of supplies. This indicates they lack an understanding of ordering procedures. Finally, most midwives did not conform with the rec=unended schedule for ham visits, over one third made less than 4 visits on average. These visits theoretically make-up the entire post-partum and well baby care and education services. Though few visits are made, it appears midwives are giving camplete exams of mother and child when they do visit. The current level of intervention during delivery is low while perinatal mortality is high. Evidence from Britain suggests infant deaths due to intrapartum anoxia in babies weighing 2500 grams or more are preventable when delivery management is improved (Chamberlain et al., 1975 or 78). TIhe Perinatal Study suggests that over a quarter of deaths are in large babies dying during or shortly after delivery. These deaths are less ccmmon in areas served by Type A hospitals. Parallel to those findings are the suggestions that cerebral birth trauma is also less common at Type A hospitals. Cerebral birth trauma was the cause of death in 52 infants of a total 420 weighing at least 2500 g at birth; it is not a major cause of death, but like intrapartum anoxia, it is a preventable one. Earlier referrals, better training, and facilities for delivery and resuscitation are suggested as factors which could spark a reduction in these causes of mortality (Jamaica-MOH, 1987).

# 7.4 GENERAL SERVICE ISSUES

The trainimng of health professionals is commnly suggested in the literature of all countries as a way to improve health; the situation is no different in Jamaica. One study in Jamaica on health professionals' knowledge of breast feeding found that medical doctors knew the most but shared their information the least. Community health aides, nurses, and domiciliaries had positive attitudes towards the practice but required more practical information (Giugliani et al., 1988). Another critique of the primary health care system claimed the medical education curriculum focuses on the teacher not the learner, and there is a need to simplify (Bollag, 1980). That critique recmmended teaching doctors about community health in the earliest parts of their education and training them to cammunicate more and work better with other health workers. The government created a cadre of auxiliary health professionals in 1972 called Ccmmunity Health Aides (CHA) to serve the low-inccme population through an island-wide network of primary health and nutrition programs. Women with relatively little education were recruited, trained for two months, and returned to their communities. The primary emphasis was greater equity in health service distribution, combatting child malnutrition, and encouraging the timely use of medical facilities. The program was evaluated in 1982 after 10 years of operation (Marchione, 1984). Results found that CHAs met more often with clients when they had a limited geographic area to cover and when there were fewer CHAs per supervisor. Outccme data indicated a positive effect from the program, but a minimal one relative to outside influences. Politics for example supervened; the best performance on outcomes was in Hanover parish, the site of an international demonstration project which was given twice the usual density of CHAs. Other outside factors with strong links to improved health outcomes include: access to jobs, land, income, and a strong household social support system. The mean distance from home to a health center in Jamaica is 2.4 miles in all but one parish, and 90% of the population lives within a 10 mile 17