Siri Suh | Brandeis University (original) (raw)
Papers by Siri Suh
Studies in Comparative International Development, 2023
Unlike prevailing research methodologies in the interdisciplinary field of global health, feminis... more Unlike prevailing research methodologies in the interdisciplinary field of global health, feminist methodologies allow researchers to unsettle the premises and assumptions of the field. This paper describes how we mobilize transnational feminist ethnography in our research on HIV in India and postabortion care in Senegal. Transnational feminist perspectives enable us to re-embed HIV prevention and post-abortion care in the politics of gender and sexuality and in postcolonial histories of health governance. They consider the role of gender and sexuality not just in terms of gendered health inequalities, but also in terms of how global health problems are defined, managed, measured, and contested. We outline how our projects put this lens into practice by pushing the methodological boundaries of time, scale, and scope and through a historicized, multisited, and multiscalar approach that triangulates multiple sources of data. Feminist ethnography requires that we turn the critical gaze upon ourselves, reflecting on multiple and shifting personal and professional positionalities during and after fieldwork and our ethical commitments to our interlocutors. While acknowledging the significant personal, institutional, and professional challenges of using feminist methodologies, especially given the dominant modes of research in global health, we urge greater consideration, among both advanced and early scholars, of the possibilities they offer for studying global health problems.
Frontiers in Sociology, Apr 12, 2021
Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment o... more 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.
Social Science & Medicine, 2019
Ontologies of intervention in global health involve a voracious appetite for data-collection of d... more 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.
Advances in Medical Sociology, 2019
To explore the politics of gender, health, medicine, and citizenship in high-income countries, me... more To explore the politics of gender, health, medicine, and citizenship in high-income countries, medical sociologists have focused primarily on the practice of legal abortion. In middle-and low-income countries with restrictive abortion laws, however, medical sociologists must examine what happens when women have already experienced spontaneous or induced abortion. Post-abortion care (PAC), a global reproductive health intervention that treats complications of abortion and has been implemented in nearly 50 countries worldwide, offers important theoretical insights into transnational politics of abortion and reproduction in countries with restrictive abortion laws. In this chapter, I draw on my ethnography of Senegal's PAC program to examine the professional, clinical, and technological politics and practices of obstetric care for abortions that have already occurred. I use the sociological concepts of professional boundary work and boundary objects to demonstrate how Senegalese health professionals have established the political and clinical legitimacy of PAC. I demonstrate the professional precariousness of practicing PAC for physicians, midwives, and nurses. I show how the dual capacity of PAC technologies to terminate pregnancy and treat abortion complications has limited their circulation within the health system, thereby reducing quality of care. Given the contradictory and complex global landscape of
Social Science & Medicine, 2019
Since the early 1990s, post-abortion care (PAC) has been advocated as a harm reduction approach t... more 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.
Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I demonstrate how h... more Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I demonstrate how health professionals have deployed indicators such as number of women and abortion type treated in government hospitals to demonstrate commitment to global mandates on reproductive rights. These indicators obscure discrimination against women suspected of illegal abortion as health workers negotiate obstetric treatment with the abortion law. By measuring hospitals' capacity to keep women with abortion complications alive, post-abortion care (PAC) indicators have normalized survival as a state of reproductive well-being.
Reproductive governance operates through calculating demographic statistics that offer selective ... more Reproductive governance operates through calculating demographic statistics that offer selective truths about reproductive practices, bodies, and subjectivities. Post-abortion care, a global reproductive health intervention, represents a transnational reproductive regime that establishes motherhood as women's primary legitimate reproductive status. Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I illustrate how post-abortion care accomplishes reproductive governance in a context where abortion is prohibited altogether and the US is the primary bilateral donor of population aid. Reproductive governance unfolds in hospital gynecological wards and the national health information system through the mobilization and interpretation of post-abortion care data. Although health workers search women's bodies and behavior for signs of illegal abortion, they minimize police intervention in the hospital by classifying most post-abortion care cases as miscarriage.
Despite impressive global investment in reproductive health programs in West Africa, maternal mor... more Despite impressive global investment in reproductive health programs in West Africa, maternal mortality remains unacceptably high and obstetric care is often inadequate. Fertility is among the highest in the world, while contraceptive prevalence remains among the lowest. This paper explores the social and technical dimensions of this situation. We argue that effective reproductive health programs require analyzing the interfaces between technical programs and the social logics and behaviors of health professionals and client populations. Significant gaps between health programs' goals and the behaviors of patients and health care professionals have been observed. While public health projects aim to manage reproduction, sexuality, fertility, and professional practices are regulated socially. Such projects may target technical practices, but access to care is greatly influenced by social norms and ethics. This paper shows how an empirical anthropology that investigates the social and technical interfaces of reproduction can contribute to improved global health.
