Obstetric Fistula: The Campaign to End Fistula

EXECUTIVE SUMMARY

Obstetric fistula is among the most severe and socially devastating injuries a woman can survive. It results almost entirely from prolonged obstructed labour without timely access to emergency obstetric care — a caesarean section or assisted delivery performed in time would prevent virtually every case. The injury creates a hole between the vagina and the bladder or rectum, causing continuous, uncontrollable leakage of urine and/or faeces. Women who develop fistula typically experience abandonment by partners, ostracism from their communities, inability to maintain livelihoods, and profound long-term psychological harm. Fistula is simultaneously a medical condition, a social emergency, and a marker of failed health systems.

Global prevalence estimates are wide and uncertain — most cited figures suggest 500,000 to 2 million women are currently living with untreated fistula, with 50,000 to 100,000 new cases arising annually, almost exclusively in sub-Saharan Africa and South Asia. These estimates are based on household survey extrapolations with limited validity; true population-level data does not exist. This data vacuum is itself a major programme challenge: without reliable baseline and incidence data, it is impossible to determine whether UNFPA's Campaign to End Fistula — launched in 2003 and now operating in over 55 countries — has actually reduced the global fistula burden over its 20+ year history.

UNFPA's Campaign is structured around three pillars: prevention (through skilled birth attendance and EmONC), treatment (through surgical repair and surgeon training), and reintegration (social and economic support for survivors after repair). The IEO evaluation of the Campaign (2021) found that the treatment pillar — especially surgical capacity building — has produced credible results: tens of thousands of repairs facilitated, hundreds of surgeons trained, and measurable increases in fistula treatment capacity in key countries. The prevention pillar is harder to evaluate, since fistula incidence reduction is entangled with the broader progress of maternal health systems. The reintegration pillar is the weakest and least funded of the three.

The fundamental strategic tension in fistula programming is between treatment and prevention — and it has not been resolved. Surgical repair is effective (~85–93% success rates for uncomplicated cases), relatively inexpensive (USD 100–400 per repair), and provides immediate relief to individual women. But surgical camps and repair programmes do not reduce the rate at which new cases occur — that requires skilled birth attendance and EmONC access. Independent evaluators and academic reviewers have consistently noted that UNFPA's Campaign has not achieved, and without radical scale-up of prevention is unlikely to achieve, elimination of the condition by 2030 as its aspiration states. The honest assessment is that surgical treatment has reached a significant but insufficient number of women, that the treatment backlog persists, and that prevention has not scaled fast enough.

