8 GAPS THAT CAN BE FILTXD This section outlines the immediate progress Jamaica can make if it now applies what we knrow can be done for maternal health. This includes monitoring services so that what has already been planned is properly implemented, and adds to this a few revisions in service models to make them work more efficiently. The largest known groups of avoidable factors in maternal mortality for Jamaica are: (1) non-use of and deficiencies in prenatal care; (2) inadequacy in ensuring hospital delivery for wmn at high-risk; and (3) delays in taking action when signs of complication develcp before, during, and after pregnancy (Walker et al., 1986). This would indicate that a prenatal education and screening program with an emphasis on enrolling new participants could have a great effect. Indeed prenatal care could provide a number of services: wcmen could be warned of danger signals to watch for ard could be instructed in basic health maintenance behaviors including appropriate nutrition; those at risk could plan to deliver at a health facility with capacity for transfusions and surgery; and all women could be instructed to set up an emergency plan in case they have unexpected acmplications. The Walker report (1986) said however that much of the prenatal care that did occur was deficient and the blame for this was given to the midwives; referrals to hospitals were not made, standard tests not perfonred (substantiated in the Perinatal Study (Jamaica-M)H, 1989)), delays were apparent in starting drug therapy for pre-eclamptic wcmen and there were delays in doctors' response to calls for aid in hemorrhage cases. Pulmonary embolism deaths were largely the result of insufficient attention to warning signs. Before prenatnl care can have an effect then, it must be improved in context, which involv 3 in-service trainina of existing midwives and improving the supervi. ton of them while they are working (note: Domiciliary supervisors were introduced in 1983-84 but have not been effective (JamaicaMOH, 1987)). A study of the quality of infant care (Walker et al., 1988) and another on the quality of care for twelve tracer conditions (Walker & Wint, 1987), in Jamaica, also recommended that important improvements could be made at this time through the inplementation of quality assurance, revised education of doctors and nurses, and attention to the professional isolation of rural practitioners. These improvements work with the present system and would not require heavy investments in additional resources. The Ministry of Health already responded by agreeing to draw up new standards for care and criteria for referrals, to review blood transfusion provisions, and to provide a senior obstetrician to visit smaller hospitals and review practices there (Walker & Wint, 1987).

The gap between readily available family planning services and use of the services by target groups could also be filled though the means to achieving this may be elusive. The demand for sterilization, conversely, exceeds the demand; five-month waits are typical for public facilities. The tubal ligations are done, moreover, in hospitals under general anaesthesia which is more costly than on an outpatient basis (Folta, 1988).

# 9 DISCJSSION

This review was undertaken to locate questions which might be undertaken in future investigations of maternal health in Jamaica. The recent Perinatal Study undertaken by the Mminstry of Health adds much no this area of 19