The “rightness” of a technology for completing a particular task is negotiated by medical profess... more The “rightness” of a technology for completing a particular task is negotiated by medical professionals, patients,
state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain
technologies may challenge the meaning of the “job” they are designed to accomplish. Manual vacuum aspiration
(MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion,
known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of
MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily
treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is
legally prohibited. Although state health authorities have championed MVA as the “preferred” PAC technology,
the primary donor for PAC, the United States Agency for International Development, does not support the
purchase of abortifacient technologies. I conducted an ethnography of Senegal’s PAC program between 2010 and
2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment
and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC.
While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label
MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and
digital curettage. Anxieties about MVA’s capacity to induce abortion have constrained its integration into routine
obstetric care. This capacity also raises questions about what the “job,” PAC, represents in Senegalese hospitals.
The prioritization of MVA’s security over women’s access to the preferred technology reinforces gendered
inequalities in health care.
Boundary work refers to the strategies deployed by professionals in the arenas of the public, the... more Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in nearly 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating abortion complications.
Senegal has recently emerged as a leader in West Africa in the extension of postabortion care (PA... more Senegal has recently emerged as a leader in West Africa in the extension of postabortion care (PAC). This paper describes the extension of PAC to the district level in Senegal, where complications of abortion continue to claim too many women's lives.
Human Resources for Health, 2007
Background In Senegal, traditional supervision often focuses more on collection of service statis... more Background In Senegal, traditional supervision often focuses more on collection of service statistics than on evaluation of service quality. This approach yields limited information on quality of care and does little to improve providers' competence. In response to this challenge, Management Sciences for Health (MSH) has implemented a program of formative supervision. This multifaceted, problem-solving approach collects data on quality of care, improves technical competence, and engages the community in improving reproductive health care. Methods This study evaluated changes in service quality and community involvement after two rounds of supervision in 45 health facilities in four districts of Senegal. We used checklists to assess quality in four areas of service delivery: infrastructure, staff and services management, record-keeping, and technical competence. We also measured community involvement in improving service quality using the completion rates of action plans. Results The most notable improvement across regions was in infection prevention. Management of staff, services, and logistics also consistently improved across the four districts. Record-keeping skills showed variable but lower improvement by region. The completion rates of action plans suggest that communities are engaged in improving service quality in all four districts. Conclusion Formative supervision can improve the quality of reproductive health services, especially in areas where there is on-site skill building and refresher training. This approach can also mobilize communities to participate in improving service quality.
Conference Presentations by Siri Suh
Eastern Sociological Society, February 2014, Baltimore, MD In Senegal, induced abortion is forbid... more Eastern Sociological Society, February 2014, Baltimore, MD In Senegal, induced abortion is forbidden under any circumstance. Since the late 1990s, American development aid to Senegal has supported emergency treatment for complications of miscarriage or induced abortion, known as post-abortion care (PAC). Yet, federal legislation prohibits American aid from supporting services related to pregnancy termination. My dissertation explores how these transnational, intersecting abortion policies have reinforced the legitimacy of PAC while simultaneously rendering induced abortion invisible in Senegal. I conducted an institutional ethnography of the national PAC program between 2010 and 2011. I interviewed 89 health providers, state health and criminal justice officials, and personnel from non-governmental organizations and donor agencies. I reviewed PAC records and observed PAC services in three hospitals. I examined state data collection instruments for PAC, epidemiological research on abortion complications, reports of operations research on PAC, national health surveys and legal records of 42 cases of illegal abortion prosecuted by the state. I found that texts across a variety of institutional settings play a critical role in legitimating PAC while obscuring induced abortion. For example, when medical professionals record suspected cases of illegal induced abortion as miscarriage in state hospital records, national health information systems omit data on induced abortion. Such documents reinforce the discursive construction of PAC by the Ministry of Health as a health intervention for mothers who have experienced miscarriage rather than women who have sought induced abortion. In a context where induced abortion is forbidden, texts ensure the political acceptability of the PAC program by obscuring induced abortion.
This paper examines how post-abortion care (PAC), a global health intervention, moves people, tec... more This paper examines how post-abortion care (PAC), a global health intervention, moves people, technology and politics around abortion in Senegal. Although induced abortion is illegal, the government introduced PAC in the late 1990s to train providers to treat abortion complications to reduce mortality. PAC transformed abortion into an object of medical rather than moral action by emphasizing the imperative of treatment irrespective of the origins of the abortion. Through its transnational network of actors, PAC leveraged significant resources towards abortion care, including research, training and the circulation of abortion technology in a context where abortion remains highly criminalized. I study PAC as a site of interface between local and global abortion politics and expertise through a multi-sited, institutional ethnography of the Senegalese national PAC program. Disputes over the meaning of abortion as well as ethical obligations of medical providers to abortion patients in this context overlap with American abortion politics attached to the flow of PAC resources into Senegal. Mapping these intersecting politics onto the landscape of PAC practices and policies is key to understanding gaps between the Senegalese and global PAC models as well as interrogating the very logic of implementing this model in settings where abortion is illegal.
