walking radius of a health center. Hospital services are available through a network of 20 tiospitals locally labeled Type A, B or C according to decreasing levEils of specialization. Type C hospitals provide basic maternal, and general medical and surgical services. The three Type A- tertiary-hospitals provide specialist obstetrical, neonatal, and pediatric care and are Located in Kingston and Montego Bay. Seven parishes have specialized h.ealth centers known as rural maternity centres and which provide intranatal services (See map and Table 1 for more detail). Women frequently cross boundaries to deliver babies. The cost and quality of transportation is making it difficult for midwives to see clients and is probably making it difficult for many womn to get services. In a preliminary release of information from the Perinatal Study, 73.1% of midwives said that the lack of mobility was a problem (JamaicaiMOH, 1987); 78.2% walked, 26.9% used taxis, 39.7% took a bus, 9% owned a car, and 2.6% used government vehicles. About 45% of the midwives claimed it took more than an hour to get public transportation. Ccopounding the problem of poor transportation in the face of an emergency is the lack of communication; 56.4% of the midwives were not within a 1-2 mile radius of a telephone or radio, 94.3% of midwives communicated using messengers (JamaicaiMOH, 1987).

Because of untidy or partial record keeping, tracking of women through the various services and referrals is difficult (Jamaica-MOH, 1987). Wcmien are sometimes given a record book which they take to a hospital when the midwife sends them for referral care but the record is not returned and the midwife has no way of following up what was done later on. The Perinatal Study could not confirm reported prenatal visits because of misplaced records or in some cases, because the institution kept none. The Ministry of Health expenditure per capita declined from $35 to $20 between 1981 and 1985. During that tirme, health care was provided free to the population with little regard for ability-to-pay. Nominal fees were charged for inpatient and outpatient services at public hospitals but fees were often not collected and hence accounted for very little of the revenues (Folta, 1988). Since that time there have been moves 'o increase the revenues of hospitals by improving the user fee system. When revenues from this source were deposited in a central office the earnings represented between 1 and 4% of hospital budget allocations; policy changes allowing hospitals to retain some of the user fee revenues have resulted in increases such that these earnings represent 6 to 28% of hospital operating budgets. Further reocmmendations for more revenue gains include stricter means testing and higher fees for those that are able (Lewis, 1989). There are dangers that go along with instituting higher fees however. Of particular concern is the fact that more women are relying on hospitals for delivery. A small 12 to 15 percent of the population currently has private iedical insurance (Lewis, 1988) and could see private practitioners or pay higher fees. Most of the population, and particularly the young, rely on public hospitals and public clinics (Lewis, 1988); efforts to raise revenues could very easily block the access to services for at-risk groups. In order to estimate further gains that are possible in the area of maternal health it would be helpful to know more about the present costs of: staff, transport, training, supervision, equipment, health education, construction, and vehicles.

18