clinics recorded: 80% of the women reported urinalysis, however, results were noted for 46.2% of the sample. Of those who had results, 68.5% had positive indications for proteinuria (an indication of preeclampsia-perhaps the biggest maternal health risk in Jamaica). 56% of the wcnen had been immunized against tetanus in the present or a preceding pregnancy; immunization status was unknown for 22.5% of the women (Jamaica-MOH, 1987). Given the importance of hypertensive disorders, anemia, and infection in maternal mortality in Jamaica, it is surprising that screening for, and monitoring of, these risk factors is so poor. The impact of prenatal care on low birth weight and prematurity has been investigated by a number of researchers. Goujon et al. (1984) implemented a prematurity prevention program in the governnent prenatal clinics of Martinique (see description of original program in Papiernik & Kaminski, 1974 or Papiernik & Vial, 1979). They found that women receiving the free public care fared as well as private patients. This indicated the prenatal care services could overcome socio-economic factors usually responsible for large differences in obstetric performance. The study was unable to answer why a third of the women did not receive either kind of prenatal care; this third group perfonned far worse on all the outcome measures. It would be interesting to know more about the activities that women do when they are pregnant and how this changes when there are complications. Knowing more about traditional beliefs surrounding pregnancy could help explain utilization patterns for prenatal care.

# 7.3 DELIVERY AND OBSTETRIC REFEURRAL SERVICES

Approximately 75% of the women in the Perinatal Study delivered in public hospitals, 17% at home, 8% in maternity centers (including private nursing homes), and another 1.3% delivered en route in taxi cabs, buses, etc. Hospital births have been increasing over the last decade, and areas served by Type A facilities continue to have lower mortality rates than other parishes (Jamaica,-MOH, 1989,. Most of the deliveries were attended by midwives (80%), 9% were attended by doctors or medical students, and at least 15.2% were unattended (this could occur in a hospital as well). Spontaneous birth occurred in about 90% of the women and only 4% had caesarean sections (Jamaica-MOH, 1989). Episiotomies were performed on 6.9% of the sample; another 13.2% experienced perineal tears. The use of analgesics during labor is also low and has been limited to the private sector and hospitals; only 12.4% of the sample received pain-killers. Midwives are requesting injectable analgesics but have been refused on the grounds that mortality might rise due to the added risks and the continued constraints in communication and transportation.

There are two kinds of midwives in Jamaica-"nanas" which are from the informal health sector, and "domiciliaries" which are trained by the Ministry of Health. The domiciliaries provide essential prenatal, intranatal, and puerperal services to wcmen regardless of where they deliver. They have recently also been assigned responsibility for child health care. The best available data on these domiciliaries comes from the recent Perinatal Study (Jamaica-MOH, 1989); in this report the domiciliaries are simply referred to as midwives. Twenty-four percent of the registered midwives were interviewed-a sample total of 78 women; 51 of these had graduated prior to 1979 before the midwife training was updated and extended from one to two years, and 87% of the sample worked in rural areas. Urban 15