October 16, 2015
Written by Seth Cochran, Founder & CEO, Operation Fistula
This post originally appeared on the blog of the Maternal Health Task Force.
I founded Operation Fistula to end obstetric fistula. While an ounce of prevention is worth a pound cure, the multitude of direct and indirect causes seemed too difficult to change. But treatment had a clear need and compelling impact.
Nearly all women who get fistula will never have the opportunity to have a surgical repair, leaving them incontinent and shamed by their community. To improve the capacity of fistula surgeons and get more women the treatment they need, we started a pilot program that provided conditional cash transfers to African fistula surgeons who were beyond the reach of funders. Along with the funding, we designed and provided safety and quality protocols and developed a one-page patient data form to also build technical capacity. As surgeons treated patients, they sent in photos and data forms and we sent them unrestricted, output-driven funding.
Very popular with surgeons, our program exploded beyond our initial goal of 5 partnerships in 3 countries to treat 200 patients. After additional rounds of funding, we closed our 2-year pilot program with 21 surgeons in 4 countries who treated 752 patients. Our cost efficiency put us at the same price point as vaccines in terms of cost-per-DALY-averted.
However, the most stunning performance statistics were related to the causes of fistula. We have always assumed that fistula happens because women cannot or do not reach a facility. But in fact, 77% of the patients we treated developed fistula when they delivered at either a hospital (63%) or health center (14%). The numbers imply issues of timing and/or quality.
In fact, 13% of our patients had their fistula caused by surgery. Digging into the data reveals even more troubling insight. Of the 133 women who had a hospital-based Cesarean delivery, 28% had their fistula caused by the procedure, termed iatrogenic fistula. Hysterectomy showed a similar causal contribution, creating fistula in 36% of women receiving this procedure.
This alarming data caused us to reconsider our approach to ending fistula. Prevention suddenly became far more tangible. By improving the quality of Cesarean delivery, we could not only prevent fistula by relieving obstructed labor, we could also reduce cases of iatrogenic fistula. Furthermore, capacity for obstetric surgery would also create better fistula surgeons.
The Lancet Global Surgery commission report added enormous wind to the sails of our new inspiration, making a compelling case for global surgical capacity. But while the report explains what the world should do at a high level, it is a bit light on the details of exactly how.
We developed an idea for how to build surgical capacity and shared the concept with the Ministry of Health in Madagascar, where we’ve worked the last couple years. They loved the idea and we left the country with an agreement to roll it out in two regions.
To finalize the details of our action plan, we studied everything we could find that had any link to the future we wanted to build. But as the old Chinese proverb says “A single conversation across the table with a wise man is better than ten years’ study of books.”
The best way we could think of to find wise people who knew about maternal and child health was to attend the preeminent conference on the subject. Enter GMNCH2015.
However, finding the truly wise people amongst the masses of convention is actually quite challenging. While, I’ve recruited some of my wisest advisors from the podium, the speaker population is not the only source of wisdom. In fact, recent experiences have taught me the power of finding wisdom in the questions asked and comments made by people in the audience.
So all of this is to say that if you see me in Mexico City and I start asking you a bunch of crazy questions, please be patient. You are indeed one of the wise ones whose conversation will most certainly help us build the future.
Photo: “Africa Partnerships Hamlin Fistula 12” © 2009 Lucy Perry/Hamlin Fistula Relief and Aid Fund Australia, used under a Creative Commons Attribution license: http://creativecommons.org/licenses/by/2.0/