Dying to Count: Post-abortion Care and Global Reproductive Health Politics in Senegal

by Siri Suh, Rutgers University Press, 2021

Reviewed by Sydney Calkin

Post-abortion care (PAC) refers to the treatment of abortion complications, whether from spontaneous abortion (miscarriage) or induced abortion. These complications might include severe bleeding, fever, or retained products of conception. PAC is a key part of the global strategy to reduce maternal mortality and reduce deaths from unsafe abortion. In her outstanding new book Dying to Count: Post-abortion Care and Global Reproductive Health Politics in Senegal, Siri Suh places PAC in a global landscape of development and reproductive governance. PAC is exempt from the funding restrictions of the Mexico City Policy (Global Gag Rule)¹ because it deals with complications of abortions that have already occurred. This exemption is significant because two-thirds of global family planning aid comes from the USA and is intermittently subject to the gag rule. Senegal is recognised as a ‘pioneer’ of PAC in West Africa, first piloting the practice in the 1990s and now offering it in hospitals around the country. Senegal’s criminal code prohibits abortion, so an estimated two-thirds of induced abortions there are classed as unsafe. This book brings together anthropology, Science and Technology studies, and feminist perspectives on development to examine global reproductive governance through the lens of PAC in Senegal. Siri Suh shows us that PAC serves many purposes and appeals to many audiences but serves to perpetuate significant harms on the people who are its supposed beneficiaries.

The book’s argument unfolds in four chapters that tackle different dimensions of PAC: its history and position in global development agendas, its status as a contested technology, the health-care providers who administer PAC, and knowledge about PAC and its efficacy. Chapter 1 overviews the emergence of PAC in the landscape of global reproductive governance and situates PAC in the context of Senegal. PAC mediates between the concrete harms of Senegal’s abortion ban – a legacy of French colonial rule – and global reproductive governance agendas that strive to reduce maternal mortality through technical interventions. Chapter 2 illustrates how the manual vacuum aspirator syringe used for PAC has acquired a reputation as a ‘troublesome’ technology that is capable of performing licit and illicit tasks. Efforts to restrict the use of this device and people who use it – to ensure it is only used to treat complications of miscarriage or illegal abortion, and not to actually provide abortion itself – have effectively limited the ways that health workers can use manual vacuum aspiration in their practice. Chapter 3 explores how medical professionals navigate the ambiguity of PAC: at times, protecting women suspected of attempted illegal abortion by recording them as having spontaneous miscarriage, at other times protecting their own professional status by assisting police who investigate illegal abortions. Reproductive governance in Senegal requires stakeholders to endorse and perpetuate the fiction that PAC is only used to medically manage spontaneous miscarriage of expectant mothers. Chapter 4 considers evidence about PAC and how it functions: there is no evidence that PAC works in Senegal to reduce maternal mortality, but it is nonetheless considered a successful strategy because it is compatible with the funding restrictions of anti-abortion funders. Despite its shaky evidence base, PAC has been ushered into reproductive development agendas because it re-frames unsafe abortion as a technical issue whose after effects can be clinically managed, rather than an issue of politics, law, or justice.

This is a rich ethnographic work with much to say about how health-care workers navigate their roles and draw boundaries as providers of PAC, a procedure that is often seen as analogous or adjacent to abortion. Just as PAC equipment is carefully monitored to prevent it being used in induced abortion, providers of PAC in countries where abortion is criminalised draw professional distinctions between abortion and post-abortion care. Health-care providers play multiple roles in Siri Suh’s book: at times, they advocate for patients and protect them from law enforcement, but they also exercise power over patients who transgress social expectations about motherhood and marriage. Throughout the work, Siri Suh vividly illustrates reproductive governance as it works at multiple scales, from the global to the local: the day-to-day practices of these health-care workers are shaped by broader reproductive governance agendas and colonial legacies over which they have little control and can exercise limited resistance.

For readers of Gender & Development who want to understand current debates and developments in sexual and reproductive health governance, development funding agendas, and contemporary population policy, this book is essential reading. Siri Suh argues PAC practices, programmes, funding, and related data offer political credibility for the harm reduction strategy but they also expose its limits. Ultimately, the evidence that is gathered about how PAC impacts on maternal mortality staves off political pressure and saps political will to move beyond harm reduction and tackle the harm itself: laws that criminalise abortion and push large numbers of people to seek out clandestine, unsafe abortion. The problem of PAC illustrates the enormous gulf between what is politically possible and what is just. PAC ‘works’ by keeping women from dying when they seek out unsafe and illegal abortion, but preventing these deaths is a long way from building reproductive justice.

Dying to Count is a model of excellent academic writing. It conveys complex ideas with concise language. It generally avoids jargon, making it highly readable. If I had to point to one weakness in this outstanding book, it would be to acknowledge that Siri Suh’s body of scholarship on this topic is already substantial, so readers who are familiar with her journal publications might not find much new data or argument here. However, Dying to Count is still worth reading because it succinctly and persuasively summarises the contribution that her work makes to the field. Running to only 150 pages (excluding notes), it is an accessible volume that would greatly enrich reading lists for classes about gender and development, reproductive and sexual health, global governance, and related topics. Siri Suh’s writing is clear, persuasive, and urgent: she skilfully blends different forms of empirical evidence and nuanced arguments to push the boundaries of major debates in gender and development policy.

Note

1. The Global Gag Rule prohibits foreign NGOs that receive American family planning aid from using any funds to engage in abortion service delivery, provide referrals to abortion services, engage in abortion advocacy, or conduct abortion research. It prohibits them from using American funds, their own funds, or funds from other sources for these purposes.