Background: In spite of existing evidence of best practices in service organization and technolog... more Background: In spite of existing evidence of best practices in service organization and technology related to post-abortion care (PAC), little is known about what it means to practice PAC where abortion is restricted. This study explores the daily practice of PAC in state hospitals in Senegal, where induced abortion is prohibited. Findings suggest that even when best practices are in place, the daily practice of PAC is profoundly shaped by the local context of the abortion law.
Methods: I conducted a multi-sited, institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included 88 in-depth interviews, observation of PAC services and records at 3 hospitals, and an archival review of abortion using medical, social science, media and legal sources. I used grounded theory to triangulate multiple sources of data.
Findings: Medical providers attempt to differentiate between spontaneous and induced abortion through a calculus of social and physiological indicators. These practices may subject women suspected of induced abortion to extensive interrogations, delays and threats to withhold treatment. Patients participate in this process by divulging or withholding information from providers. Providers manage suspected cases of induced abortion as spontaneous unless the patients confess to inducing abortion.
Conclusion: Daily practices in post-abortion care may not always align with best practices as defined by public health experts. In Senegal, post-abortion care practices reflect providers’ desire to protect themselves from the police within the context of the abortion law.
This study explores how medical providers in state hospitals in Senegal deploy medical records to... more This study explores how medical providers in state hospitals in Senegal deploy medical records to maintain authority over abortion, a legally prohibited practice. Between 2010 and 2011, I conducted in-depth interviews with 88 individuals, observation of post-abortion care at three hospitals and a review of abortion records at each hospital. The register where providers document the treatment of abortion complications represents a site where providers and patients actively coproduce a particular account of the type of abortions treated. By using ambiguous terminology to record suspected cases of induced abortion in the register, or by omitting the type of abortion altogether, providers render induced abortion invisible within the hospital. Women patients participate in this process by withholding or divulging information about the abortion. This study shows how medical records function as a professional boundary work tool. By obscuring suspected induced abortion in the record, providers aim to circumvent police inquiry at the hospital. In this context, the medical register not only inscribes social relations between patients and providers, but also reinforces abortion stigma through the reproduction of knowledge about women’s bodies and delineates the boundaries of medical authority over a forbidden practice.
This study explores how measuring abortion constitutes a tool of professional boundary work among... more This study explores how measuring abortion constitutes a tool of professional boundary work among medical providers in Senegal. Although induced abortion in Senegal is illegal under any circumstance, providers are permitted to treat complications of induced and spontaneous abortion (miscarriage). Treating abortion complications poses an important problem for medical professionals as it requires the differentiation between induced and spontaneous abortion. In turn, the identification of suspected cases of induced abortion raises the possibility of intervention by the police at the hospital. This paper explores how providers draw on different kinds of knowledge to differentiate between spontaneous and induced abortion. I argue that within this calculus of knowledge, providers produce uncertainty about the type of abortion in order to maintain professional authority over abortion. Data collection methods included in-depth interviews with 88 individuals including health professionals, government health authorities, law enforcement officials and members of women’s rights organizations and professional legal and medical associations. I observed treatment services and reviewed abortion records at three hospitals. I also conducted an archival review of abortion using medical, public health, social science, media and legal sources. Findings show that uncertainty about the type of abortion permits providers to manage and record suspected cases of induced abortion as spontaneous abortion, which typically does not merit police scrutiny. By containing such cases within the hospital, medical professionals reduce the likelihood of police intervention. At the same time, obscuring induced abortion in hospital records and state health information systems reinforces the notion that induced abortion is rare.
Technology is both constructed by and embedded within the social, political and economic context ... more Technology is both constructed by and embedded within the social, political and economic context of its practice. Sociologists have investigated technological meaning by identifying the competing stakes claimed to its functional capacity. Manual vacuum aspiration (MVA) is a form of uterine evacuation that can diagnose pathologies, treat complications of abortion, and induce abortion. It is precisely MVA’s capacity to induce abortion that generates jurisdictional anxiety in the United States and other contexts where abortion remains legally restricted. This project uses ethnography to study the meaning and practice of MVA in Senegal, where it is used for post-abortion care (PAC), or the treatment of abortion complications. In Senegal, a diverse and complex range of actors and institutions claims jurisdiction over MVA, including the United States government, local and international non-governmental organizations, national health authorities, medical professionals and women. Data collection methods include observation of MVA practices at 3 hospitals; 88 in-depth interviews with medical professionals, health officials and NGO and donor personnel, and key informants; and an archival review of PAC and abortion in Senegal. Findings suggest significant tensions between the discourse and practice among actors invested in MVA. Although local and international institutions have championed MVA as the best technology for PAC, the procurement, circulation and utilization of MVA is highly restricted by national health authorities and individual health facilities. A ‘dangerous’ technology, MVA is located at the intersection of local and global abortion politics and multiple and contradictory discourses regarding public health, professional authority and women’s reproductive autonomy.