KEY FACTS

Fistula definition: A hole between the vagina and the bladder (vesico-vaginal fistula, VVF) or vagina and rectum (recto-vaginal fistula, RVF), most commonly caused by prolonged obstructed labour. VVF is far more common than RVF.
Estimated global prevalence: 500,000–2 million women currently living with fistula (WHO/UNFPA estimates). The enormous range reflects the weakness of the underlying data — no country has a reliable population-based fistula register.
Annual new cases: Approximately 50,000–100,000 per year, based on indirect estimates (Wall, 2012; UNFPA programme data). Actual incidence data does not exist for any high-burden country.
Geographic concentration: Over 90% of cases occur in sub-Saharan Africa and South Asia. Nigeria, Ethiopia, Niger, Democratic Republic of Congo, Chad, Mali, and Tanzania are among the countries with highest estimated burden. In South Asia, Bangladesh and Pakistan carry significant burden.
Surgical repair success rate: 85–93% for uncomplicated (fresh) fistulas performed by experienced surgeons (Hilton & Ward, 1998; Arrowsmith et al., 1996; Raassen et al., 2014). Success rates for complex or recurrent fistulas are substantially lower (~50–60%).
Cost per repair: USD 100–400 for uncomplicated surgical repair (Stanton et al., 2007; UNFPA programme data). This makes it one of the most cost-effective surgical interventions in global health.
Campaign scale: The Campaign to End Fistula has operated in 55+ countries since 2003 and has facilitated tens of thousands of repairs (UNFPA reporting). UNFPA estimates approximately 75,000 repairs facilitated over the campaign lifetime through 2022, though methodology for counting is not standardised across country programmes.
Surgeons trained: UNFPA estimates 1,500+ fistula surgeons trained globally through the Campaign (UNFPA Annual Report 2022). Surgeon training uses the WHO/UNFPA Global Competency-Based Fistula Surgery Training Manual.
Risk factors for fistula: Young age at first delivery (girls under 18 face significantly higher risk due to pelvic immaturity), short stature, poverty, rural location, distance from EmONC facilities, and non-use of skilled birth attendance. Child marriage (see UNFPA-W-07) is a direct fistula risk factor.
Social consequences: Documented consequences include: divorce/abandonment (reported in 50–90% of cases across studies), social isolation, inability to work, depression, and malnutrition (women with fistula often restrict fluid intake, worsening renal function). Muleta et al. (2008, Ethiopia) found that 62% of women with fistula had been abandoned by their husbands; 88% could not maintain normal social activities.
IEO Evaluation (2021): Found the Campaign effective in treatment capacity-building and advocacy, but weak in prevention attribution, reintegration, and data. Recommended stronger government ownership, investment in prevention, and improved M&E.
Continent of surgery: The majority of fistula surgeries globally are performed in a small number of high-volume centres (Addis Ababa Fistula Hospital, Khartoum, Niamey, Lagos) with large surgical caseloads. Geographic concentration of surgical expertise limits access for the most remote women.
Continent of cases: Conversely, women with fistula are heavily concentrated in rural areas — most distant from surgical centres. The geographic mismatch between where cases are and where surgeons operate is a major access barrier.
Fistula and child marriage: A study in Niger (population with among the highest child marriage rates in the world) found that women who first gave birth under age 18 had a 3-fold higher risk of fistula than those who first gave birth at 20+ (Wall, 2012 review synthesis). The UNFPA child marriage programme (UNFPA-W-07) is therefore directly linked to fistula prevention.
Post-repair follow-up gap: Studies consistently show that 10–30% of women who have successful repairs (continent at discharge) develop recurrence or new incontinence within 12 months. Long-term follow-up is inadequate in most programmes (Raassen et al., 2014; UNFPA IEO, 2021).
Fistula and HIV: Studies in high-burden countries have found elevated HIV prevalence among women with fistula compared to community controls, likely reflecting shared social vulnerability rather than direct causation. HIV positive status may complicate surgical outcomes and require integrated care protocols.

BACKGROUND AND CONTEXT

Medical and Historical Context

Obstetric fistula was common in Europe and North America until the late 19th century — before hospital-based obstetrics, every health system experienced fistula. The condition was largely eliminated in high-income countries through a combination of: skilled birth attendance, access to EmONC (especially caesarean section), and reductions in child marriage and stunting that narrowed the cephalopelvic disproportion at the root of most obstructed labours.

Fistula persists in sub-Saharan Africa and South Asia for exactly the reverse reasons: home birth without skilled attendance is common; EmONC is geographically or financially inaccessible; girls are married and deliver their first child before full pelvic development; and malnutrition and stunting remain prevalent.

The modern era of fistula treatment was substantially shaped by the work of Dr. Reginald and Catherine Hamlin at the Addis Ababa Fistula Hospital (AAFH), founded in 1974. The AAFH became the global reference centre for fistula surgery, trained generations of surgeons from across Africa, and demonstrated that high surgical volume was achievable even in low-resource settings. UNFPA's Campaign to End Fistula built on this foundation and scaled it globally through a government-partnership model.

The Campaign to End Fistula: Origins and Structure

Launched in 2003 under the leadership of then-UNFPA Executive Director Thoraya Ahmed Obaid, the Campaign emerged from a recognition that fistula was "a hidden crisis" — a condition affecting hundreds of thousands of women that received virtually no global health funding or attention. The Campaign's political and advocacy success in bringing fistula onto the global agenda is its clearest uncontested achievement: the International Day to End Obstetric Fistula (May 23) and the inclusion of fistula in SDG monitoring frameworks both reflect this advocacy work.

The Campaign operates through a country-level implementation model: UNFPA country offices in high-burden countries coordinate national fistula programmes, working with ministries of health, international NGOs (Fistula Foundation, AMSATI, AMREF, Partners in Health), and national civil society. Globally, UNFPA convenes the annual Global Fistula Map survey and manages the Global Competency-Based Fistula Surgery Training curriculum.

