The Paradox of Post-Abortion Care: A Global Health Intervention at the Intersection of Medicine, Criminal Justice and Transnational Population Politics in Senegal Julia Siri Suh Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2014 ©2014 Julia Siri Suh All rights reserved ABSTRACT The Paradox of Post-Abortion Care: A Global Health Intervention at the Intersection of Medicine, Criminal Justice, and Transnational Population Politics in Senegal Julia Siri Suh Sociologists have used boundary work theory to explore the strategies deployed by professionals to define and defend jurisdictional authority in the arenas of the public, the law and the workplace. My dissertation investigates how medical providers and public health professionals negotiate authority over abortion in Senegal. Although induced abortion is prohibited in Senegal, medical providers are permitted to treat complications of spontaneous and induced abortion, known as post-abortion care (PAC). Introduced to Senegal in the late 1990s, the national PAC program is primarily supported by American development aid. This study explores how medical providers manage complications of abortion and in particular, how they circumvent the involvement of criminal justice authorities when they encounter suspected cases of illegal abortion. I also study how boundary work is accomplished transnationally through the practice of PAC within the policy framework of American anti-abortion population assistance and the national prohibition on abortion. Findings are based on an institutional ethnography of Senegal’s national PAC program conducted over a period of 19 months between 2009 and 2011. Data collection methods included in-depth interviews with 89 individuals, observation of PAC services, and review of PAC records at three hospitals. I also conducted an archival review of abortion and PAC in court records, the media, and public health literature. Findings show that medical providers and public health professionals perform discursive, technical and written boundary work strategies to maintain authority over PAC. Although these strategies have successfully integrated PAC into maternal health care, they have reinforced the stigma of abortion for women and health professionals. They have also reproduced gendered disparities in access to quality reproductive health care. PAC has been implemented in nearly 50 countries worldwide with varying legal restrictions on abortion. This study illustrates not only how medical professionals practice abortion care in such settings, but also how they navigate a precarious array of medical, legal and global health obligations. Table of Contents List of Figures and Tables .......................................................................................................................... ii Acknowledgements .................................................................................................................................... iii Dedications.................................................................................................................................................. iv (1) Introduction ........................................................................................................................................... 1 (2) Background .......................................................................................................................................... 14 (3) Literature Review ................................................................................................................................ 34 (4) Methodology ........................................................................................................................................ 78 (5) Policing institutional boundaries: separating PAC from induced abortion ................................ 121 (6) ‘In the hands of trustworthy men’: the transnational politics of Manual Vacuum Aspiration in Senegal ..................................................................................................................................................... 161 (7) Boundaries at work: practicing abortion care at the intersection of medicine, criminal justice and transnational abortion politics in Senegal ..................................................................................... 198 (8) Conclusion .......................................................................................................................................... 241 References ................................................................................................................................................ 251 Appendix 1: Map of Senegal .................................................................................................................. 276 Appendix 2: Administrative regions of Senegal ................................................................................... 277 Appendix 3: Agencies involved in PAC in Senegal ............................................................................. 278 i List of Figures and Tables Figures Figure 1: Manual Vacuum Aspiration (MVA) .................................................................................... 16 Figure 2: Uterine evacuation at 3 hospitals, 2009-2010 .................................................................... 143 Figure 3: Digital Curettage ................................................................................................................ 167 Figure 4: Uterine evacuation at Hospital 1, 2006-2010 ..................................................................... 175 Figure 5: Uterine evacuation at Hospital 2, 2004-2010 ..................................................................... 176 Figure 6: Uterine evacuation at Hospital 3, 2006-2010 ..................................................................... 176 Figure 7: MVA initial supply and re-supply ...................................................................................... 187 Figure 8: Maternity ward admissions and abortions in Hospitals 1 and 3, 2006-2009 ...................... 195 Figure 9: Abortion as a proportion of admission to the maternity ward in 3 hospitals, 2006-2010 .. 200 Figure 10: Abortions treated in 3 hospitals over 24 months, 2009-2010 ........................................... 200 Figure 11: Map of Senegal ................................................................................................................. 276 Figure 12: Administrative regions of Senegal ................................................................................... 277 Tables Table 1: Number, profession and institutional affiliation of health professionals interviewed in 3 regions ......................................................................................................................................... 89 Table 2: Number, institutional affiliation and profession of Ministry of Health officials by region ... 90 Table 3: Number, profession, institutional affiliation, nationality and location of NGO personnel .... 90 Table 4: Gender, profession, institutional affiliation and nationality of key informants ..................... 91 Table 5: Gender profile of PAC practitioners by institutional affiliation and profession .................... 92 Table 6: Type of health provider.......................................................................................................... 93 Table 7: PAC practitioners by region and institutional affiliation ....................................................... 93 Table 8: Training in uterine evacuation among health professionals .................................................. 93 Table 9: Review of PAC and abortion data at 3 hospitals ................................................................. 100 Table 10: Type of PAC provider at Hospital 3, 2009-2010 ............................................................... 179 Table 11: Estimated availability of functional MVA in 3 hospitals, 2010 ........................................ 188 Table 12: Providers indicating that abortion should be permitted under certain circumstances ....... 205 Table 13: Indicators used differentiate between induced and spontaneous abortion ......................... 215 Table 14: Type of abortion recorded in the PAC register at 3 hospitals, 2009-2010 ........................ 222 Table 15: Selected indicators of admitted and possible induced abortions in 6 months of PAC register data in 3 hospitals, 2009-2010 ................................................................................................... 224 Table 16: Total number of abortions treated in 3 hospitals, 2004-2010 ............................................ 229 Table 17: Agencies involved in PAC in Senegal ............................................................................... 278 ii Acknowledgements This research was supported by graduate fellowships from the National Institutes of Child Health and Human Development (NICHD), the Social Science Research Council (SSRC), the American Council of Learned Societies (ACLS), and the Institute of African Studies at Columbia University. I am grateful to the West African Research Association (WARA) in Dakar, Senegal for providing administrative and institutional support during my preliminary and dissertation fieldwork. I wish to thank the following individuals for offering