Abortion in Post‐revolutionary Tunisia: Politics, Medicine and Morality. Irene Maffi, New York: Berghahn Books, 2020, 218 pp.
Irene Maffi’s Abortion in Post-revolutionary Tunisia is a compelling portrait of the landscape of clinical reproductive health care in the 2013–2014 period following the revolution. The focus of Maffi’s argument revolves around what she identifies as a paradox: that reproductive health care services were in many ways easier to obtain and abortion less contested pre-revolution (2011), despite the democratization of Tunisian society post-revolution. Pre-revolution, health care workers were required to adhere to state policies toward abortion provision, many of which emphasized population reduction, and abortion access was an important part of family planning policy. However, in the aftermath of 2011, some health care providers exercised their increased individual freedom of “free expression and public conduct” (p. xi) to deny some women abortions and subject them to moralizing discourses about their reproductive health care choices, often attempting to dissuade women from having abortions (p. 171). Maffi details how political and social changes created abortion access issues at the individual and institutional levels and caused internal conflicts among health care staff with differing views regarding abortion’s moral acceptability.
Abortion in Post-revolutionary Tunisia primarily utilizes descriptions of clinical encounters between patients and staff at both hospitals and public clinics. Maffi pays particular attention to the “local moral worlds” of health care providers, who are her primary interlocutors (p. 21). A key point of analysis is how women’s sexual and reproductive health care practices are subject to the medical and social norms of the health care system, and how these practices are essential to understanding the social and political transformations that were occurring in Tunisia after the revolution (p. xi). This is particularly cogent in Maffi’s evaluation of how married and unmarried women are considered different “moral and social categories of citizens and patients” in their treatment by reproductive health care practitioners (p. 22).
Maffi describes how “youth friendly clinics” are subjected to additional surveillance mechanisms, both bureaucratic and through providers’ treatment of unmarried women (p. 107). Furthermore, women, married and unmarried, are subject to biomedical ideas about self-regulation of their reproduction and sexuality, where planned pregnancies and adhering to a regular regimen of birth control are considered the only acceptable actions of responsible citizens. Maffi argues that reproductive health clinics are spaces in which women are disciplined and made into responsible patients (p. 99). Here, women endure “humiliating and stigmatizing discourses” to receive abortion care (p. 111).
A main point of the book is that this language matters. Maffi analyzes the language used by different reproductive health care providers to show how stigma against abortion in providers’ speech is a form of symbolic violence. Maffi notes, for example, that in clinical consultations, some providers unconsciously used phrases such as “eliminate the little one” and described all pregnant women as “mothers” when discussing abortion, while others did this intentionally as “ontological manipulation” to discourage patients from having an abortion (p. 45). Maffi shows how feminist NGOs sought to change the language used when discussing abortion with patients; in seminars and training sessions for health care workers led by feminist NGOs, trainers attempted to convince health practitioners to use value-neutral biomedical terms such as “pregnancy” instead of “baby” and “ending the pregnancy” rather than “killing the baby” (p. 44). Patients in the book nonetheless seemed to disregard these discourses and were willing to express the required emotions of distress, grief, sorrow, or trauma to secure access to abortion care (p. 120).
Furthermore, patients hold different ontological views on women’s reproductive bodies, the process of abortion, and ways of conceptualizing the fetus than their biomedical providers. Maffi primarily describes these ontologies through culturally specific language about menstruation (p. 65), and the different values that women seeking abortion services and providers place on visual depictions of the fetus such as sonograms (p. 142). Maffi notes that ethical concerns about patient discomfort led her to decide not to formally interview patients (especially unmarried women) about their experiences, though she talked with patients informally. Here, however, the argument would have benefited from a more in-depth analysis of women’s moral understandings of their own abortions, bolstering the limited discussion of women’s feelings, doubts, and fears (p.153). Even without interviewing this population, additional analysis of the performative aspects of the clinic encounter between patients and health care providers, particularly the language used by patients to advocate for themselves when attempting to access abortion services, would have strengthened the argument even further.
The main strength of the book is the discussion of symbolic and institutional violence that restrict individual abilities to access abortion care (p. 119). Maffi argues that health care workers have ambiguous attitudes toward what may be considered a morally acceptable or allowable abortion. Many of these ideas seem to revolve around experiences of patient suffering or preserving the social order. For instance, unmarried women, minors, and “virgins” (persons who have superficial sexual relationships to preserve the hymen) are usually provided with abortion care, as their future prospects and social standing would be damaged by continuing the pregnancy (p. 112). However, other patients are labeled pejoratively as “recidivists (people who have multiple abortions),” “unmarried mothers,” and “social outcasts (sex workers)” (p. 128). These categories of patients are subjected to additional moralizing discourses about abortion and are more likely to be denied abortion care, as are married women whose social status will not be as detrimentally impacted by continuing a pregnancy.
Maffi clearly describes the discourses and practices of clinic staff as a particular form of reproductive governance based on the history of Tunisia (p. 20). However, the examples Maffi provides—of stigmatizing language and admonishments by clinic staff against women who have multiple abortions or who become pregnant while not adhering to a birth control regimen—are not unique to the Tunisian context. Indeed, the potential for comparisons between the Tunisian context and other biomedical settings is one of the major contributions of this work. The rhetoric she describes providers using such as “kill the baby” and “murderer” echoes that of the U.S. anti-abortion movement, where such language is used to support personhood arguments. Better understanding the ways that the clinic encounter perpetuates abortion stigma will be useful to a wide variety of reproductive health scholars in examining how people navigate unequal power relationships within clinical encounters to access services that are ostensibly legal but often inaccessible. Furthermore, comparisons between language used in this context and other biomedical settings around the world might show how abortion stigma travels through the rhetoric used by various anti-abortion and pro-abortion rights movements around the world.
Maffi’s clear writing style and argument make this book a useful teaching aid for an introductory course in medical anthropology. The introductory depiction of the varied interpretations of the moral status of abortion in Islamic traditions would be useful in courses topically focused on the role of religion in health care or anthropological approaches to bioethics. Likewise, the historical overview in the introduction and Chapter 1 of the social and political movements that kept abortion legal could be read comparatively with work on reproductive governance and rights, or the impact of social movements on health care access. Ultimately, Abortion in Post-revolutionary Tunisia makes a cogent argument for how the larger political and social changes in Tunisia have made visible preexisting and new conservative attitudes toward abortion, contraception, and gendered notions of reproductive responsibility.