WHAT UNFPA DOES: PROGRAMME DETAIL

Pillar 1: Prevention

Fistula prevention is logically inseparable from the broader maternal health agenda — it requires the same interventions (skilled birth attendance, EmONC) that prevent the full spectrum of maternal mortality. However, UNFPA has additional prevention activities specifically targeting fistula risk:

Reducing child marriage: UNFPA's dedicated child marriage programme (UNFPA-W-07) addresses the most important modifiable risk factor for fistula. Advocacy for legislative reform, community norm change, and girl empowerment programmes are the main mechanisms. Evidence that these reduce fistula incidence specifically is indirect — no RCT exists — but the causal pathway is biologically and epidemiologically established.

Reducing obstetric access delays: Community health worker programmes that identify pregnant women, facilitate ANC attendance, and arrange referral for delivery contribute to fistula prevention by reducing the proportion of deliveries that become prolonged, obstructed labours without intervention.

EmONC scale-up: Ensuring that communities have access to facilities capable of performing caesarean section and assisted delivery is the most direct prevention mechanism. UNFPA's EmONC programme (see UNFPA-W-01) is the operational mechanism.

Operational challenge: Prevention efforts are fundamentally health system change efforts — slow, expensive, and attributable to many actors. The Campaign's prevention mandate is real but its specific contribution is very difficult to measure or attribute.

Pillar 2: Treatment (Surgical Repair Programme)

This is the most operationally specific and measurable pillar of the Campaign.

Surgeon training: UNFPA uses the WHO/UNFPA Global Competency-Based Fistula Surgery Training Manual (revised 2018), which defines the minimum competencies for fistula surgeons. The standard training model involves a preceptorship at a high-volume centre (such as AAFH or a national reference centre), with defined case numbers required before certification. UNFPA country offices arrange and fund these preceptorships and provide support for in-country training.

Surgical camps and outreach: A "surgical camp" model concentrates multiple fistula repairs at a single facility over a defined period (typically 1–2 weeks), bringing together a visiting fistula surgeon with locally available nursing and anaesthesia support. This model increases throughput but has been criticised for: not building local sustainable capacity; providing inadequate post-operative follow-up; and selecting for uncomplicated cases (leaving complex cases behind). UNFPA has moved toward integrating fistula repair into permanent facility services — the "centre of excellence" model — but the camp model persists in many country programmes because it is cheaper and faster to organise.

Facility strengthening for fistula treatment: Supporting designated fistula treatment centres with equipment (operating table, anaesthesia, lighting, instruments), supplies, and staff deployment. UNFPA has supported the designation of fistula treatment centres in most high-burden countries.

Cost and scale: A typical fistula surgical camp of 30–50 repairs costs approximately USD 30,000–100,000 including surgeon fees, supplies, and patient transport — roughly USD 600–2,000 per repair in camp settings, higher than facility-level estimates due to mobilisation costs. At UNFPA's reported rate of approximately 3,000–5,000 repairs facilitated per year in recent programme cycles, the annual global investment in UNFPA-facilitated fistula surgery is approximately USD 10–20 million — a fraction of the scale required to eliminate the treatment backlog.

The treatment backlog arithmetic: If there are 500,000 women currently living with fistula and 75,000 have been repaired over 20 years of the Campaign, while approximately 50,000–100,000 new cases arise annually, the backlog is either stable or growing. Even doubling surgical throughput to 10,000 repairs per year (an ambitious target) would take 50 years to address existing cases if new incidence continued at 50,000 per year. This arithmetic makes the case for prevention investment starkly. It also illustrates why the Campaign's goal of ending fistula by 2030 requires dramatic reductions in incidence, not just increased surgical capacity.

Pillar 3: Reintegration

Post-repair reintegration — returning women to full social, economic, and family life — is the least funded and least evaluated component of the Campaign.

What reintegration involves:

Psychosocial counselling: Trauma-informed counselling for women who have often lived with fistula for years and experienced abandonment, isolation, and loss. In many programmes, psychosocial support is provided by "fistula counsellors" — trained community members, often survivors themselves.
Economic empowerment: Vocational training, income-generating activity support, and microcredit linkages for survivors who are unable to return to previous livelihoods (common in agricultural contexts where physical demands exceeded post-repair capacity).
Community and family reconciliation: Working with communities and families to facilitate reintegration — particularly re-establishing marital relationships or explaining to communities the nature and treatability of fistula.
Survivor network building: UNFPA supports fistula survivors' groups in several countries — networks that provide mutual support, advocacy, and referral.

