midwives de-livered a mean of 3.8 babies in homes per year while rural midwives had a mean of 21.5 home deliveries. A mean of only 0.7 deliveries per midwife were unattended in the urban areas compared to a mean of 5.4 unattended deliveries per midwife in rural areas. The unattended deliveries are at especially high risk and reasons for delivering unattended should be identified. Midwives who lived and worked in the same area delivered more babies in homes than midwives who traveled to work; nonetheless, the trends indicate a decreasing reliance on midwives for home delivery. The performance of midwives in prenatal care was not good in a number of areas. Laboratory tests were underutilized, scores on knowledge tests were mediocre, and emphasis given to various tasks was misplaced. The VDRL test was routinely oraered by all midwives and the test for hemoglobin was ordered routinely by 85.9% of the midwives, 57.7% ordered blood group, 67.9% ordered sickle cell and less than 5% routinely ordered Rhesus factor, Coombs, and wormIDtests4. Urinalysis was routine with 24.4% and pap smears with 3.8% of the midwives. Twenty-eight percent of the midwives sent pregnant women to private laboratories for required lab tests (Jamaica-M0H, 1987 and 1989). The study al;o noted time lags in getting results back that were beyond the control of the midwives. The scores of the midwives on knawledge tests were unremarkable though the result itself was not surprising. Most midwives had graduated from an older curriculum, there was little ongoing supervision, and continuing education is optional and minimal. A risk factor test recorded the percent of women spontaneously listing a particular risk factor; the results for each risk factor were: teenager-69%, women over 35-68%, primiparous-90%, multiparous-87% (51% were able to correctly name the parity which is really at risk), very short women-50%, tall women-24%, previous postpartum hemorrhage-73%, previous abortion-60%, previous stillbirth-41%, previous complications in labor or delivery-51%, coexisting pre-eclanipsia-86%, diabetes-81%, heart disease-67%, anenia-60%, and positive VDRL-42%, antepartum hemorrhage-68%, malpresentation-59%, multiple pregnancy-59%, and breech-47%. Other risks were mentioned but by fewer midwives. An "indicators of emergency" test using 11 indicators had the following percents of midwives identifying each indicator: elevated blood pressure, hemorrhage/shock, and fetal distressaround 85%, eclampsia and failure of labor to progress-around 71%, fresh meconium staining-67%, prolapsed umbilical cord-66%, depressed blood pressure-26%, and prolonged rupture of membranes-39%. The survey also tested infant high risk factors and how to care for newborns and mothers, the scores of which are not reported here. Midwives knew most about maternal risk factors and least about newborn's as indicated by the percent of midwives with poor scores: 26% low for maternal risks, 31% for care of newborns, and 33% for newborn risk factors. Other findings on midwives include insufficient record keeping and reporting of events (and providing certificates) by a large proportion of midwives while simultaneously, many undertake tasks no longer considered necessary such as giving enemas and shaving. Some were unable to perform certain tasks, such as giving vitamin K or eye drops, because they were out 4 The VDRL is a common nontreponemal serologic test used for screening syphilis; hemoglobin tests for anemia; the Cocmbs test provides an indication of the effects of Rhesus incompatibilities.

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