studies in Jamaica are discussed in the section on Family Planning Services. Prior studies in other countries found that women dropped out of clinics because of transportation difficulties, pregnancy, poor service, characteristics of the particular method, preferring private physicians, or no longer needing birth control (Creedy & Polgar, 1963; Reynolds, 1970; Hall, 1969). The variables affecting continuation then, ccm in three classes 1) those describing the client, 2) those describing the social milieu, and 3) clinic and method characteristics (Bracken & Kasl, 1973).

7 EXISTING HEALITH SERVICES Jamaica has achieved levels of health close to those of developed countries despite the fact that in 1920 its level of health was similar to that of the poorest sub-Saharan countries today. The achievements have been attributed to basic public health measures, improved medical technology, increasing incomes, literacy, and public awareness of health matters, and the emergence of national cammitment on the part of health professionals (Cumper, 1983). The main gains in health were largely achieved in the period 1921 to 1945 when infectious diseases were brought under control and health manpower was expanded. Fran 1945 to 1970 infectious diseases declined and chronic diseases increased in importance while the quality and efficiency of medical services was enhanced. In this period, hospital deliveries rose to 60% of the total, a counter trend to the general movement towards decentralization of health care. The decade of the 1970s was marked by economic difficulties which limited the purchase power of Lhe health sector and witnessed its decreasing efficiency (Boyd, 1988; Cumper, 1983). High national debt, rising inflation and reductions in public health budget allocations were paralleled by evident declines in the quality of care (Leswis, 1989). Nonetheless, improvements continued in health indicators, perhaps due to more targeted efforts by government health services and the willingness of the public to purchase private medical care. Jamaica managed its improvements in health without serious dependence on external resources, without recourse to modern health technology, and in spite of worsening economic conditions (OCmper, 1983). The situation today is somewhat bleaker; the Jamaican Weekly Gleaner, reporting on the deterioration of the health care sector, claimed that levels of manpower are inadequate, rates of pay are low, resources are insufficient, and maintenance of equipment is so poor that the efficiency of services is rapidly declining (Anon, 1989). In 1987, on the 25th anniversary of independence and the 10th anniversary of a ccmmitment to primary health care, the Ministry of Health announced a reform program for the national health service which will boost primary health care (Dressekie, 1988). The Walker study on maternal mortality identified the stage-of-pregnancy at which women died; this helps determine how much of an effect improvements in any particular service might have. 15% of deaths were associated with abortion or ectopic pregnancies, 3% more died undelivered before the 28th week of pregnancy, 13% died before delivery of a potentially viable child, and a further 59% died after delivery of a potentially viable child. Only 4% of the deaths occurred more than 6 weeks after delivery or termination of pregnancy.

7.1 FAMILY PLANNING Voluntary agencies began introducing family planning services in Jamaica 12