often the sole financial, social, and emotional providers for their families. Segree clains the main health issues in Jamaica are: nutrition, fertility, infection, chronic diseases, and stress and social problems. These categories are used below as a framework to guide the discussion on wcen 's health.

# 3.1 ANEMIA

Anemia stands out as the most significant nutritional disorder impacting on maternal health. About 55% of all pregnant and lactating wcmen in Jamaica are currently believed to be anemic; the iron deficiencies are believed to be due to inadequate intake of necessary nutrients, 1ow le-vels of absorption, short birth intervals, and hiqh fertility (World Bank, 1987). In 1978, an island-wide survey found that 61.6% of pregnant women and 69.1% of preschool children had hemoglobin levels below llg/d1 2 (Simmns et al., 1982). Anemia deficiencies were more pronounced in women in the seoond or third trimester of pregnancy. There was not a significant difference between Trb&a and rural experiences; however, there were some parish variations which were attributed to dietary differences--wcmen in the areas with low incidence of anemia were more likely to have family goats and gardens and to grow vegetables, peas, and red kidney beans. The higher incidence areas are more likely to have farms of bananas, oranges and sugar cane. Jamaica has addressed the need for anemia prevention by implementing food fortifications (mainly of imported wheat), oral supplementation in prenatal clinics, educational units for health employees, and public health measures to enhance iron absorption such as parasite and safe-water controls (Simmans, 1980). Jamaica also has relatively high levels of endemic sickle cell anemia. Although this is a genetic condition and not a nutritional problem, sickle cell, like nutritional anemia, calls for special obstetric protocols includinq "aggressive" prenatal and delivery care and postpartbum monitoring for evidence of complications (Morrison, 1987). Sickle cell disease, coupled with pregnancy, creates a risk of sickle-cell crisis and the womran is more susceptible to infection, pregnancy-induced hypertension, and other oomplications. Sickle-cell disease is also associated with growth retardation of the fetus and "significant perinatal wastage" (Morrison, 1987). In an hospital outoome study of 664 pregnancies in 297 Jamaican women with hamozygous sickle cell disease between 1959 and 1984, the spontaneous abortion rate was 118/1,000 births, the stillbirth rate was 128/1,000 births, the perinatal mortality was 171/1,000 births and the maternal mortality was 1100/100,000 live births, all of these are significantly<sup>higher than levels</sup> in the general population (Poddar et al., 1986). The<sup>fetal and infant</sup> mortality experienYces in the sample increased with time indicatinq greater survival and pregnancy rates among the wamn with sickle<sup>cell</sup> disease and an increasing likelihood to abort as the womien grew older. The infants born to wcmen with sickle cell disease had lower birth weights (an average of 2,720 grams ccrpared to a hospital average of 3,110).

# 3.2 FERIILITY

2 A significant anemia during pregnancy is usually defined by a hemoglobin concentration less than lOg/dl. Significant<sup>anemia places the</sup> _<oman_ at greater risk of hemorrhage, infection, and death (Abrams, 1989).

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