care. They draw this conclusion because the causes of death in black women are largely preventable, as in the Jamaican case, and few of the wanen obtain what is considered adequate prenatal care. The maternal mortality ratio for black women in the Uaited States is 20.4/100,000 live births which is nearly four times the white ratio, 5.2/100,000. Like the Elack women in the United States, Jamaican omneri have relatively low prenatal care participation rates. Training Is an important part of improving services, and it should include in-service training to existing staff to bring their skills up to date. Additionally, monitoring and supervision are required to ensure that services theoretically in place actually exist at the intended quality level. Proposed services to include in training are: review of aseptic techniques, blood transfu-;ions, application of oxytocic for hemorrhage, and antibiotics for long labor. Tholugh controversial, there is sane discussion of traininx nurses in isolated areas to do surgeries. The training must be adapted to local circumstances and need. Through moderate investments in training and supervision, and sane equipment and facility improvements, delivery services can be greatly enhanced.

6 HEALTH BELIE=S AND UTILIZATION OF FORMAL SERVICES The popular culture in Jamaica, perhaps because of its roots in slave and colonial cultures and due to periods of resistance and self reliance (Campbell, 1980), has popular medical concepts which enrcurage self treatment by traditional and over-the-counter medications. medicines are chosen as they adhere to popular notions of disease etiology; purgatives for example, have been used for abortions because they "cut" the womb (Mitchell, 1983). Problem arise because most people do not understand the western medicines and doctors do not explain their prescriptions. When prescribed medicines do not have the physical characteristics 'ahich fit the local concepts of what is needed, they are not used. Over-the-counter medicines, on the other hand, are easily abused; many are purchased for ailments which they are not designed for but for which they fit the popular medical notions. The use of traditional healers and the choice between western and local medicine have been studied in Jamaica (see for example: Hogg, 1961; long, 1973; Seaga, 1956), but very little has been said about the traditional practices surrounding reproductive health medicine. A preliminary release of the Perinatal Study reported some use of home remed-.es during pregnancy. The most popular items were teas which were mainly used for gas and nausea (Jamaica-MOH, 1987). Studies on women's beliefs about contraceptive methods and their knowledge of reproduction found that wonen worried about altered menstruation, irreversible sterility, and other consequences of contraception. These worries were translated into low use of family planming services; 42% of one sample had never used contraceptives and many of the remaining women only used them sporadically (MacCormack, 1985). Ccmmon misperceptions were: intrauterine devices (IUDs) could get lost in the body; the IUD-believed to be located in the vagina-causes pain to the women's sexual partners; the contact of the IUD with menstrual blood and semen over time causes it to become dirty and to smell; Depo-Provera blocks a woman's tubes so she doesn't menstruate-this causes high blood pressure as the menstrual blood held in the body accumulates; the pill acts as a physical barrier-one needs castor oil to reduce the build-up of pills over time; pills cause "clots"-these can be seen in the menstrual blood; tubal 10