Teaching Documents by Siri Suh
The term " global health " often conjures up alarming images of infectious disease epidemics such... more The term " global health " often conjures up alarming images of infectious disease epidemics such as Ebola, H1N1, or HIV. Included in these images are " global " actors that aim to control disease outbreaks such as the World Health Organization or Doctors Without Borders. But global health encompasses much more than infectious disease. In fact, in 2013, noncommunicable conditions such as cancer and heart disease accounted for a greater proportion of global mortality than infectious disease. Furthermore, a multiplicity of agencies, institutions, and individuals play a role in global health, including pharmaceutical companies like Pfizer, philanthropic organizations like the Bill and Melinda Gates Foundation, programs like the US President's Emergency Plan for AIDS Relief (PEPFAR), national health authorities, local health workers, and people suffering from illness and seeking care. Drawing on perspectives from anthropology, sociology, geography, human rights, law, history, population and development, science and technology studies, and public health, this class explores the meanings, practices, and politics of global health within broader processes, structures, and inequalities of globalization. For example, how do we explain current distributions of and disparities in global disease mortality and morbidity? How did contemporary global health models and actors evolve from earlier processes of European colonialism, US imperialism, and postWorld War II development? Who is responsible for developing global health interventions, and what are the politics of measuring effectiveness and impact? How do geopolitical relations influence research on and access to lifesaving drugs? In what ways do globally circulating images, narratives, and representations of illness facilitate or hinder disease prevention, treatment or eradication? Although the course explores these questions primarily through the lens of infectious disease like malaria, polio, HIV, and Ebola, we also attend to reasons contributing to the marginalization of other global health conditions such as reproductive and maternal health. We end by reflecting on the responsibilities and challenges faced by first line of global health practitioners: health workers in places like Pakistan, Papua New Guinea, and Senegal.
Studies in Comparative International Development, 2023
Unlike prevailing research methodologies in the interdisciplinary field of global health, feminis... more Unlike prevailing research methodologies in the interdisciplinary field of global health, feminist methodologies allow researchers to unsettle the premises and assumptions of the field. This paper describes how we mobilize transnational feminist ethnography in our research on HIV in India and postabortion care in Senegal. Transnational feminist perspectives enable us to re-embed HIV prevention and post-abortion care in the politics of gender and sexuality and in postcolonial histories of health governance. They consider the role of gender and sexuality not just in terms of gendered health inequalities, but also in terms of how global health problems are defined, managed, measured, and contested. We outline how our projects put this lens into practice by pushing the methodological boundaries of time, scale, and scope and through a historicized, multisited, and multiscalar approach that triangulates multiple sources of data. Feminist ethnography requires that we turn the critical gaze upon ourselves, reflecting on multiple and shifting personal and professional positionalities during and after fieldwork and our ethical commitments to our interlocutors. While acknowledging the significant personal, institutional, and professional challenges of using feminist methodologies, especially given the dominant modes of research in global health, we urge greater consideration, among both advanced and early scholars, of the possibilities they offer for studying global health problems.
Frontiers in Sociology, Apr 12, 2021
Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment o... more 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.
Social Science & Medicine, 2019
Ontologies of intervention in global health involve a voracious appetite for data-collection of d... more 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.
Advances in Medical Sociology, 2019
To explore the politics of gender, health, medicine, and citizenship in high-income countries, me... more To explore the politics of gender, health, medicine, and citizenship in high-income countries, medical sociologists have focused primarily on the practice of legal abortion. In middle-and low-income countries with restrictive abortion laws, however, medical sociologists must examine what happens when women have already experienced spontaneous or induced abortion. Post-abortion care (PAC), a global reproductive health intervention that treats complications of abortion and has been implemented in nearly 50 countries worldwide, offers important theoretical insights into transnational politics of abortion and reproduction in countries with restrictive abortion laws. In this chapter, I draw on my ethnography of Senegal's PAC program to examine the professional, clinical, and technological politics and practices of obstetric care for abortions that have already occurred. I use the sociological concepts of professional boundary work and boundary objects to demonstrate how Senegalese health professionals have established the political and clinical legitimacy of PAC. I demonstrate the professional precariousness of practicing PAC for physicians, midwives, and nurses. I show how the dual capacity of PAC technologies to terminate pregnancy and treat abortion complications has limited their circulation within the health system, thereby reducing quality of care. Given the contradictory and complex global landscape of
Social Science & Medicine, 2019
Since the early 1990s, post-abortion care (PAC) has been advocated as a harm reduction approach t... more 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.
Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I demonstrate how h... more Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I demonstrate how health professionals have deployed indicators such as number of women and abortion type treated in government hospitals to demonstrate commitment to global mandates on reproductive rights. These indicators obscure discrimination against women suspected of illegal abortion as health workers negotiate obstetric treatment with the abortion law. By measuring hospitals' capacity to keep women with abortion complications alive, post-abortion care (PAC) indicators have normalized survival as a state of reproductive well-being.
Reproductive governance operates through calculating demographic statistics that offer selective ... more Reproductive governance operates through calculating demographic statistics that offer selective truths about reproductive practices, bodies, and subjectivities. Post-abortion care, a global reproductive health intervention, represents a transnational reproductive regime that establishes motherhood as women's primary legitimate reproductive status. Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I illustrate how post-abortion care accomplishes reproductive governance in a context where abortion is prohibited altogether and the US is the primary bilateral donor of population aid. Reproductive governance unfolds in hospital gynecological wards and the national health information system through the mobilization and interpretation of post-abortion care data. Although health workers search women's bodies and behavior for signs of illegal abortion, they minimize police intervention in the hospital by classifying most post-abortion care cases as miscarriage.
Despite impressive global investment in reproductive health programs in West Africa, maternal mor... more Despite impressive global investment in reproductive health programs in West Africa, maternal mortality remains unacceptably high and obstetric care is often inadequate. Fertility is among the highest in the world, while contraceptive prevalence remains among the lowest. This paper explores the social and technical dimensions of this situation. We argue that effective reproductive health programs require analyzing the interfaces between technical programs and the social logics and behaviors of health professionals and client populations. Significant gaps between health programs' goals and the behaviors of patients and health care professionals have been observed. While public health projects aim to manage reproduction, sexuality, fertility, and professional practices are regulated socially. Such projects may target technical practices, but access to care is greatly influenced by social norms and ethics. This paper shows how an empirical anthropology that investigates the social and technical interfaces of reproduction can contribute to improved global health.
The “rightness” of a technology for completing a particular task is negotiated by medical profess... more The “rightness” of a technology for completing a particular task is negotiated by medical professionals, patients,
state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain
technologies may challenge the meaning of the “job” they are designed to accomplish. Manual vacuum aspiration
(MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion,
known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of
MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily
treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is
legally prohibited. Although state health authorities have championed MVA as the “preferred” PAC technology,
the primary donor for PAC, the United States Agency for International Development, does not support the
purchase of abortifacient technologies. I conducted an ethnography of Senegal’s PAC program between 2010 and
2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment
and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC.
While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label
MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and
digital curettage. Anxieties about MVA’s capacity to induce abortion have constrained its integration into routine
obstetric care. This capacity also raises questions about what the “job,” PAC, represents in Senegalese hospitals.
The prioritization of MVA’s security over women’s access to the preferred technology reinforces gendered
inequalities in health care.
Boundary work refers to the strategies deployed by professionals in the arenas of the public, the... more Boundary work refers to the strategies deployed by professionals in the arenas of the public, the law and the workplace to define and defend jurisdictional authority. Little attention has been directed to the role of documents in negotiating professional claims. While boundary work over induced abortion has been extensively documented, few studies have examined jurisdictional disputes over the treatment of abortion complications, or post-abortion care (PAC). This study explores how medical providers deploy medical records in boundary work over the treatment of complications of spontaneous and induced abortion in Senegal, where induced abortion is prohibited under any circumstance. Findings are based on an institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included in-depth interviews with 36 health care professionals, observation of PAC services at three hospitals, a review of abortion records at each hospital, and a case review of illegal abortions prosecuted by the state. Findings show that health providers produce a particular account of the type of abortion treated through a series of practices such as the patient interview and the clinical exam. Providers obscure induced abortion in medical documents in three ways: the use of terminology that does not differentiate between induced and spontaneous abortion in PAC registers, the omission of data on the type of abortion altogether in PAC registers, and reporting the total number but not the type of abortions treated in hospital data transmitted to state health authorities. The obscuration of suspected induced abortion in the record permits providers to circumvent police inquiry at the hospital. PAC has been implemented in nearly 50 countries worldwide. This study demonstrates the need for additional research on how medical professionals negotiate conflicting medical and legal obligations in the daily practice of treating abortion complications.
Senegal has recently emerged as a leader in West Africa in the extension of postabortion care (PA... more Senegal has recently emerged as a leader in West Africa in the extension of postabortion care (PAC). This paper describes the extension of PAC to the district level in Senegal, where complications of abortion continue to claim too many women's lives.