Evidence quality: Near-absent. The reintegration literature is dominated by small qualitative studies and programme reports. No rigorous evaluation of any reintegration model has demonstrated measurable improvements in social or economic outcomes at population level. The evidence base for what works in fistula reintegration is one of the weakest areas in UNFPA's entire programme portfolio.

THE EVIDENCE BASE

Surgical Outcomes — Evidence Quality: Moderate to Strong

Success rates:

Hilton and Ward (1998): Largest single-centre series from the AAFH (n=2,484 operations, 1981–1992). Success (dry at discharge): 92.5% for vesico-vaginal fistulas. Complex cases: 71%. This remains the most cited reference for fistula surgical outcomes.
Raassen et al. (BJOG, 2014): Multi-centre series from sub-Saharan Africa (n=842). Closure achieved in 92%, dry at discharge in 79%. Predicting success: small, fresh, uncomplicated fistulas have the best outcomes; complex, radiation-induced, or recurrent fistulas have significantly worse outcomes.
Arrowsmith et al. (Obstetrics & Gynecology, 1996): Documented the spectrum of associated injuries in fistula patients (bladder neck damage, urethral destruction) that complicate repair and predict incontinence even after anatomical closure.

Limitation of the evidence: Almost all surgical outcome data comes from high-volume referral centres with experienced surgeons. Outcomes from less experienced surgeons operating in camp settings or smaller facilities are much less well documented. The evidence on quality of surgery by the 1,500+ surgeons trained through the Campaign is essentially absent — UNFPA does not systematically track outcomes for surgeons trained under its programme once they return to their home facilities.

Prevention — Evidence Quality: Weak (for fistula-specific prevention); Strong (for underlying maternal health interventions)

No study has specifically evaluated a fistula prevention programme with fistula incidence as an outcome. This is partly a methodological problem — fistula incidence is too low and data too poor to power a randomised or quasi-experimental study. The evidence on prevention is therefore inferred from:

The known causal pathway (obstructed labour → fistula, interrupted by SBA and EmONC)
Cross-country ecological correlations showing that fistula rates are lowest in countries with highest SBA coverage and EmONC access
Historical epidemiological evidence that fistula disappeared from high-income countries as skilled delivery universalised

This is scientifically strong inference but not direct evidence on programme effectiveness.

Prevalence Data — Evidence Quality: Very Weak

The most fundamental limitation in fistula research is that no reliable prevalence or incidence data exists. Most estimates are derived from:

DHS household surveys: The DHS includes a question on chronic vaginal discharge, from which fistula prevalence is inferred. This methodology is unreliable — "vaginal discharge" is not the same as fistula, and many women with fistula may not report the symptom or attribute it correctly. Tsui et al. (2007) evaluated DHS-based fistula estimates and found significant measurement problems.
Facility-based case series: Hospital data systematically underestimates community prevalence because women who never access surgical facilities are invisible to facility data.
Extrapolation from small surveys: Several country-level surveys (Nigeria, Uganda, Tanzania) using community-based clinical screening have produced prevalence estimates, but none are nationally representative.

The consequence: it is currently impossible to determine whether UNFPA's Campaign has reduced global fistula prevalence over its 20-year history. This is a profound accountability gap that the Campaign itself has acknowledged but not resolved.

Reintegration — Evidence Quality: Very Weak

The reintegration literature consists primarily of qualitative studies, programme reports, and cross-sectional surveys of survivor outcomes. There are no RCTs, no quasi-experimental evaluations, and no systematic reviews with outcome data on reintegration programme effectiveness. Key descriptive studies include Weston et al. (Int J Gynaecol Obstet, 2011) and Mselle et al. (BMC Health Services Research, 2011) — both qualitative analyses of survivor experiences showing severe social consequences and inadequate programme support. These establish the problem but not the solution.

IMPLEMENTATION REALITIES

The High-Volume Centre vs. Decentralised Access Problem

Fistula surgery requires specific skills that take significant time to develop. The AAFH model — a specialised, high-volume centre with dedicated fistula surgeons — produces the best surgical outcomes but is accessible only to women who can travel to Addis Ababa (or equivalent national reference centres). Most women with fistula in remote rural areas cannot make that journey. The alternative — decentralised surgery in district hospitals by less experienced surgeons — has lower success rates and higher complication rates. UNFPA's Campaign has largely supported the high-volume centre model and surgical camps. The trade-off between quality (high-volume centres) and equity (decentralised access) has not been resolved, and the current programme design systematically advantages women who live closer to urban surgical centres.

