Review of Dying to Count: Post‐abortion Care and Global Reproductive Health Politics in Senegal. Siri Suh, New Brunswick, NJ: Rutgers University Press, 2021, 226 pp.

Reviewed Book

Dying to Count: Post‐abortion Care and Global Reproductive Health Politics in Senegal. Siri Suh, New Brunswick, NJ: Rutgers University Press, 2021, 226 pp.

Dying to Count: Post-abortion Care and Global Reproductive Health Politics in Senegal. Siri Suh, New Brunswick, NJ: Rutgers University Press, 2021, 226 pp.

Mounia El Kotni

Centre de recherche, médecine, sciences, santé, santé mentale, société (Cermes3)

In Dying to Count, medical sociologist Siri Suh dives into the politics of post-abortion care (PAC), emergency obstetric procedures that follow (spontaneous or induced) abortion complications. While PAC is praised on the global health scene as a means to reduce maternal mortality, Suh shows how PAC is situated at the intersection of care and violence and ultimately enacts control over poor women’s reproductive behavior. Through carefully documented ethnographic research in three Senegalese hospitals, the author analyzes PAC using the framework of reproductive governance and demonstrates how, rather than pushing for abortion reforms, PAC maintains a legislative status quo in countries with restrictive abortion laws: While wealthy women manage to access abortion services, underprivileged women, whose lives do not “count,” face poor quality care in public hospitals.

This clear and powerful book is organized around four chapters, an introduction, a conclusion and two methodological Appendices. The introduction situates PAC as a tool of global reproductive governance, a framework that brings attention to the ways in which a wide array of institutions and social groups exercise control over reproductive behaviors (Morgan and Roberts 2012). The first chapter provides an overview of how PAC is framed as a global maternal health intervention, while Chapter 2 dives into the layers of PAC on the ground: how it is performed, by whom, and how it is a tool of both care and violence. Chapter 3 highlights the ambiguous position of local health workers; in their discourse, they frame PAC as a strictly medical problem unrelated to the causes of abortion, but in practice they implement l’interrogation, a heavy questioning of women deemed morally suspicious to hunt down induced abortion cases. Chapter 4 highlights the consequences of the global push to produce statistical data: for women to “count,” they need to experience a life-threatening obstetric complication. In the Conclusion, the author shows how, by working as a tool of reproductive governance, PAC limits the possibilities of achieving reproductive justice for underprivileged women in Senegal.

Dying to Count demonstrates how, by prioritizing statistical data over qualitative research on the provision of PAC, global discourses prevent conversations on important health issues such as the material conditions under which PAC is implemented, the possibilities for women to access this form of care, and the obstetric violence that occurs in the context of abortion prohibition. Suh importantly points out that the legal prohibition on abortion means that Senegalese women must comply with the only narrative available to them regarding their need for post-abortion care: having suffered a miscarriage following a desired pregnancy.

Following the day-to-day practices and procedures of PAC, Suh’s ethnographic research describes how instead of taking place in a private room as per PAC guidelines, women undergo procedures in the delivery room due to the lack of space in public health facilities. The author also shows how the excessive use of medical equipment used in manual vacuum aspiration makes them less effective, pushing medical providers to rely on unsafe methods such as digital evacuation. Suh also illustrates the financial burden that access to PAC represents for women and their families in rural areas, as well as how women are disciplined into deserving patients. Still, even the medical personnel who witness PAC breakdowns on a daily basis continue to portray it as an effective maternal health policy. This performative discourse is reinforced by the lack of reliable data on the causes of abortion: in the hospitals where Suh conducted research, almost all abortions were registered as “spontaneous,” sometimes despite medical evidence of induced abortion. These numbers, aggregated at the national level, contribute to securing international donor funding for the only abortion related procedure exempted from the Mexico City policy—a U.S. government policy that forbids federally funded organizations to provide any kind of abortion-related activities.

For Suh, PAC enacts reproductive governance by curtailing women’s reproductive rights. If induced abortion does not exist, then it cannot be registered, and the only acceptable option for Senegalese women is to perform the narrative of spontaneous abortion and behave like deserving mothers. In fact, the only reproductive identity available to pregnant women is that of motherhood. In Senegal, all pregnancies are expected to be desired pregnancies and all loss must thus generate grief. When health personnel perform l’interrogation, they expect women to play the role of the grieving mother, so as to register the abortion as spontaneous, which also protects themselves and women from police investigation and potential imprisonment. When women’s stories trouble the category of good motherhood, they are subject to verbal abuse and mistreatment, paying the high price for reproductive behaviors deemed morally unfit. This well-documented research shows the ways in which life-saving care can become oppressive, and limit possibilities for reproductive justice for poor women living in rural areas. Even though primary health care facilities have since been allowed to perform PAC, the difficulties of obtaining adequate material such as syringes remains, as does the cost of travel (including taking days off work) for women and their families.

Suh’s research critically analyzes the relationship between the local, regional, and global dynamics of PAC. It is solidly grounded in medical anthropological literature and anthropological and public health research on reproductive and abortion care in Africa. However, while Suh describes the conditions that push women to seek unsafe abortion (poverty, migration, gender expectations), she could have examined these conditions further for readers unfamiliar with the West African context. The combination of interviews, observation and archival work, and the details provided in the Appendices, make it a useful teaching tool in sociology, anthropology, public health, and women and gender studies. Suh’s writing finely walks the line of care and violence and shows the humanity of the people interviewed. Suh also describes the realities of fieldwork, including interview refusal and witnessing obstetric violence. This latter point raises ethical questions about our practice and position as researchers and is a contemporary question for anthropologists, especially in the field of obstetric violence.

To sum up, Dying to Count represents an important addition to the literature on reproduction. Even though the primary focus of the book is on abortion care, its analyses go beyond abortion and contribute to contemporary debates on reproductive governance and justice.

Reference Cited

Morgan, L., and E. F. S. Roberts. 2012. Reproductive Governance in Latin America. Anthropology & Medicine 19: 241–54.