Human Resources for Health, 2007
Background In Senegal, traditional supervision often focuses more on collection of service statis... more Background In Senegal, traditional supervision often focuses more on collection of service statistics than on evaluation of service quality. This approach yields limited information on quality of care and does little to improve providers' competence. In response to this challenge, Management Sciences for Health (MSH) has implemented a program of formative supervision. This multifaceted, problem-solving approach collects data on quality of care, improves technical competence, and engages the community in improving reproductive health care. Methods This study evaluated changes in service quality and community involvement after two rounds of supervision in 45 health facilities in four districts of Senegal. We used checklists to assess quality in four areas of service delivery: infrastructure, staff and services management, record-keeping, and technical competence. We also measured community involvement in improving service quality using the completion rates of action plans. Results The most notable improvement across regions was in infection prevention. Management of staff, services, and logistics also consistently improved across the four districts. Record-keeping skills showed variable but lower improvement by region. The completion rates of action plans suggest that communities are engaged in improving service quality in all four districts. Conclusion Formative supervision can improve the quality of reproductive health services, especially in areas where there is on-site skill building and refresher training. This approach can also mobilize communities to participate in improving service quality.
Eastern Sociological Society, February 2014, Baltimore, MD In Senegal, induced abortion is forbid... more Eastern Sociological Society, February 2014, Baltimore, MD In Senegal, induced abortion is forbidden under any circumstance. Since the late 1990s, American development aid to Senegal has supported emergency treatment for complications of miscarriage or induced abortion, known as post-abortion care (PAC). Yet, federal legislation prohibits American aid from supporting services related to pregnancy termination. My dissertation explores how these transnational, intersecting abortion policies have reinforced the legitimacy of PAC while simultaneously rendering induced abortion invisible in Senegal. I conducted an institutional ethnography of the national PAC program between 2010 and 2011. I interviewed 89 health providers, state health and criminal justice officials, and personnel from non-governmental organizations and donor agencies. I reviewed PAC records and observed PAC services in three hospitals. I examined state data collection instruments for PAC, epidemiological research on abortion complications, reports of operations research on PAC, national health surveys and legal records of 42 cases of illegal abortion prosecuted by the state. I found that texts across a variety of institutional settings play a critical role in legitimating PAC while obscuring induced abortion. For example, when medical professionals record suspected cases of illegal induced abortion as miscarriage in state hospital records, national health information systems omit data on induced abortion. Such documents reinforce the discursive construction of PAC by the Ministry of Health as a health intervention for mothers who have experienced miscarriage rather than women who have sought induced abortion. In a context where induced abortion is forbidden, texts ensure the political acceptability of the PAC program by obscuring induced abortion.
This paper examines how post-abortion care (PAC), a global health intervention, moves people, tec... more This paper examines how post-abortion care (PAC), a global health intervention, moves people, technology and politics around abortion in Senegal. Although induced abortion is illegal, the government introduced PAC in the late 1990s to train providers to treat abortion complications to reduce mortality. PAC transformed abortion into an object of medical rather than moral action by emphasizing the imperative of treatment irrespective of the origins of the abortion. Through its transnational network of actors, PAC leveraged significant resources towards abortion care, including research, training and the circulation of abortion technology in a context where abortion remains highly criminalized. I study PAC as a site of interface between local and global abortion politics and expertise through a multi-sited, institutional ethnography of the Senegalese national PAC program. Disputes over the meaning of abortion as well as ethical obligations of medical providers to abortion patients in this context overlap with American abortion politics attached to the flow of PAC resources into Senegal. Mapping these intersecting politics onto the landscape of PAC practices and policies is key to understanding gaps between the Senegalese and global PAC models as well as interrogating the very logic of implementing this model in settings where abortion is illegal.
Background: In spite of existing evidence of best practices in service organization and technolog... more Background: In spite of existing evidence of best practices in service organization and technology related to post-abortion care (PAC), little is known about what it means to practice PAC where abortion is restricted. This study explores the daily practice of PAC in state hospitals in Senegal, where induced abortion is prohibited. Findings suggest that even when best practices are in place, the daily practice of PAC is profoundly shaped by the local context of the abortion law.
Methods: I conducted a multi-sited, institutional ethnography of Senegal’s national PAC program over a period of 13 months between 2010 and 2011. Data collection methods included 88 in-depth interviews, observation of PAC services and records at 3 hospitals, and an archival review of abortion using medical, social science, media and legal sources. I used grounded theory to triangulate multiple sources of data.
Findings: Medical providers attempt to differentiate between spontaneous and induced abortion through a calculus of social and physiological indicators. These practices may subject women suspected of induced abortion to extensive interrogations, delays and threats to withhold treatment. Patients participate in this process by divulging or withholding information from providers. Providers manage suspected cases of induced abortion as spontaneous unless the patients confess to inducing abortion.