Surgical Camp Models: Output vs. Sustainability

Surgical camps are the most commonly reported fistula treatment activity. A camp provides a clear, countable output (number of repairs performed). But multiple programme evaluations have found that:

Camps select for uncomplicated cases — complex fistulas are often deferred or referred, creating a "cream-skimming" dynamic
Post-operative follow-up is inadequate in camp settings — women go home without access to trained follow-up, and recurrence or complications are undetected
Camps do not build the permanent surgical capacity of the facilities where they operate — visiting surgeons repair, leave, and local staff remain untrained
Women mobilised to camps through community outreach are not always those with the greatest need — they are those who are most easily reached, which again advantages women in less remote areas

UNFPA has formally acknowledged these limitations and its programme documentation now emphasises "integration" of fistula repair into permanent facility services. Whether this shift has been operationalised at country level is not clearly documented.

Post-Repair Incontinence: The Under-Acknowledged Outcome

A significant proportion of women who are "repaired" (fistula surgically closed) continue to experience stress urinary incontinence — leakage during physical activity — even after successful anatomical repair. Studies at high-volume centres report continuing incontinence in 10–30% of successfully closed fistulas. For women who expected surgical repair to restore them to full continence, residual incontinence is a major quality-of-life failure that is often not addressed in programme reports. Pelvic floor physiotherapy, which can address this outcome, is available at a handful of specialist centres but is absent from virtually all camp-based or district hospital programmes.

Government Ownership and Sustainability

The IEO evaluation (2021) identified government ownership as the most important unresolved issue for the Campaign's long-term viability. In the majority of programme countries, fistula treatment is funded primarily by UNFPA, bilateral donors, and the Fistula Foundation — not by national health budgets. Governments have formally endorsed fistula programmes (national fistula plans exist in over 40 countries), but few have incorporated fistula treatment as a funded line item in their health budgets. When UNFPA's programme support declines or ends, surgical capacity tends to decline with it. The Campaign has not produced durable government ownership in most settings — a 20-year programme limitation that the IEO has consistently highlighted.

FUNDING, SCALE AND RESOURCES

Campaign Funding

UNFPA does not publish a disaggregated budget for the Campaign to End Fistula. Available data from programme reports and donor disclosures:

Estimated annual UNFPA investment in fistula programming: USD 15–30 million per year (incorporating surgical programme support, surgeon training, reintegration, and coordination)
The Fistula Foundation (a US-based NGO that is UNFPA's most significant fistula-specific partner) has channelled approximately USD 50+ million to fistula surgery programmes since its founding in 2000, primarily to partner organisations in Africa and Asia
USAID has historically funded fistula programming through partnerships with UNFPA and the Fistula Foundation; this funding has been subject to the same political vulnerability as other USAID UNFPA contributions
The United Nations Trust Fund for the Campaign to End Fistula was established to pool donor contributions; its annual disbursements have typically been in the range of USD 5–15 million

The funding gap: Modelling by Stanton et al. (2007) estimated that eliminating the fistula treatment backlog would require approximately USD 450 million over 10 years for surgery alone, not including prevention, reintegration, or health system strengthening. Current annual investments are a fraction of this. This funding gap is the single most important reason the backlog persists.

Cost-Effectiveness

Fistula repair is among the most cost-effective surgical interventions in global health:

Cost per DALY averted: approximately USD 25–55 in sub-Saharan Africa (based on Stanton et al., 2007 estimates and updated for current costs), making it highly competitive with most other priority global health interventions
This cost-effectiveness is exceptionally strong relative to the social and human rights impact, which goes beyond the DALY metric — the restoration of a woman's social standing, reproductive and economic capacity represents value that DALYs do not capture

KEY DEBATES AND CONTESTED QUESTIONS

1. Can Fistula Be Eliminated by 2030?

UNFPA's Campaign has articulated a vision of ending fistula by 2030, aligned with SDG commitments. Most independent analysts regard this as extremely unlikely on current trajectory. The arithmetic is stark: if there are 500,000–2 million women living with fistula, new cases arise at 50,000–100,000 per year, and current surgical throughput through the Campaign is approximately 5,000–10,000 per year, elimination by 2030 requires both near-elimination of new cases (requiring dramatic SBA and EmONC scale-up) and a 5–10x increase in surgical throughput simultaneously. Neither is on current trajectory. The goal of "ending fistula" may be more useful as an advocacy framing than as a programme target.

