical aid to people in crisis in more than 70 countries. A cost-effectiveness analysis to assess surgical care of injuries was performed at Teme Hospital in Nigeria and La Trinité Hospital in Haiti.	Nigeria	$172 and $223, respectively
Operation Rainbow performs free orthopedic surgeries for children and adults. This study compares the cost-effectiveness of the organization's usual elective missions with the emergency relief provided after the 2010 Haiti earthquake.	Haiti	$343
Investigators estimated cost per DALY averted for 2611 patients admitted for surgical interventions (elective cesarean sections) in a 106-bed private for-profit hospital in northern India.	India	$140

• Abbreviation: DALY, disability-adjusted life-year.

There are some limitations that may impact these findings. Data were reported to the Fistula Foundation through the Patient Log and are subject to data entry errors. Given the large sample size, we believe these limitations are negligible. The Fistula Foundation asks partners to follow standardized diagnosis and outcome assessment procedures based on FIGO (the International Federation of Gynecology & Obstetrics) guidelines, but it is possible that a partner could misclassify a severe perineal tear as an RVF or fail to recognize residual incontinence. The Fistula Foundation's Medical Advisor, an expert fistula surgeon, reviews each log and connects with partners as needed to support data integrity. However, the authors acknowledge that even with the right assessment, surgical outcomes at the time of discharge may differ from long-term outcomes. In addition, the direct costs of surgery were predictively estimated based on their grant budgets for the respective year. However, generalizing the average cost per surgery for each partner may overlook variations in procedure costs. The costs of VVF and RVF repair could be different, but we used a single average for each partner that is based on all types of surgeries funded by the Fistula Foundation. Last, our study assumed that each patient underwent a single intervention, without considering their surgical history. In cases where patients received surgery multiple times during the study period, each surgery was evaluated independently.

Furthermore, a cost-effectiveness analysis is only one aspect of performance assessment, and humanitarian, political, and programmatic considerations should not be overlooked in resource allocation decisions.

5 CONCLUSIONS

The results of the current study present several avenues for further research. Investigating the cost-effectiveness of certain interventions not included in the 2019 GBD study—including surgery for other childbirth-related injuries, such as third- and fourth-degree perineal tears—would be valuable. Evaluating DALYs averted for these procedures would provide additional evidence to highlight the significance of interventions that improve reproductive health. More broadly, the study reinforces the urgent need to prioritize fistula treatment on the global healthcare agenda and to improve resource allocation for maternal health. The profound significance of this intervention is evident in the restoration of continence and the rebuilding of lives among tens of thousands of women. Positive outcomes extend beyond physical healing, as fistula survivors report experiencing newfound freedom, increased confidence, personal growth, and improved income-earning ability. The beneficial effects of a woman's restored health also extend to her family and community, in the form of improved relationships, reduced social stigma, and increased community participation. New evidence that repair surgery for obstetric fistula is highly cost-effective—particularly relative to comparable interventions—highlights the value of investing in the well-being of women affected by this devastating condition.

AUTHOR CONTRIBUTIONS

Kee Rajagopal, Jesse Chu, and Lindsey Pollaczek conceptualized the paper and contributed to the manuscript at all stages including design, planning, data collection, data abstraction, and manuscript writing. Hannah Mann, an intern at the time of drafting the paper, assisted with data analysis. All authors read and approved the final manuscript.

ACKNOWLEDGMENTS

We would like to express our sincere gratitude to the Fistula Foundation's network of hospitals and skilled health teams for tirelessly providing life-changing surgical interventions to women with childbirth injuries. We want to extend our gratitude to Dr Andrew Browning, Fistula Foundation's medical advisor, for his feedback and input on this paper and his careful review of our grants and partnerships. We also want to extend our sincere appreciation to Michael Slind, Chief Marketing Officer, for his assistance with copyediting the manuscript. We are likewise grateful for Fistula Foundation's staff in the United States, Kenya, Zambia, DRC, and Tanzania, who serve as a bridge between women who suffer needlessly and selfless people who want to help them access the treatment they deserve. Most importantly, we are immensely thankful for the generosity of our global community of supporters spanning over 60 countries. Their kindness fuels our mission and enables the Fistula Foundation to reach more and more women every year. Finally, we thank the women who did not give up hope and who persevered to reach treatment despite all the obstacles.

FUNDING INFORMATION

No funding was received for this research or for publication.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

Open Research

DATA AVAILABILITY STATEMENT

Data available on request from the authors.