Conclusion: Daily practices in post-abortion care may not always align with best practices as defined by public health experts. In Senegal, post-abortion care practices reflect providers’ desire to protect themselves from the police within the context of the abortion law.
This study explores how medical providers in state hospitals in Senegal deploy medical records to... more This study explores how medical providers in state hospitals in Senegal deploy medical records to maintain authority over abortion, a legally prohibited practice. Between 2010 and 2011, I conducted in-depth interviews with 88 individuals, observation of post-abortion care at three hospitals and a review of abortion records at each hospital. The register where providers document the treatment of abortion complications represents a site where providers and patients actively coproduce a particular account of the type of abortions treated. By using ambiguous terminology to record suspected cases of induced abortion in the register, or by omitting the type of abortion altogether, providers render induced abortion invisible within the hospital. Women patients participate in this process by withholding or divulging information about the abortion. This study shows how medical records function as a professional boundary work tool. By obscuring suspected induced abortion in the record, providers aim to circumvent police inquiry at the hospital. In this context, the medical register not only inscribes social relations between patients and providers, but also reinforces abortion stigma through the reproduction of knowledge about women’s bodies and delineates the boundaries of medical authority over a forbidden practice.
This study explores how measuring abortion constitutes a tool of professional boundary work among... more This study explores how measuring abortion constitutes a tool of professional boundary work among medical providers in Senegal. Although induced abortion in Senegal is illegal under any circumstance, providers are permitted to treat complications of induced and spontaneous abortion (miscarriage). Treating abortion complications poses an important problem for medical professionals as it requires the differentiation between induced and spontaneous abortion. In turn, the identification of suspected cases of induced abortion raises the possibility of intervention by the police at the hospital. This paper explores how providers draw on different kinds of knowledge to differentiate between spontaneous and induced abortion. I argue that within this calculus of knowledge, providers produce uncertainty about the type of abortion in order to maintain professional authority over abortion. Data collection methods included in-depth interviews with 88 individuals including health professionals, government health authorities, law enforcement officials and members of women’s rights organizations and professional legal and medical associations. I observed treatment services and reviewed abortion records at three hospitals. I also conducted an archival review of abortion using medical, public health, social science, media and legal sources. Findings show that uncertainty about the type of abortion permits providers to manage and record suspected cases of induced abortion as spontaneous abortion, which typically does not merit police scrutiny. By containing such cases within the hospital, medical professionals reduce the likelihood of police intervention. At the same time, obscuring induced abortion in hospital records and state health information systems reinforces the notion that induced abortion is rare.
Technology is both constructed by and embedded within the social, political and economic context ... more Technology is both constructed by and embedded within the social, political and economic context of its practice. Sociologists have investigated technological meaning by identifying the competing stakes claimed to its functional capacity. Manual vacuum aspiration (MVA) is a form of uterine evacuation that can diagnose pathologies, treat complications of abortion, and induce abortion. It is precisely MVA’s capacity to induce abortion that generates jurisdictional anxiety in the United States and other contexts where abortion remains legally restricted. This project uses ethnography to study the meaning and practice of MVA in Senegal, where it is used for post-abortion care (PAC), or the treatment of abortion complications. In Senegal, a diverse and complex range of actors and institutions claims jurisdiction over MVA, including the United States government, local and international non-governmental organizations, national health authorities, medical professionals and women. Data collection methods include observation of MVA practices at 3 hospitals; 88 in-depth interviews with medical professionals, health officials and NGO and donor personnel, and key informants; and an archival review of PAC and abortion in Senegal. Findings suggest significant tensions between the discourse and practice among actors invested in MVA. Although local and international institutions have championed MVA as the best technology for PAC, the procurement, circulation and utilization of MVA is highly restricted by national health authorities and individual health facilities. A ‘dangerous’ technology, MVA is located at the intersection of local and global abortion politics and multiple and contradictory discourses regarding public health, professional authority and women’s reproductive autonomy.