2. Prevention vs. Treatment: Resource Allocation

The deepest strategic tension is how to allocate limited resources between surgical treatment (immediate benefit to existing sufferers) and prevention (reducing future incidence). The Campaign officially commits to both but in practice allocates more funds to treatment because surgical camps produce visible, countable outputs. The argument for prioritising prevention is that it addresses the root cause and is the only sustainable pathway to elimination. The argument for treatment is that women currently living with fistula cannot wait for prevention to work — their rights and human dignity require immediate action.

Neither argument is wrong; the question is one of portfolio balance. Most independent reviewers believe the current balance is tilted too heavily toward treatment.

3. Validity of Prevalence Estimates

The debate about fistula prevalence has significant implications for both programme design and donor communications. Some researchers (Adler et al., Lancet 2013) have argued that DHS-based estimates substantially overstate fistula prevalence, and that actual prevalence may be lower than the 500,000–2 million range suggests. If the actual burden is lower, the programme implications change (more achievable surgical backlog, different prevention priorities). UNFPA has an institutional interest in the higher estimates — they generate more donor urgency — but the scientific basis for the estimates is genuinely weak. This is an unresolved empirical debate with real resource allocation implications.

4. Quality vs. Volume in Surgical Training

Training 1,500+ surgeons produces large numbers of partially trained practitioners rather than smaller numbers of highly competent specialists. Some fistula surgery experts have argued (based on analysis of outcomes by surgeon volume) that quality surgical outcomes require high case volumes — 50+ fistula repairs per year to maintain competency — and that distributing training across many low-volume surgeons produces poor outcomes. Others argue that even imperfect surgery closer to home is better than no surgery. The evidence on minimum surgical volumes for quality fistula repair is limited but suggests that low-volume surgeons have substantially worse outcomes (Barone et al., BJOG, 2012).

5. Male Partner Role in Prevention

Some prevention programmes have experimented with engaging male partners in fistula prevention — the argument being that men's attitudes toward health-seeking behaviour for their wives strongly influence whether women access skilled delivery. Evidence on male partner engagement for fistula prevention specifically is very limited; it is borrowed largely from maternal health programming more broadly.

IMPLICATIONS BY AUDIENCE

For Frontline Staff and Practitioners

Identification and referral:

Fistula diagnosis is clinical: history of prolonged labour, current urinary and/or faecal incontinence without normal voiding pattern. The dye test (methylene blue instilled in the bladder to confirm VVF) can be performed at district hospital level.
Referral pathways to surgical centres must be established and known before cases arise. When a woman presents with fistula, the default is referral to the nearest designated fistula treatment centre. Do not attempt repair at facilities without a trained fistula surgeon.
Interim management: women awaiting surgery need: regular catheterisation (for some types of fresh fistula), skin care (preventing excoriation from continuous urine leakage), nutritional support, and psychological support.
Peri-operative care: antibiotic prophylaxis is standard; bladder rest (indwelling catheter for 10–14 days post-repair) is essential. Premature catheter removal is a common cause of repair failure in lower-volume settings.

Identifying complex fistulas: Refer complex cases (radiation-induced, large circumferential, involving the urethra or bladder neck, third or fourth repair attempt) to the highest available volume centre. These cases require surgeons with 100+ lifetime repairs; attempting them at lower-volume facilities produces high failure rates and can make future repair more difficult.

Prevention in your setting: Every skilled birth attendant and facility-based midwife is practising fistula prevention by being present when labour complications arise and facilitating timely caesarean section or assisted delivery. Active management of labour, early identification of obstructed labour (partograph use), and prompt decision-to-incision time for caesarean section are the three most important clinical prevention practices.

Community outreach: Community mobilisation activities should include fistula awareness — many women live with fistula for years without knowing it is treatable. Survivor testimonials (with consent) are the most effective community awareness tool.

For Programme Managers and Decision-Makers

Invest in post-repair follow-up: The current programme failure most consistently identified in evaluations is inadequate follow-up after surgery. At minimum, a 6-week post-operative review should be standard; ideally, a 12-month follow-up to identify residual incontinence or recurrence.
Track surgeon performance, not just surgeon numbers: UNFPA-trained surgeons should have their outcomes tracked by case (closure rate, continence rate, complication rate). This requires a programmatic case registry — an investment that most country programmes have not made.
Reintegration is underfunded relative to its importance: Post-repair reintegration support should be budgeted at a minimum of 30% of surgical programme cost. Surgical repair without reintegration leaves women medically cured but socially isolated.
Government handover planning: Every UNFPA-supported fistula programme should have a named transition plan — a defined timeline and mechanism for fistula treatment to be incorporated into the government health budget. Without this, UNFPA is funding a permanent replacement for government responsibility.
Use the treatment backlog calculator: For programme planning, calculate the local treatment backlog (estimated prevalence of untreated fistula in the catchment area) and compare it to your annual surgical throughput. This provides an honest picture of whether the programme is reducing, holding constant, or growing the backlog.

For Donors and Board Directors

The cost-effectiveness case is extremely strong: At USD 25–55 per DALY averted, fistula repair is among the most cost-effective surgical interventions available. If you fund maternal health generally, fistula surgical support is a high-value component.
The 2030 goal is not achievable on current investment: Be cautious of campaign materials that imply the fistula burden will be eliminated by 2030. On current trajectory and current funding levels, this is not plausible. A more honest framing: current investment is building capacity, training surgeons, and reducing the backlog in the highest-capacity settings. Eliminating the condition requires 5–10x scale-up in both surgical throughput and prevention investment.
Prevention investment is underfunded relative to the long-term goal: If donors want to actually end fistula rather than manage it indefinitely through surgical programmes, the proportion of fistula-specific funding going to prevention (SBA, EmONC scale-up, child marriage elimination) needs to increase substantially. This is a different investment profile than surgical camps.
Fund the data gap: A relatively modest investment in population-based fistula surveys — using clinical screening rather than DHS proxies — in the five or six highest-burden countries would resolve the most critical evidence gap. Without reliable incidence data, it is impossible to evaluate whether the Campaign is reducing the burden. This is a knowledge investment with high leverage.
US funding volatility: Like all UNFPA programming, the fistula campaign is exposed to US political cycles through USAID funding. Donors who value programme continuity should consider funding mechanisms that buffer against this.

For Researchers

Priority research need 1 — population-based prevalence and incidence studies: Design and conduct community-based clinical screening studies (not DHS proxy data) to establish reliable prevalence estimates in high-burden countries. These require community-based clinical examination by trained providers and large enough sample sizes to produce stable estimates.
Priority research need 2 — long-term outcomes tracking: Establish prospective cohort studies of women who receive fistula repair, with 1, 5, and 10-year follow-up. Outcome measures should include: anatomical closure, continence status, reproductive outcomes (subsequent pregnancy and delivery), social reintegration indicators, and psychological wellbeing. UNFPA needs to mandate that UNFPA-facilitated repairs are enrolled in such registries.
Priority research need 3 — reintegration intervention evaluation: Design and evaluate psychosocial and economic reintegration interventions using controlled designs where feasible. The complete absence of evaluative evidence in this area is a major gap.
Priority research need 4 — surgeon volume and quality: Establish minimum case volume requirements for fistula surgeons using outcomes data. This requires pooling outcome data across multiple centres.
Priority research need 5 — prevention attribution: Use quasi-experimental methods (difference-in-differences, synthetic control) to estimate whether specific SBA/EmONC scale-up programmes have reduced fistula incidence in districts or regions — even without direct fistula incidence data, proxy measures (rate of obstructed labour presenting to facilities, C-section rates for obstructed labour) may allow inference.

CURRENT STATUS AND FUTURE DIRECTIONS

The Campaign to End Fistula is ongoing under UNFPA's 2022–2025 Strategic Plan. The IEO evaluation recommendations (2021) have been formally acknowledged; the key operational responses include:

A shift in focus from camp-based surgery toward integration of fistula repair into permanent obstetric services
Increased investment in national fistula plans and government health budget advocacy
Enhanced post-repair follow-up standards being piloted in several country programmes
Efforts to strengthen the data infrastructure, including piloting a digital fistula case registry in Ethiopia and Nigeria

The Sustainable Development Goals' 2030 deadline has concentrated attention on whether "ending" fistula is achievable. The emerging consensus among programme staff and researchers is that this requires redefining "ending" — from zero cases (aspirational but implausible by 2030) to "no woman dies or lives in isolation from fistula" (achievable with significant investment in treatment access and reintegration). Prevention at sufficient scale to reduce new cases to near-zero is a decade-longer project tied to the overall trajectory of maternal health system strengthening.

