Summary: Am I making a mistake in assuming that an obstetric fistula can be prevented for $20? If not, should TLYCS recommend a charity that prevents fistulas?
According to Fistula Foundation, a TLYCS recommended charity, one successful surgery costs a total of about $700. ($586–$694)/surgery and 86% success rate.
It can cost about $0.1 to inform a person about a recommendation by a series of radio ads, newspapers, posters, and in-person interactions of local community members/volunteers so that 1 in 10 people implements an otherwise unthought of preventive healthcare behavior (% mask wearing graph). This should be $1/person to implement a preventive measure. Assuming that the prevalence of fistulas is 0.3% and that the measure is 50% effective, then the prevention of one case should cost ~$670, which is close to the $700 to provide curative treatment.
Another approach can be targeting midwives to share information on when to seek specialized care and identify at-risk patients, training doctors at government (free of charge) clinics, providing equipment, and potentially offering travel stipend to extremely poor households. Assuming that a midwife takes care of 10,000 patients and training costs $100, that is $0.01/patient (considering the 0.3% prevalence, $3.3/patient). A doctor can take care of 1,000 at-risk patients, with the counterfactual prevention rate of 8% (assuming that 10% of patients would have otherwise developed a fistula and that the success rate of an intervention is 80%). Their training and additional equipment can cost $1,000, so additional $12.5/patient. A travel stipend can be $10 and 20% of patients can need it. That is $2/patient. This may motivate or enable 50% of patients who would otherwise suffer from a fistula to visit the clinic. So, $4/patient assuming the counterfactual. In total, training midwives and doctors, providing equipment, and providing travel stipend can prevent an obstetric fistula for about $20. This targeted preventive healthcare cost is about 35× lower than curative healthcare cost.
The counterargument is that all midwives and doctors are trained, have equipment, and travel stipend is available or that the additional cost is much higher for the remaining ones, which I do not think is the case.
Is there an organization working on preventing fistulas? Should TLYCS recommend that charity instead?
Tldr: Yes, it may be more cost-effective to prevent than to treat obstetric fistulas. Yes, there is an organisation working on preventing fistulas, and yes, TLYCS should probably consider it, but not necessarily for that reason. The cost of preventing vs treating obstetric fistula (OF) is comparable, but preventing OF has additional benefits such as preventing the associated stillbirth, infertility, psychological trauma, and social detriments. Furthermore, the life-saving value of training midwives in low HDI countries far outweighs the value of OF prevention generated by the same intervention.
Fully training one midwife to international standards, through the Catherine Hamlin Fistula Foundation (CHFF) costs 18,000 AUD. I would estimate that one midwife is likely to attend something closer to 5000 births across their career, although they may also drive change by providing family planning services and directly or indirectly educating many members of a community besides the birthing women they attend.
According to CHFF,
We know that OF is highly preventable with basic educational and healthcare shifts because it is virtually unheard of in high-income countries, even in comparatively disadvantaged populations. If "drops to zero" reflects an OF RR of ~0-0.2 in communities cared for by CHFF midwives, the prevalence of OF in these areas is ~0.4% per birth, and one midwife attends ~5000 births, that midwife may only prevent 16-20 obstetric fistulae across their career. That means simply training midwives in Ethiopia (and comparable countries) could prevent OF in the absence of any other interventions, for a similar cost per fistula to $619 surgical repair, but with far greater reduction in suffering. In particular, prevention of OF also prevents many of the stillbirths which would otherwise occur alongside 93% of cases. Similarly, OF is strongly associated with infertility; divorce; mental health conditions; and years of a mother's separation from her children and community, due to the stigma of OF-related incontinence. These flow on effects of OF are far more difficult to reverse with surgery than the injury itself.
To me, it seems unlikely that additional interventions, with the possible exception of travel stipends, would increase the cost-effectiveness of prevention, compared to midwifery training alone. I am assuming that midwives can provide key education, e.g., regarding child marriage, early pregnancy, and nutrition, and that facilities for common obstetric interventions are already available. It seems likely that available medical resources in areas with high rates of OF are under utilised, and would continue to be so even with greater funding, due to ~70% of birthing women lacking an attendant trained in detecting and escalating intrapartum abnormalities as needed. If these assumptions are valid, investing in media interventions, training doctors or building hospitals/specialist clinics would provide negligible additional benefits.
However, it may be possible to modify the midwifery training approach to prevention to increase cost-effectiveness. For example, up-skilling traditional birth workers to safely care for low-risk birthing women, including recognising and escalating common complications, could provide many of the benefits of fully-trained midwives at a lower cost and higher cultural acceptability.
All that being said, while training midwives (or even traditional birth workers) to prevent OF may be only marginally more cost-effective than curative healthcare, the "side-effects" of this intervention are far more impressive. The primary benefit of training midwives in low HDI countries would not be OF prevention, but stillbirth and maternal and neonatal mortality reduction. According to Nove et al. (2021),
Ethiopia, where CHFF is based currently has baseline rates of 0.267% maternal deaths (mat. D) and 4.18% early neonatal deaths (neonat. D) per live birth (LB) and 0.92% stillbirths (SB) per birth (B).
(0.00267mat. D+0.0418neonat. D)991LB+9.20SB1000total B∗5000midwife B∗0.65of D and SB averted=173lives saved per midwife
$18000per midwife173lives saved per midwife=$103per life saved
I'm sure there are many other complicating factors (or maybe my maths needs to be corrected?), but to me, that seems like a similarly, perhaps even more, surprising and exciting estimate than $20 to prevent obstetric fistula!
The WHO's article on midwifery education and care has some further information about the global health benefits of midwifery training which I haven't mentioned here but may be of interest.
I should also add that those calculations are based on a study on the impact of universal midwifery coverage compare to current coverage in low HDI countries, so they are assuming an ideal scenario where the midwife is able to attend every birth in her area, in addition to any ante- and postnatal care within the midwifery scope of practice.
My estimate of 5000 births may be an optimistic one. A midwife in a busy city hospital may attend 1-3 births per shift, summing to >250 births per year, while a privately practicing midwife in a remote village may only attend 1-3 births per month, <36 per yer. Attending 5000 births in ~40 working years as a midwife would equate to an average of 125 births per year, and that may not be realistic for a midwives working in areas with the highest rates of OF.