Siri Suh

African women's uteri have long been objects of biomedical and technological control, from the promotion and discouragement of births by colonial authorities and development experts, to the neoliberal and feminist achievements of reproductive autonomy through consuming pharmaceutical products. We explore misoprostol - a medication for abortion and hemorrhage - as a technology for reproductive control in Burkina Faso and Senegal. By tracing authorized and unauthorized misoprostol use and distribution within and beyond hospitals, and in official and unofficial pharmaceutical circuits, we examine the perils of and possibilities for uterine control offered by this medication to local, national, and global stakeholders.

Despite evidence of a growing interest in reproductive justice (RJ) among feminist economists, this interest is nascent. To avoid RJ becoming a buzzword and losing its political and critical edge, it is important to fully grasp what the RJ framework means and brings to research. This Dialogue aims to create a space where the possibility of an interdisciplinary, transnational exchange of knowledge and ideas could be explored and encouraged. It presents four views about what it means to adopt and commit to the RJ framework in feminist research. One of the contributors was trained as an economist and the remaining contributors trained in other disciplines. The contributions discuss directly or show by example how research guided by the RJ framework can contribute to the development of an ethical and effective transformative response to an increasingly oppressive policy trajectory in the current historical moment.

Since the early 1990s, global treaties on maternal and reproductive health have obligated governments to ensure quality postabortion care: emergency obstetric care for women experiencing medical complications following abortion. While postabortion care is available in hospitals around the world, little is known about how this global model has been integrated into daily obstetric care in countries with restrictive abortion laws. Drawing on ethnographic fieldwork in Argentina and Senegal, we explore how health workers have adapted the global postabortion care model in ways that simultaneously challenge and reinforce national prohibitions on abortion. We use the term “subversive epidemiology” to describe how health workers adjudicate between allegedly legitimate and illegitimate cases of pregnancy termination or loss. In Argentina, these practices have expanded access to safe abortion in certain health facilities. In Senegal, these practices have redefined postabortion care as an intervention for the treatment of complications of miscarriage. Although the global postabortion care model aimed to depoliticize the problem of unsafe abortion, we find that health workers’ clinical and record-keeping decisions are decidedly political as they contribute to an epidemiological record that often does more to obscure than elucidate the incidence of abortion. Our research highlights the importance of cross-national microanalyses of health workers’ experiences and practices in understanding how reproductive governance unfolds at the intersection of global and national health policies and proposes applying the reproductive justice framework to abortion politics in the global South.

Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol’s potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol’s abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world’s highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally.

During the early 1990s, global health experts developed a new model of emergency obstetric care: post-abortion care or PAC. In developing countries with restrictive abortion laws and where NGOs relied on US family planning aid, PAC offered an apolitical approach to addressing the consequences of unsafe abortion. In Dying to Count, Siri Suh traces how national and global population politics collide in Senegal as health workers, health officials, and NGO workers strive to demonstrate PAC’s effectiveness in the absence of rigorous statistical evidence that the intervention reduces maternal mortality. Suh argues that pragmatically assembled PAC data convey commitments to maternal mortality reduction goals while obscuring the frequency of unsafe abortion and the inadequate care women with complications are likely to receive if they manage to reach a hospital. At a moment when African women face the highest risk worldwide of death from complications related to pregnancy, birth, or abortion, Suh’s ethnography of PAC in Senegal makes a critical contribution to studies of global health, population and development, African studies, and reproductive justice

Since the early 1990s, post-abortion care (PAC) has been advocated as a harm reduction approach to maternal mortality and morbidity in countries with restrictive abortion laws. PAC indicators demonstrate that the intervention integrates safer uterine aspiration technology such as the Manual Vacuum Aspiration (MVA) syringe into obstetric practice and facilitates task-shifting from physicians to midwives. In other words, PAC not only saves women's lives, but more generally enhances the organization, quality, and cost-effectiveness of obstetric care. This article draws on my ethnography of Senegal's PAC program, conducted between 2010 and 2011, to illustrate how PAC indicators obscure the professional and technological complexities of treating abortion complications in contexts where abortion is illegal. Data collection methods include observation of PAC services and records at three hospitals; 66 in-depth interviews with health workers, government health officials, and NGO personnel; and a review of national and global PAC data. I show how anxieties about the capacity of the MVA syringe to induce abortion have engendered practices and policies that compromise the quality and availability of care throughout the health system. I explore the multivalent power of MVA statistics in strategically conveying commitments to national and global maternal mortality reduction agendas while eliding profound gaps in access to and quality of care for low-income and rural women. I argue that PAC strategies, technologies, and indicators must be situated within a global framework of reproductive governance, in which safe abortion has been omitted from maternal and reproductive health care associated with reproductive rights. Ethnographic attention to daily obstetric practices challenges globally circulating narratives about PAC as an apolitical intervention, revealing not only how anxieties about abortion ironically suppress the very rates of MVA utilization that purportedly convey PAC quality, but also how they simultaneously give rise to and obscure obstetric violence against women.
•Illustrates how restrictive abortion laws reduce the quality of post-abortion care.•Shows how post-abortion care indicators obscure gaps in access to and quality of care.•Demonstrates why less safe and effective obstetric techniques persist in hospitals.•Identifies policies and practices that constrain the use of manual vacuum aspiration .•Locates Senegal's post-abortion care program in global reproductive health politics.

Ontologies of intervention in global health involve a voracious appetite for data - collection of data as evidence of what is intervention is needed, the establishment of metrics to organize and make sense of that data, further surveillance and measures to determine whether interventions were successful and targets were met, and, increasingly, predictions that determine whether interventions will provide good returns on investments. This part-special issue, an ethnographic interrogation of contemporary metrics and ontologies of intervention enacted in the global South, investigates “behind the measures” of maternal and reproductive health: the imperfect but pragmatic processes of quantification, inventory, and recording; how metrics are imbued with meaning, morality, and power; and how targets and indicators shape or drive individual and institutional behavior, as well as policy and program creation.