Two emerging issues deserve attention:

Iatrogenic fistula: As caesarean section rates increase in some settings, vesico-vaginal fistula resulting from surgical injury at C-section is an increasing cause of non-obstetric fistula. This is documented in Ethiopia, Nigeria, and Tanzania and will require adaptation of fistula programme designs to address a different causal pathway.
Climate and conflict displacement: Displacement from conflict or climate events further restricts access to the skilled delivery services that prevent fistula and to surgical services that treat it. As the scale of forced displacement increases, fistula burden among displaced populations will grow.

SOURCES

UNFPA IEO: Evaluation of the Campaign to End Fistula (2021) — The most comprehensive independent assessment of the Campaign's 18-year history at the time of publication. Key findings: treatment pillar relatively stronger; prevention attribution weak; reintegration underfunded; data inadequate; sustainability concerns. Mandatory reading for programme design. [unfpa.org/evaluation]
Hilton P, Ward A, "Epidemiological and surgical aspects of urogenital fistulae: a review of 25 years' experience in south-east Nigeria," International Urogynecology Journal, 1998 — One of the foundational surgical case series. Documents success rates and surgical complexity classification that remains the basis of modern fistula surgical outcome measurement.
Arrowsmith SD, Hamlin EC, Wall LL, "Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world," Obstetrical & Gynecological Survey, 1996 — Defines the full spectrum of injury associated with obstructed labour. Establishes why fistula surgical success cannot be measured by anatomical closure alone.
Raassen TJIP et al., "Retrospective analyses of 1204 fistula repairs at the CCBRT Disability Hospital in Dar es Salaam, Tanzania," BJOG, 2014 — Multi-year series from Tanzania documenting outcomes by fistula type, surgeon, and patient characteristics. One of the most reliable outcome datasets outside AAFH.
Wall LL, "Obstetric vesicovaginal fistula as an international public-health problem," Lancet, 2006 — Comprehensive review of the global burden, epidemiology, aetiology, and programme response. The most widely cited single-source overview of the fistula problem. Honest about data limitations.
Muleta M et al., "Obstetric fistula in rural Ethiopia," East African Medical Journal, 2008 — Community-based study documenting the social consequences of fistula in Ethiopia. Key source for the social isolation data cited in this document.
Adler AJ et al., "Two decades of Demographic and Health Surveys: a systematic review," Lancet, 2013 — Critical analysis of DHS-based fistula prevalence estimates, arguing they significantly overstate true prevalence. Essential for understanding the data quality debate.
Stanton C et al., "Innovations in the management of obstetric fistula," International Journal of Gynaecology and Obstetrics, 2007 — Provides cost-effectiveness estimates for fistula repair and scaling scenarios. The source for the USD 450 million backlog elimination estimate.
Barone MA et al., "A systematic review of the outcomes of transvaginal fistula repair," BJOG, 2012 — Systematic review documenting the relationship between surgical volume and outcomes. Important for the quality vs. volume debate.
WHO/UNFPA: Global Competency-Based Fistula Surgery Training Manual (2018 revision) — The operational standard for surgeon training. Defines competency requirements, training methodology, and assessment criteria. [unfpa.org]
UNFPA: Campaign to End Fistula — Programme Documentation and Annual Reports — Available at endfistula.unfpa.org. Contains country-level programme data, surgical statistics, and policy commitments. To be read with awareness of attribution and output-counting methodology limitations.
Mselle LT et al., "I am nothing: presenting the loss of social roles among women with obstetric fistula in rural Tanzania," BMC Women's Health, 2011 — Qualitative study documenting the social experience of living with fistula. Key reference for reintegration programming.
Tsui AO et al., "Estimating obstetric fistula incidence: a systematic review," International Urogynecology Journal, 2007 — Analysis of available incidence data and methodological approaches. Establishes the severe limitations of current data.
Stenberg K et al., "Investing in maternal and newborn health in 74 high-burden countries," Bulletin of WHO, 2007 — Provides the cost-per-DALY-averted estimates for fistula repair referenced in this document.