The Global Politics of Post-Abortion Care in Senegal
GWSS' newest full-time faculty member, Professor Siri Suh, is interested in the global politics of reproductive governance. She explores how transnational population policies intersect in ways that jeopardize women's reproductive health in Senegal. Specifically, Suh examines how global and national reproductive health policies that restrict access to safe abortion lead to a disproportionate risk of obstetric death and disability among young, unmarried, and low-income women.
Although Senegal's penal code forbids induced abortion under any circumstance, women with life-threatening complications of abortion can receive emergency obstetric care followed by contraceptive services in government hospitals. Obstetric complications may occur after a miscarriage or an induced abortion that is conducted under unsafe conditions and/or by an untrained practitioner. Known as "post-abortion care," these services have been available in government hospitals since the late 1990s. Suh investigates what happens when women with complications of what are likely illegal abortions seek post-abortion care at government hospitals. Her research draws on observation of post-abortion care services and records at three hospitals; in-depth interviews with medical workers, health officials, and national and international NGO and donor personnel; and archival review of accounts of illegal abortion obtained from regional courts and national newspapers.
Sometimes, the police receive tips from anonymous sources that a woman with complications of illegal abortion is receiving treatment at a health facility. In 2009, for example, police officers arrived at a district hospital in Dakar to interrogate a patient within two hours of receiving such a tip. The woman "confessed" to taking medication to terminate an unwanted pregnancy. The regional court sentenced her to six months in prison. Alternatively, health workers themselves inform the police of patients receiving treatment for complications of illegal abortion. In 2012, medical providers in the region of Tambacounda contacted the police after treating a woman suspected of illegal abortion. The woman "confessed" to the police that she had ingested pills obtained from a traditional healer to restore her menstrual period. She received a three-month prison sentence.
Despite the involvement of some health workers in the investigation of illegal abortion, Suh's research on post-abortion care suggests that most cases of hospitalized abortion are classified as miscarriage. She demonstrates how medical providers frequently disguise possible or probable induced abortions as miscarriages in hospital records to protect themselves and their patients from policy scrutiny. While these record-keeping practices offer health workers a measure of control over what happens in the gynecological ward, they also engender the notion that most post-abortion care patients are expectant mothers experiencing the miscarriage of a desired pregnancy. Suh argues that by obscuring the epidemiological scope of induced abortion, post-abortion care exacerbates the stigma of abortion as a reproductive practice.
Senegal's identity as a predominantly Muslim country, a former French colony, and a recipient of US foreign aid since the 1960s profoundly complicates the meaning and availability of reproductive health services such as contraception and abortion. During the period of French colonization, both abortion and contraception were prohibited. The Senegalese government lifted the ban on contraception in the early 1980s. Around the same time, the United States Agency for International Development (USAID) began to emphasize the role of fertility reduction in the form of birth control as a catalyst for economic development. To ensure the compatibility of contraception with Islamic principles, the Senegalese Ministry of Health has promoted family planning as a matter of birth spacing for the purposes of preserving maternal and infant health. Consequently, while contraceptives are available in government health facilities, health workers are primarily accustomed to prescribing them to married women. The widespread association between family planning and married women may discourage young, single women from seeking contraceptive care at government health facilities. In turn, this barrier increases the likelihood of unwanted pregnancy, which often results in abortion. Although the colonial-era prohibition on abortion remains firmly in place, some Islamic scholars have found a degree of flexibility in their interpretations of the moment of fetal personhood, and in turn, the circumstances under which abortion is morally permissible. Despite these theological allowances, induced abortion is widely understood as immoral in Senegal.
USAID is the primary donor of reproductive health aid to Senegal. American NGOs contracted by USAID collaborate with the national Ministry of Health to procure technology and train health workers around the country to improve the quality of reproductive health care. This aid includes monitoring and evaluating health services and working with community-based organizations to raise awareness about contraceptives, emergency obstetric care, and diseases like HIV and malaria that can influence maternal and infant outcomes. In addition to supporting family planning and maternal and infant health, USAID has significantly invested in Senegal's national post-abortion care program. Post-abortion care is compatible with US foreign aid policy that prohibits the "promotion of abortion as a form of family planning" because it merely treats complications of miscarriage or previously initiated abortions. While USAID has supported training of health workers in the use of uterine evacuation technology like the Manual Vacuum Aspiration syringe, it does not procure this device as the syringe can also be used to induce first-trimester abortion.
Suh's research explores what it means for Senegalese health workers to provide post-abortion care at the intersection of contradictory national and global policies regarding abortion. Despite the promotion of the Manual Vacuum Aspiration syringe as the most effective technology for post-abortion care, health workers have limited access to this device due to anxieties on the part of hospital managers and Ministry of Health officials that it will be improperly used to conduct illegal abortion. Consequently, health workers continue to use less effective methods to treat women that pose a greater risk of infection and uterine perforation, are more expensive, and require a longer hospital stay. Suh's research illustrates how health workers’ practices, within the context of intersecting global and national abortion policies, reproduce inequalities in women's reproductive health.
Socio-economic status plays a significant role in determining women's abortion outcomes and experiences in Senegal. Wealthy women may obtain safe, albeit clandestine, abortion services from trained health professionals. Low-income women often resort to untrained practitioners and unsafe procedures that increase the likelihood of severe injury or death. This situation is not unique to Senegal. Half of all global mortality related to unsafe abortion occurs in sub-Saharan Africa, a region with some of the world's most restrictive abortion laws. Suh notes that "no matter the law on the books, women with unwanted pregnancies will always seek abortions, always have and always will." An estimated 32 percent of women in Senegalese prisons have been convicted of abortion or infanticide. In addition to financial barriers, the stigma of abortion, including the fear of arrest, may discourage women from seeking post-abortion care. Up to 42 percent of women who experience complications following induced abortion do not receive post-abortion care. These reproductive realities make Suh's work on abortion and post-abortion care incredibly important.
Prof. Suh plans to continue her research on abortion and reproductive health in Senegal by investigating the use of Misoprostol by women and health workers. Although this drug (also known as Cytotec) has long been available in Senegal to treat stomach ulcers, the Ministry of Health recently approved Misoprostol for two obstetric indications—treating postpartum hemorrhage and uterine evacuation for incomplete abortion. Misoprostol also happens to function as a highly effective method of abortion during the first trimester of pregnancy. Suh's next research project will explore how under-the-table Misoprostol use for terminating pregnancy in Senegal compares to similar practices in other sub-Saharan African and Latin American countries.
Explore some of Prof. Siri Suh's publications:
Jaffré, Yannick and Siri Suh (2016). Where the lay and the technical meet: using an anthropology of interfaces to explain persistent disparities in reproductive health in West Africa. Social Science & Medicine, 156, 175-183.