The term " global health " often conjures up alarming images of infectious disease epidemics such... more The term " global health " often conjures up alarming images of infectious disease epidemics such as Ebola, H1N1, or HIV. Included in these images are " global " actors that aim to control disease outbreaks such as the World Health Organization or Doctors Without Borders. But global health encompasses much more than infectious disease. In fact, in 2013, noncommunicable conditions such as cancer and heart disease accounted for a greater proportion of global mortality than infectious disease. Furthermore, a multiplicity of agencies, institutions, and individuals play a role in global health, including pharmaceutical companies like Pfizer, philanthropic organizations like the Bill and Melinda Gates Foundation, programs like the US President's Emergency Plan for AIDS Relief (PEPFAR), national health authorities, local health workers, and people suffering from illness and seeking care. Drawing on perspectives from anthropology, sociology, geography, human rights, law, history, population and development, science and technology studies, and public health, this class explores the meanings, practices, and politics of global health within broader processes, structures, and inequalities of globalization. For example, how do we explain current distributions of and disparities in global disease mortality and morbidity? How did contemporary global health models and actors evolve from earlier processes of European colonialism, US imperialism, and postWorld War II development? Who is responsible for developing global health interventions, and what are the politics of measuring effectiveness and impact? How do geopolitical relations influence research on and access to lifesaving drugs? In what ways do globally circulating images, narratives, and representations of illness facilitate or hinder disease prevention, treatment or eradication? Although the course explores these questions primarily through the lens of infectious disease like malaria, polio, HIV, and Ebola, we also attend to reasons contributing to the marginalization of other global health conditions such as reproductive and maternal health. We end by reflecting on the responsibilities and challenges faced by first line of global health practitioners: health workers in places like Pakistan, Papua New Guinea, and Senegal.
The term biopolitics, coined by philosopher and historian Michel Foucault, highlights the power r... more The term biopolitics, coined by philosopher and historian Michel Foucault, highlights the power relations shaping the scientific, medical and technological governance of populations. This course explores the intersection of race and gender in the management of illness and health in populations of African descent from the periods of slavery and colonization until the present day. We begin by comparing biomedical and social science perspectives on the definition, distribution, and experience of disease. The course then examines how intertwining ideologies of race and gender have shaped understandings of disease etiology, transmission and susceptibility. We trace how gendered and racialized ideologies of disease translate into diagnosis and treatment during the medical encounter and the design and implementation of pharmacological and public health interventions. In other words, we evaluate how the pathologization of the African body has engendered inequitable—and unethical—treatment of blacks in the clinical practice of medicine, the execution of health research, and the management of public health systems. Drawing on perspectives from anthropology, sociology, history, science and technology studies, geography, population and development, human rights, and public health, we look at the historical and contemporary management across the African diaspora of infectious and chronic conditions such as heart disease, sickle cell disease, obesity, cancer, mental illness, HIV/AIDS, and reproductive health. This course identifies the ways in which population governance co-constitutes and reinforces political power. We explore how interpersonal and structural racial and gender inequalities undergird and reproduce disparities in health outcomes and experiences. At the same time, we attend to strategies adopted by populations of African descent to combat harmful stereotypes and hold authorities accountable for disproportionate distributions of disease in their communities.
Instructor: Siri Suh, MPH, PhD Office hours and location: TBA
This class explores reproduction in global context as a lens through which social, economic, and ... more This class explores reproduction in global context as a lens through which social, economic, and political relations of power can be understood. Reproduction is neither limited to the professional domain of demographers, biologists and physicians nor to individuals' decisions and practices regarding childbearing and family. Instead, reproduction is a site of broader social struggle over meanings and practices related to nation, empire, parenthood, gender, sexuality, the body and technology. We will explore historical and contemporary social constructions of fertility, pregnancy and birth. We will study how policies, technologies and practices related to reproduction are embodied, negotiated and contested according to gender, class, race and nationality. The course will explore domestic and global politics of reproduction and examine the social, economic and political linkages between the two. Throughout the course, we will interrogate reproduction at three interlocking levels of analysis: local/global, personal/political and past/present.
In 2011, the global population reached 7 billion. Environmentalists, demographers and experts in ... more In 2011, the global population reached 7 billion. Environmentalists, demographers and experts in development and public health renewed calls to regulate population growth in order to reduce poverty and conserve the world's resources for future generations. At the same time, China's one child policy, arguably one of the world's most well--known population control policies, has faced mounting criticism in light of recent evidence of highly coercive practices. The study of population is not limited to the jurisdiction of demography, a discipline concerned with the calculation and prediction of population growth and decline. Rather, the measurement of population is a deeply political process that determines the allocation of resources within society. Policymakers and their expert advisors in health, environment and the economy draw on demographic data to develop policies designed to regulate population such as access to contraception and abortion, work/family benefits, the regulation of assisted reproductive technology (ART) and adoption, and fertility incentives or disincentives. This class uses a feminist approach to trace the emergence of population science as a form of social regulation. We will examine how ideologies of race and gender have shaped historical and contemporary population discourse and policy around the world. We will identify and critique various phases in global population discourse and goals articulated by the United Nations, from the end of the colonial era to the Millennium Development Goals of 2000. Throughout the course, we will pay attention to the intersection between global and national population discourse and the everyday meanings and practices related to fertility and reproduction in women's lives. We will also investigate how population policies and technologies create new reproductive opportunities and constraints that are inextricably linked to broader gender and economic inequities between the global North and South. This course embraces a multi--disciplinary approach to studying population, drawing on literature from sociology, anthropology, political science, history, human rights, demography and epidemiology. Course objectives: