Sm. Sci. Med. Vol. 35, No. 10, pp. 12251232, Printed in Great Britain. All rights reserved
1992 Copyright
TRANSFORMATIONS
IN MATERNITY JAMAICA
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021%9536192 $5.00 + 0.00 1992 Pergamon Press Ltd
SERVICES
IN
CAROLYN SARGENT’and JOAN RAWLINS~ ‘Department of Anthropology, Southern Methodist University, Dallas, TX 752754336, U.S.A. and %tstitute of Social and Economic Research, University of the West Indies, Kingston, Jamaica Abstract-Analysis of the current organization and delivery of maternity care in Jamaica profits not only from an assessment of recent health issues but from consideration of the development of maternity services over the past century. Historical analysis indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical care and to eliminate the lay midwife. However, while women increasingly patronize hospitals, the delivery of services has deteriorated, resulting in widespread client dissatisfaction. Economic contingencies have contributed to the decline in maternity services, but health personnel manifest the ideology prevalent throughout the colonial era equating social irresponsibility with health complications. The cultural construction of illegitimacy and maternity is shown to be a dimension of class relations having an impact on health policy throughout Jamaica’s history. Key words-reproduction,
Research
on the history
Caribbean, maternity care, medical history
of childbirth
practices
in
Europe, Great Britain, and the U.S.A. has documented the conversion of female-controlled community management of birth to male-controlled medical management [l-7]. Similarly, analyses of the management of birth in developing countries have also demonstrated increasing medicalization [8-lo]. However, many studies have shown the persistence of lay midwifery in the context of Third World medical systems allowing women to choose among such alternatives as home delivery assisted by a lay midwife, nurse-midwife assisted delivery at home or in hospital, or physician-supervised hospital delivery 18, 111. The Caribbean state of Jamaica represents an anomaly among Third World societies in that home delivery, attended by lay midwives, has almost disappeared in the urban setting [12]. However, while home delivery is no longer an option, serious stresses affect contemporary hospital-based maternity services in Jamaica [13], challenging the capacity of the system to serve low-income women. In order to trace the origins of the current pattern of maternity service use, this paper will present a historical analysis of the emergence of hospital-based maternity care in Kingston, the capital of Jamaica. With regard to delivery of health care in India, Jeffery [14] has observed that “. . . health services today . . . are conditioned in important ways by the legacy of health services established under British rule”. Similarly, the structure and organization of maternity services in Jamaica have been significantly influenced by health policy directives during colonial administration by Britain, and following independence in 1962. The paper will point out similarities between the development of maternity services in Jamaica and
those in England and the U.S., as well as indicate striking differences between the Jamaican maternity care system and that of other developing countries. In addition, a historical perspective on maternity care in Jamaica will demonstrate longstanding themes of class tensions between health policy-makers, health care providers, and clients of the health system. These tensions are evident in the following account illustrating the dissatisfaction of a group of lowincome pregnant women seeking prenatal care at Victoria Jubilee Hospital, the institution providing maternity services for low-income women in the corporate area of Kingston-St Andrew, and supervising approx. 25% of deliveries on the island. DISSATISFACTIONAT
VICTORIA
JUBILEE
In July 1988, 50 pregnant women demonstrated outside the offices of the Gleaner, the principal newspaper in Kingston. They hoped to publicize their dissatisfaction with the organization of prenatal care services at the Victoria Jubilee Maternity Hospital. The impetus for this spontaneous demonstration was the announcement to pregnant women waiting to register at the prenatal clinic that the hospital had no charts or forms on which to enter patient information and could therefore not process women for prenatal care at that time. Some women encountered this response on several visits to the hospital and delivered without registering, or ‘booking’, prior to delivery. Because of the difficulties in arranging bookings, many women obtained late prenatal care, or none at all. Women interviewed regarding the hospital during this period expressed antagonism toward hospital personnel and criticized prenatal care as well as labor and delivery services offered at Victoria Jubilee.
CAROLYN SARGENT and JOAN RAWLINS
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Nurses and nurse-midwives, on the other hand, complained of overwork, inadequate salary, lack of supplies, and client attitudes [13]. Analysis of the factors leading up to this demonstration indicates that Victoria Jubilee Hospital has experienced increasing overcrowding, shortage of supplies and staff shortages resulting in alienation of nurse-midwives and dissatisfaction among clients [ 151. In large, these severe problems reflect an almost total absence of maternity care alternatives for low-income urban women. This paper traces developments in the establishment of hospital-based maternity care that help to explain the current dilemma. The analysis will focus on four key phases in the development of public maternity services on the island: (1) the establishment of institutional maternity care in the early 1900s; (2) the expansion of prenatal services and hospital delivery services subsequent to the Royal West Indies Commission Report of 1938; (3) the proposal for national comprehensive health care in the context of Democratic Socialism in the 1970s; and (4) the reorganization or rationalization of health services during the 1980s. Retrospective assessment of maternity care in Jamaica indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical services, primarily nurse-midwives, and to eliminate reliance on the lay midwife or nana [16]. This paper attempts to trace the growth of institutional obstetrics and the decline of lay midwifery, using historical and contemporary records to document these processes. Sources employed for this discussion include material from the government archives in the Institute of Jamaica, data from the records of Victoria Jubilee Hospital, and University of the West Indies library holdings, as well as interviews with nurse-midwives and with women using Kingston prenatal clinics [171. THE ORIGINS
OF INSTITUTIONAL
MATERNITY
CARE
The years 1867-1897 represented a period of development of public health laws and regulations in the wake of cholera and smallpox epidemics in 1850, 1861, and 1874 [18, 191 and the foundation of island medical services emerged in this era. Jamaica, at this time, was a British colony, featuring plantation production of sugar, primarily using African slave labor. According to Roberts, Jamaican maternity care during the 18th and 19th centuries was extensively managed by the ‘grandy’, or nana, a woman who cared for women in pregnancy and at delivery and also provided child health care [19, p. 2391. Prior to emancipation in 1834, plantations had included a minimal range of medical services [18, p. 71 and the nana served as the primary health resource for reproductive complaints and maternity care [19]. Prior to the late 18th century, neither the administration nor plantation owners emphasized a self-reproducing slave population, preferring to import new cohorts of
adult slaves. However, from the early 19th century, the decline in the slave trade led to enhanced interest among Jamaican planters in slave reproduction. It might well be that the role of the nana increased in importance during this period [20]. In a discussion of reproduction and health status among slave populations, Roberts reports descriptions of reductions in work loads for pregnant women on the estates. He also notes that “about 14 days before delivery they were sent to a woman operating a midwifery establishment” [19, p. 2391. His data suggest that the lay midwife held a respected role on the plantation, in contributing to the wellbeing of slave women of reproductive age. By the turn of the century, however, emergent government health policy took the position that the care provided by these midwives was of dubious competence. The Handbook of Jamaica from 1894 states that “it was felt by those best able to judge that great hardship and a large mortality resulted from want of midwives who could undertake even the most simple care of labor” [21]. Accordingly, the Victoria Jubilee Lying-In Hospital was established in 1894 with 12 beds, to commemorate Queen Victoria’s Jubilee [21]. This institution was initially intended to serve the needs of elite women [22] while lay midwives continued to attend most births. These developments in Jamaica paralleled the evolution of maternity care in Britain. The 19th century in England witnessed the establishment of lying-in hospitals, the recognition of obstetrics as a medical specialty, and the growing control of birth by male doctors [4, p. 1381. Correspondingly, female midwives came to serve primarily the poorest women, while middle and upper-class women increasingly relied on the services of male physicians [23, p. 1711. By the late 19th century, trained hospital midwives, supervised by physicians, staffed English lying-in hospitals [4, p. 1581. To provide a source of certified midwives in Jamaica hospitals, Victoria Jubilee provided a midwifery training program for “respectable women of good character and strong constitution” [24]. Women desiring to be trained as midwives received instruction leading to a certificate in midwifery. The colonial government showed increasing concern with maternal health as is evident in the Midwifery Law of 1919 providing for the registration of midwives and establishing criteria for qualification, however, only a minority of midwives trained in the hospital program. Others apprenticed under private physicians while the majority of midwives in practice were the nanas, trained by apprenticeship to other midwives [25]. In general, public health policy throughout the 19th and early 20th century was oriented to the containment of epidemic diseases such as cholera and smallpox [18, p. 81; concern with control of epidemic disease led to the organization of the central and local Parochial Boards of Health. However, the increasingly centralized organization of island-wide public
Transformations
in maternity
health services and regulations did not appear to extend to maternal and child health. Policy statements in this domain reflect a concern with the incompetence of the lay midwife [21, p. 61 and periodically address the inadequacies of the ‘female wards’ of Kingston Public Hospital, described in one report as being “as wretched an apology for a Hospital as can be well conceived” with a “death rate. . . more than double what it has been in the Male Hospital” [26, pp. 8-91. Subsequent to the construction of Victoria Jubilee Hospital, annual reports indicate less concern with the hospital facility and its impact on mortality and morbidity than with the perceived relationship between mortality and the social attributes of the population. In this regard, the Annual Report of Kingston Public Hospital for 1902 discusses high infant mortality rates with reference to “the violation of moral laws” by the female sex [27, p. 81 stating that Examination of the statistics has hitherto shown that in those districts where the highest infant death rate obtains, there also has the highest illegitimate rate been registered, pointing to the conclusion that in the presence of unsatisfactory birth surroundings the maternal parent is either indifferent or unequal to the fulfillment of those duties so essential to the life of the offspring. The report also suggests that education for women regarding the moral perils of illegitimacy would contribute to a reduction in infant mortality [28].
EXPANSION
OF HOSPITAL
OBSTETRICS
The period 1921-1950 represents a phase of increasingly effective control over a wide range of epidemic and endemic diseases as well as a substantial decline in infant and child mortality, from 192 deaths per 1000 live births in the period 1906-1910 to 85.5 deaths per 1000 live births in the period 19461950 [20, pp. 185-l 871. Roberts presents data indicating that mortality among illegitimate children “is manifestly higher than the legitimate at all times. . . and has obviously widened considerably within recent years” [20, p. 1891. The discrepancy, which exists for both sexes, is lowest for neonatal mortality, suggesting that obstetrical practices are less likely to be implicated in this mortality difference than environmental factors. Unlike the colonial medical reports, however, Roberts’ association of environment and disease implicates features of poverty such as poor sanitation, unemployment, and malnutrition rather than moral status and social irresponsibility as determinants of mortality [29]. With regard to females of childbearing age, the period 1921-1946 registered lesser mortality declines than for males, although declines for females after 1946 were marked largely in response to increased availability of prenatal services, as we will discuss below [19, p. 200, 5, p. 11.
services in Jamaica
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In analyzing maternal health policy in this phase it appears that a gradual increase in reliance on hospital delivery as well as on home deliveries assisted by public health nurses or certified midwives occurred. In 1936, seven district public health nurses under the supervision of district medical officers assumed responsibility for providing some prenatal care services throughout the island. Following the recommendation of the secretary general of the British Social Council in 1935 that prenatal clinics be provided in all hospitals and clinics [3O,p. lo], in 1938 the Midwifery Service was reorganized and expanded to include “maternal and infant hygiene and health education” [31, p. 10, 321. The Moyne Commission Report of the West Indies Royal Commission, established in 1938 to investigate conditions generating labor unrest throughout the region, provides a review of policy concerns regarding maternal and child health issues during this period. The Commission in its report on public health generally emphasized the need to develop preventive health services and for immediate progress in maternal and child welfare [33, pp. 1541561. The recommendations were made in the context of a high rate of unemployment and a decline in food crops in relation to export crops; these conditions were associated with an increase in malnutrition and in the incidence of endemic and deficiency diseases [34, p. 4501. The Commission’s emphasis on maternal and child welfare arose in response to high infant and child mortality rates (137 deaths per 1000 live births, and 33% of deaths occurring among children under five) [34, p. 4541. In its discussion of maternal and child health, the Commission report echoes the theme of the 1902 Annual Report of Kingston Public Hospital, deploring high infant mortality and implicating large families, illegitimacy, and lack of parental responsibility as the causes of infant mortality and morbidity [27, p. 1541. However, the Commission does not specifically address maternity care except to comment that the maternal mortality rate in Jamaica was lower than in most tropical countries [33, p. 1301 and to urge that improved midwifery training be developed throughout the West Indies. Carley, in a report on the development of medical services in Jamaica, offers a more precise insight into the position of the nana and the growth of hospital maternity facilities in the period 1930-1940. She states: Maternity work is another branch of medical work receiving much more attention in recent years, in an endeavour to supersede the ‘Mother Gamps’ or inefficient private midwives of Jamaica. By 1938, 10 hospitals outside Kingston had special maternity wards. To these can be added two more which will be available at the Port Antonio and Spalding hospitals. A large increase in accommodations has been made at the Jubilee Maternity Hospital, the daily average number of patients having increased from 22 in 1921 to 150 in 1939 [18,p. 121.
1228
CAROLYN
SARGENT~~~ JOANRAWLINS
The effort to eradicate indigenous midwifery was furthered by the establishment in 1949 of a government administrative domiciliary midwifery service, which extended the duties of the public health nurse to include birth attendance. In his observations on maternal mortality in Jamaica, Williams notes that maternal mortality rates reflect the standard of obstetrical care available to a population [21, p. 11.Assessing the transformation in maternity care since the establishment of Victoria Jubilee Maternity Hospital in 1894, he remarks on a 60% decline in maternal mortality between 1938 and 1960. He relates this decline both to improved and more accessible prenatal care as well as to an increase in hospital delivery; thus he points to the highest maternal mortality in the parishes of Portland and Hanover, where home births were most common. In contrast, the lowest maternal mortality rates were in Kingston, which had the lowest rate of home delivery. It is clear that Jubilee Hospital played a critical role in hospital delivery; by 1955, 64% of live births in Kingston and St Andrew and 22% of live births in the country occurred at this hospital; these figures also indicate the increasing popularity of hospital, rather than home delivery. The hospital also had a special ‘abortion ward’ and had moved from its initial clientele of elite women to a broader constituency. A 1950 report of the Medical Services of Jamaica indicated that prenatal clinics were now held regularly though the island and at Jubilee Hospital; Jubilee had attracted a growing number of rural admissions leading to “a decided increase in the number of deliveries of babies” at Victoria Jubilee Hospital [35, p. 51. There was a corresponding increase in home deliveries assisted by District Midwives rather than by indigenous midwives. While District Midwives attended 7121 home deliveries in 1950, they attended 10,686 deliveries only 2 yr later and 12,477 deliveries by 1956 [35, p. lo]. Island-wide, home deliveries assisted by District Midwives ranged from 18.7% in the parish of St Elizabeth to 56.7% in Trelawny. However, a cautionary remark in the Medical Report for 1955 notes a tendency for women to attend a prenatal clinic at Jubilee but to deliver elsewhere [36, p. 271. This same report documented excessive overcrowding at Jubilee leading to early discharges of mothers and babies and subsequent complications such as cord infections associated with ‘home remedies’ employed to dress the cord. The following year the Medical Report described ‘formidable problems’ at Jubilee including lack of accommodation for abnormal cases and fluctuation in the number and experience of medical staff but applauded the increasing popularity of prenatal clinics [37, p. 281. The ‘severe and increasing problems’ were attributed to the growing practice of rural patients delivering at Jubilee by claiming to reside in Kingston, thus indicating the growing appeal of hospital birth [37, p. 291.
By 1969, Williams urged rethinking of the need for a home delivery service, due to the widespread acceptance of hospital obstetrics: domiciliary midwifery is both uneconomical in time and effort and unpopular with our patients. It is not only idle but cruel to suggest that a woman be confined in an overcrowded and unsanitary environment. What is needed is small inexpensive units with a resident midwife.
In spite of policy critiquing lay midwifery and emphasizing hospital delivery or at a minimum ‘trained and certified’ midwives to serve as home birth attendants, information on lay midwifery is surprisingly scant. Williams [21, p. 141states that in 1964 midwives were responsible for 68% of deliveries in the country and ‘unqualified attendants’ for 26%; he adds that the role which the unqualified attendant or nana plays in Jamaican midwifery is uncertain. Also uncertain is how much she contributed to maternal morbidity and mortality; while it is gratifying to note the gradual increase in deliveries by midwives and a corresponding gradual decrease in deliveries by unqualified attendants: it will be several years before the unqualified attendant is eliminated. Although an Advisory Council to the Minister of Health recommended an interim program for training and supervision of ‘unqualified’ attendants, until such time as all deliveries could be attended by personnel meeting government standards, this project never materialized. In addition to financial constraints, nurse midwives pressured the Ministry to refrain from implementing programs to train the nanas [29]. By 1962, then, urban residents routinely delivered in hospital and domiciliary midwifery was in decline. Home deliveries, when they occurred, were likely to be attended by district nurse midwives, and govemment policy worked explicitly to decrease the role of lay midwives. In comparison, home delivery was comparatively rare in the U.S. by this time; in England during this period, domiciliary midwifery was also in decline [4, p. 2491, the home delivery rate having dropped to 35.4% by 1957 [4, p. 2501. Only one category of midwife, licensed and regulated by government statute, assisted at hospital or home deliveries in England; physician assisted births had supplanted female midwifery in the U.S. POST INDEPENDENCE
MATERNITY
CARE IN JAMAICA
Jamaica’s independence in 1962 generated a reorganization of medical services in which national staff took on policy making responsibility [38, pp. 451. The Five Year Independence Plan (196331968) emphasized public health efforts such as clinical immunization and clean water supplies but did not diverge dramatically from previous policy regarding the practice of midwifery. At this time, 40.6% of deliveries occurred in hospitals or clinics; in 1964, registered midwives attended 68% of births while 26% of deliveries were attended by a nana or ‘unqualified personnel’ [21, p. 131.
Transformations
in maternity services in Jamaica
With regard to Kingston maternity services, continuing reports of problems plaguing Jubilee hospital emerged in relation to the expanding clientele. For example, Kitzinger [9, p. 197, conducting research in 1965 describes obstacles confronting hospital nurses, midwives and clients: Between 35 and 40 women were delivered in each of two eight-bedded delivery rooms every 24 hr. Equipment was
1229
to the establishment of this paraprofessional category of personnel, the government proposed to increase the number of district midwives and to involve these personnel in the training and supervision of traditional birth attendants [39, p. 1121. However, this proposal suffered the fate of previous plans to involve the nanas in the national health system as the plan was never implemented.
always in short supply and was not reordered until it had
run out. Sterilization of swabs took 48 hr. There was no hot water after early morning, no isolation ward and no means of effectively communicating up the staff hierarchy. Kitzinger [9, p. 1971 reports overt conflicts between staff and laboring women over expectations for behavior during delivery, as “doctors and nurses are engaged in a struggle to acquire and maintain control over their patients”. In the ongoing effort to move from home delivery to viable institutional maternity care, significant efforts at transforming the health service occurred in the proposal by the People’s Nationalist Party government under the leadership of Michael Manley in 1974 for comprehensive health care in the context of Democratic Socialism. It is beyond the scope of this paper to assess in its entirety Manley’s health scheme. Rather, we note specific elements of the health program: (1) more emphasis on family planning within maternal and child health services; (2) a shift from construction of large public general hospitals to local health centers and clinics; (3) mandatory health insurance; (4) requirements for medical graduates to work in rural health care centers [39, pp. 81-831. Following upon this initial set of policy proposals, the National Health Plan of Jamaica for 1978-1983 selected as a high priority total maternal and child health care coverage focusing on pregnancy, childbirth, and early childhood health concerns such as gastroenteritis and malnutrition [40, p. 1061. To meet the objectives of the comprehensive health plan, efforts were made to restructure health care delivery to extend primary coverage throughout the population. That restructuring proposed four categories of clinic differing in size, service, category of staff and target population. The Type I clinic was to provide a district midwife, health aides and a custodian, and offer prenatal, postnatal and child health clinics; among the duties of the district midwife was attendance at home deliveries. Following the model of the Barefoot Doctors of People’s Republic of China, the Plan proposed a category of Community Health Aides, or primary health workers to provide a link between the community and the health system. With regard to maternal and child health, these aides were to offer basic care in the home and advice regarding such concerns as prenatal care, nutrition and family planning, as well as to screen and refer complicated cases. In addition
CONTEMPORARY MATERNITY SERVICES
A consideration of maternity services in the 1980s contributes to an assessment of the extent to which the Manley National Health Plan generated enduring changes in the delivery of midwifery services to Jamaican women, especially those residing in Kingston and St Andrew. Government reports assessing the health care system throughout the 1980s reflect a concern with shortage of personnel in all categories-nurses, physicians, and midwives: the 1980 Economic and Social Survey noted that in the context of political strife between supporters of the People’s Nationalist Party and the Jamaica Labor Party “the delivery of health services especially in the Kingston metropolitan area was made more difficult. . by high levels of violence and industrial action. . . economic instability, and a shortage of health staff’ [41, p. 16.11. Attendance at health facilities such as prenatal clinics also declined during this period [41, p. 16.81 and the Victoria Jubilee Hospital experienced a critical shortage of nurses. Similarly, from 1984-1986, prenatal and family planning visits declined so that the average number of prenatal visits per pregnant woman was 2.5 in 1984 and 1.7 by 1986. In the period 1984-1986, under the leadership of Edward Seaga and the Jamaica Labor Party, health policy focused on “rationalization and alternate financing to insure more cost efficient and effective delivery of health care services” [42, p. 20.11 with rationalization defined as reduction of hospital beds, regionalization of specialist services, and improvement of quality of care. Pregnant women throughout the island relied heavily on hospital midwifery services: while approx 20% of births occurred in institutions in 1950, by 1985 77% of deliveries were in hospitals [12, p. 1901. Certain rural parishes such as Trelawny, St Elizabeth, Clarendon and Westmoreland continued to show the highest rate of home deliveries assisted by a nana. By 1987 the Ministry of Health reported that 21.5% of deliveries in rural areas occurred at home while c 5 % of Kingston births were home deliveries. However, a closer examination of maternity care in Table I. Birth assistance in 1985 Type of assistance
%
Public hospital birth/Kingston Public hospital birth/island Domiciliary births/certified midwife ‘Unqualified attendants’ Private hospital
85 71 I3 10 6
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CAROLYN SARGENT and JOAN RAWLINS
Kingston indicated that at the Victoria Jubilee Hospital, where 25% of all deliveries in Jamaica occur, 65% of deliveries were unattended; in other words, women selecting to give birth in the hospital delivered without attendance of a midwife or physician [42]. This situation reflects an economic context in which budget reductions for both recurrent and capita1 expenditures exacerbated problems in health service delivery. In a review of the Jamaican economy during this period, Boyd [43, p. 1221 states that the total expenditure by the government for health care fell from J$70.00 per person in 1981 to JS47.00 per person in 1985. The decline in government expenditure “coincided with significantly poorer personal service as patients frequently had to take their own linen and in some cases food, as hospital supplies became increasingly unreliable and poor. This was in addition to the increasing difficulty of obtaining treatment”. CONCLUSION We then return to our opening discussion concerning the dissatisfaction of pregnant women attempting to obtain prenatal care at Jubilee. A historical perspective on the development of maternity services in Jamaica has indicated the evolution of the current crisis. Colonial policy consistently worked towards the abolition of the lay midwife, the mainstay of rural maternity care from the 19th century. A comparison of the development of maternity services in Jamaica, England and the U.S.A. suggests a similar move from female, midwife-assisted home delivery, to medicalized, hospital births. While midwifery has been largely eradicated in the U.S. (although experiencing a revival), England has retained state certified midwives to serve primarily as assistants at hospital births. Similarly, in Jamaica, certified midwives continue to staff public maternity hospitals but have ceased to perform an urban domiciliary function. In spite of intermittent policy statements proposing training programs for lay midwives in Jamaica to enable them to provide an additional alternative for birth assistance, these efforts never materialized. In this regard, Jamaica contrasts markedly with other former colonies in the Third World where a more laissez-faire attitude prevailed with regard to midwifery and where independence has been accompanied by a resurrection and glorification of indigenous medicine in the context of nationalism. A number of sub-Saharan African states, for example, have established training sessions for lay midwives as well as for herbalists and other categories of healers in efforts to integrate indigenous medicine with national health systems [44]. While the colonial period in Africa did witness measures to eradicate dimensions of indigenous medicine-for example the Witchcraft Suppression Act of 1899 in Northern Rhodesia-in the post-independence period, indigenous healers have generally retained legitimacy. In some cases the state has legally recognized such
healers [44, p. 351 and associations of healers have emerged. In contrast, the nationalist movement in Jamaica did not glorify this dimension of African tradition; as Lewis [45, p. 1781 points out “it is impossible to restore a. . . continuity violently broken for more than two hundred years”. Similarly, with regard to Jamaican perspectives on indigenous medicine, Kitzinger [9, p. 1891 noted that “for many members of the Jamaican middle class, nanas are evil old busybodies who kill almost as many as they help and who are opposed to every benefit conferred on Jamaica by science and medicine, embarrassing symbols of customs associated with slavery and subjugation”. Further, the decline of lay midwifery was hastened by the establishment of hospital-based midwifery services as well as by the involvement of public health nurses in domiciliary midwifery in rural Jamaica. While Jamaican women increasingly give birth in hospitals, the delivery of services has deteriorated. The demonstration of pregnant women at the Gleaner Newspaper offices indicates the intensification of dissatisfaction with contemporary maternity care. These women articulated the views of many other low-income women in Kingston, discussing their antagonism towards hospital midwives, to whom they attributed responsibility for the inadequate service. They also protested the unsanitary conditions at Jubilee, as well as lack of bed linen, inedible food and staff indifference. Many women had delivered at Jubilee unattended by a midwife, a situation they attributed to ‘rude’ personnel but which midwives themselves explained in terms of staffing shortages. While broader economic contingencies have indeed contributed to a deterioration in maternity services, we see in the orientation of hospital personnel the theme explicit among the colonial elite equating poverty, immorality, and ill health. Thus midwives, though cognizant of organizational problems affecting the hospital, attribute to women social irresponsibility leading to ill advised pregnancy and health complications. This cultural construction of illegitimacy and maternity manifest in colonial documents and in contemporary medical practice is a dimension of class relations that has had an impact on health policy and on delivery of maternity services in Jamaica throughout its history. Thus while analyses of the transformation in maternity care in England and the U.S. have emphasized the relegation of midwifery to a “secondary status health profession” [l, p. 13, 5, p. 51, in Jamaica an additional issue is the secondary status of the public hospital in the national health system, as well as class-based tensions between doctors, hospital midwives, and their clients [46]. Yet in spite of the prevalence of unassisted births in hospital, urban women did not favor home deliveries. As one woman explained “You could die if you stayed home”. From the client perspective, then, we see the perception that home delivery is no longer a
Transformations
in maternity services in Jamaica
viable option. As in Europe and the U.S., women have come to view birth as requiring medical supervi-
sion, preferably in a hospital setting [5, pp. 133, 1531. For working class and indigent women, however, structural problems facing the primary public maternity hospital in Kingston have reduced its viability as an alternative to home delivery whether assisted by a certified or indigenous midwife.
14.
Acknowledgement-We
15.
are grateful to Dennis Cordell, Department of History, Southern Methodist University, for his assistance with data analysis.
16. REFERENCES
1. Ehrenreich B. and English D. Witches, Midwives, and Nurses. A History of Women Healers. The Feminist Press, Old Westbury, New York, 1973. Oakley A. Women Confined. Towards a Sociology of Child&b. Schocken Books, New York, 1980. _- _ Michaelson K. L. (Ed.) Childbirth in America. Berain and Garvey, South‘Hadley, MA, 1988. Towler J. and Bramall J. Midwives in History and Society. Croom Helm, London, 1986. Wertz R. W. and Wertz D. C. Lying-In. A History of Childbirth in America. The Free Press, New York, 1977. 6. Rothman B. K. Awake and aware, or false consciousness: the cooption of childbirth reform in America. In Childbirth: Alternatives to Medical Control (Edited by Romalis S.), pp. 150-181. University of Texas Press, Austin, 1981. 7. Romalis S. Overview. In Childbirth: Alternatives to Medical Control (Edited by Romalis S.), pp. 3-33. University of Texas Press, Austin, 1981. 8. Sargent C. Maternity, Medicine and Power. University of California Press, Berkeley, 1989. 9. Kitzinger S. The social context of birth: some comparisons between childbirth in Jamaica and Britain. In Ethnography of Fertility and Birfh (Edited by MacCormack C.), pp. 181-205. Academic Press, New York, 1982. 10. Cosminsky S. Childbirth and change: A Guatemalan study. In Ethnography of Fertility and Birth (Edited by MacCormack C.), pp. 2055231. Academic Press, New York, 1982. 11. Kay M. (Ed.) Anthropology of Human Birth. Davis, Philadelphia, 1982. 12. Samuels A. Health sector review. Ministry of Health, Kingston, 1987. 13. Rawlins J. and Sargent C. Factors influencing prenatal care use among low-income Jamaican women. International Center for Research on Women Report No. 14, Washington, D.C., 1990. More detailed analyses of these data will be presented in forthcoming publications such as [15]. Briefly, we summarize that research involving 125 women attending prenatal clinic and 100 postnatal patients at Victoria Jubilee Hospital has elicited opinions regarding care received at the Hospital. In addition, 50 women have been interviewed in a lowincome Kingston neighborhood, regarding health care experiences. Approximately 25% of the prenatal patients interviewed expressed some negative comment in direct response to questionnaire items eliciting information on trust in midwife, and concerns about labor, delivery or hospital. However, 25 community women interviewed both with structured and unstructured interview schedules were uniformly negative in their retrospective histories of prenatal and delivery experiences at VJH. These women reported incidents such as being yelled at or “handled rough” by nurses, delivering
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18. 19. 20.
21. 22. 23. 24. 25.
26.
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unattended, and complained of hospital shortages in such supplies as bedsheets, cutlery, dishes, and appropriate food. Clinic patients when asked explicitly if they had heard such reports indicated they had, and often had similar experiences but did not translate these observations into a negative comment on staff or hospital. Reluctance to do so may be a product of the interview setting, given the widespread critiques of the hospital in mo& informal circumstances. _ Jefferv R. The Politics of Health in India. D. 20. University of California Press: Berkeley, 1988.’_ Sargent C. and Rawlins J. Factors influencing prenatal care among Jamaican women. Human Organ. 50(2), 179-188. The World Health Organization has suggested use of the term ‘Traditional Birth Attendant’ to avoid confusion with biomedically trained nurse-midwives. Here the term lay midwife or the local term nana will be used for those trained by apprenticeship, and nurse-midwife will refer to those midwives who are government certified and employed in the hospital system. The research presented here was financed by the International Center for Research on Women through Cooperative Agreement No. DAN-lOlO-A-O&-70614 with the Office-of Nutrition and Health of the U.S. Agency for International Development, and by the National Science Foundation. BNS-8703627. Carey M. M. Medical Services in Jamaica. Institute of Jamaica, Kingston, 1943. Roberts G. W. The Population of Jamaica. The Conservation Foundation, University Press, Cambridge, 1957. It would be interesting to assess the transformation of lay midwifery over the past century; however, there seem to be very few detailed descriptions of the nana’s work. Possible changes in midwifery practice are suggested in research by Kitzinger, who interviewed a number of nanas in the 1960s; several had daughters studying to be certified midwives in England. The nanas studied their daughters’ midwifery texts to update their practice [9, pp. 103-1051. The nanas observed by Kitzinger customarily advised on prenatal care (diet, massage), provided delivery and postpartum assistance, infant care, and emotional support, resulting in “a prototype of family and home-centered maternity care” [9, p. 1071. Older Kingston women interviewed in Sargent’s research [15, 17] report that few urban women recall or practice prenatal and postpartum ritual observances such as those described by Kitzinger’s informants, and mentioned in Carol MacCormack and Alizon Draper’s Social and cognitive aspects of female sexuality in Jamaica. In The Cultural Construction of Sexuality (Edited by Pat Caplan), pp. 143-165. Tavistack, London, 1987. Williams L. L. Some observations on maternalmortality in Jamaica. West Ind. Med. J. 22, l-14, 1973. Matron C. Stuart Victoria Jubilee Hospital, pers. commun. Leavitt J. W. Brought lo Bed. Childbearing in America. Oxford Universitv Press. New York, 1986. Dann N. History-of Victoria Jubilee.Hospital or Lying in Hospital, Kingston, Jamaica. Inservice Education, Victoria Jubilee Hospital, 1974. Towler and Bramall present a detailed history of midwifery in England including statutory acts regulating the practice of midwifery, training alternatives for midwives during the 19th and 20th centuries, and tracing the decline of domiciliary midwifery. While no available texts explicitly link the growth of hospital-based midwifery in England with the development of maternity care in Jamaica, many parallels are evident. Anonymous. The report of the ordinary and resident medical officers and the annual report of the inspector
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27. 28.
29. 30.
31.
32.
33. 34. 35.
36.
37.
CAROLYNSARGENTand JOAN RAWLINS
and director of the public hospital for 1864. Levy, Kingston, Jamaica, 1865. Anonymous. Annual report, Kingston Public Hospital, Kingston, 1902. Similarly, in the late 19th century in the U. S., doctors and patrons urged impoverished young girls to deliver in hospitals, wishing to rescue them from “degenerating into depravity” [S, p. 1331; Towler and Bramall also address the role of maternity hospitals in 18th century England, as a response to the needs of women in circumstances of distress, in industrial towns (p. 128). Roberts G. Personal communication, September, 1988. Wedderburn C. C. The development of public health in Jamaica. Unpublished report, Department of Social and Preventive Medicine, University of the West Indies. Diggory H. J. P. The history of public health in the Carribean. Unpublished report, Department of Social and Preventive Medicine, University of the West Indies. Prenatal care in England drew greater clinic attendance subsequent to the Maternal and Child Welfare Act of 1918, but was not widely recognized as necessary until the 1930s [25, pp. 200,224]; thus the attention of the British Social Council in Jamaica to the need for prenatal care paralleled the growing legitimacy of prenatal care in England. West India Royal Commission report. Her Majesty’s Stationary Office, London, 1945. Williams E. From Columbus to Castro. The History of the Caribbean 1492-1969. Deutsch, U.K., 1970. Medical department. Report of the medical services of Jamaica and its dependencies for 1950. The Medical Department, Kingston, 1950. Ministry of health. Report of the medical services of Jamaica and its dependencies for 1950. Ministry of Health, Kingston, 1955. Ministry of health. Report of the medical services of Jamaica and its dependencies for 1956. Ministry of Health, Kingston, 1956.
38. Standard Sir K. Development of Public Health in the Commonwealth Caribbean. Department of Social and Preventive Medicine. Universitv of the West Indies. Kingston, 1973. 39. Barrett I. R. The delivery of health care in Jamaica and its implications for public policy. MSc. thesis, Department of Government, University of the West Indies, 1979. 40. Economic and Social Survey Jamaica. National Planning Agency, Kingston, 1981. 41. Planning Institure of Jamaica. Economic and Social Suruey Jamaica. Planning Institute of Jamaica, Kingston, 1987. and morbidity 42. Ministry of health. Perinatal mortality survey. Report of the preliminary findings. Ministry of Health, University of the West Indies, Kingston, 1987. 43. Boyd D. A. C. Economic Management, Income, Distribution, and Poverty in Jamaica. Praeger, New York, 1988. 44. Last M. and Chavunduka G. L. (Eds) The Professionalisation of African Medicine. Manchester University Press, Manchester, 1986. 45. Lewis G. R. The Growth of the Modern West Indies. Monthly Review Press, New York, 1968. has been described as having problems of 46. Jamaica economic development and social injustice which include a rigid class system, extremes of wealth and poverty, and a deteriorating economy dominated by bauxite and sugar. Correspondingly, the health care system is characterized by a maldistribution of services favoring the urban elite, as well as by inadequate financing and infrastructure for facilities targeting low income populations (see, for example, Manley M., Jamaica. Struggle in the Periphery, pp. 5, 49-50. Third World Media Limited, Oxford, 1982; Bolles L. A. Kitchens hit by priorities: employed working-class Jamaican women confront the IMF. In Women, Men and the Infernational Division of Labor (Edited by Nash J. and Fernandez-Kelly M. P.), p. 139. State University of New York Press, Albany, 1983.
1992 Copyright
TRANSFORMATIONS
IN MATERNITY JAMAICA
0
021%9536192 $5.00 + 0.00 1992 Pergamon Press Ltd
SERVICES
IN
CAROLYN SARGENT’and JOAN RAWLINS~ ‘Department of Anthropology, Southern Methodist University, Dallas, TX 752754336, U.S.A. and %tstitute of Social and Economic Research, University of the West Indies, Kingston, Jamaica Abstract-Analysis of the current organization and delivery of maternity care in Jamaica profits not only from an assessment of recent health issues but from consideration of the development of maternity services over the past century. Historical analysis indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical care and to eliminate the lay midwife. However, while women increasingly patronize hospitals, the delivery of services has deteriorated, resulting in widespread client dissatisfaction. Economic contingencies have contributed to the decline in maternity services, but health personnel manifest the ideology prevalent throughout the colonial era equating social irresponsibility with health complications. The cultural construction of illegitimacy and maternity is shown to be a dimension of class relations having an impact on health policy throughout Jamaica’s history. Key words-reproduction,
Research
on the history
Caribbean, maternity care, medical history
of childbirth
practices
in
Europe, Great Britain, and the U.S.A. has documented the conversion of female-controlled community management of birth to male-controlled medical management [l-7]. Similarly, analyses of the management of birth in developing countries have also demonstrated increasing medicalization [8-lo]. However, many studies have shown the persistence of lay midwifery in the context of Third World medical systems allowing women to choose among such alternatives as home delivery assisted by a lay midwife, nurse-midwife assisted delivery at home or in hospital, or physician-supervised hospital delivery 18, 111. The Caribbean state of Jamaica represents an anomaly among Third World societies in that home delivery, attended by lay midwives, has almost disappeared in the urban setting [12]. However, while home delivery is no longer an option, serious stresses affect contemporary hospital-based maternity services in Jamaica [13], challenging the capacity of the system to serve low-income women. In order to trace the origins of the current pattern of maternity service use, this paper will present a historical analysis of the emergence of hospital-based maternity care in Kingston, the capital of Jamaica. With regard to delivery of health care in India, Jeffery [14] has observed that “. . . health services today . . . are conditioned in important ways by the legacy of health services established under British rule”. Similarly, the structure and organization of maternity services in Jamaica have been significantly influenced by health policy directives during colonial administration by Britain, and following independence in 1962. The paper will point out similarities between the development of maternity services in Jamaica and
those in England and the U.S., as well as indicate striking differences between the Jamaican maternity care system and that of other developing countries. In addition, a historical perspective on maternity care in Jamaica will demonstrate longstanding themes of class tensions between health policy-makers, health care providers, and clients of the health system. These tensions are evident in the following account illustrating the dissatisfaction of a group of lowincome pregnant women seeking prenatal care at Victoria Jubilee Hospital, the institution providing maternity services for low-income women in the corporate area of Kingston-St Andrew, and supervising approx. 25% of deliveries on the island. DISSATISFACTIONAT
VICTORIA
JUBILEE
In July 1988, 50 pregnant women demonstrated outside the offices of the Gleaner, the principal newspaper in Kingston. They hoped to publicize their dissatisfaction with the organization of prenatal care services at the Victoria Jubilee Maternity Hospital. The impetus for this spontaneous demonstration was the announcement to pregnant women waiting to register at the prenatal clinic that the hospital had no charts or forms on which to enter patient information and could therefore not process women for prenatal care at that time. Some women encountered this response on several visits to the hospital and delivered without registering, or ‘booking’, prior to delivery. Because of the difficulties in arranging bookings, many women obtained late prenatal care, or none at all. Women interviewed regarding the hospital during this period expressed antagonism toward hospital personnel and criticized prenatal care as well as labor and delivery services offered at Victoria Jubilee.
CAROLYN SARGENT and JOAN RAWLINS
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Nurses and nurse-midwives, on the other hand, complained of overwork, inadequate salary, lack of supplies, and client attitudes [13]. Analysis of the factors leading up to this demonstration indicates that Victoria Jubilee Hospital has experienced increasing overcrowding, shortage of supplies and staff shortages resulting in alienation of nurse-midwives and dissatisfaction among clients [ 151. In large, these severe problems reflect an almost total absence of maternity care alternatives for low-income urban women. This paper traces developments in the establishment of hospital-based maternity care that help to explain the current dilemma. The analysis will focus on four key phases in the development of public maternity services on the island: (1) the establishment of institutional maternity care in the early 1900s; (2) the expansion of prenatal services and hospital delivery services subsequent to the Royal West Indies Commission Report of 1938; (3) the proposal for national comprehensive health care in the context of Democratic Socialism in the 1970s; and (4) the reorganization or rationalization of health services during the 1980s. Retrospective assessment of maternity care in Jamaica indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical services, primarily nurse-midwives, and to eliminate reliance on the lay midwife or nana [16]. This paper attempts to trace the growth of institutional obstetrics and the decline of lay midwifery, using historical and contemporary records to document these processes. Sources employed for this discussion include material from the government archives in the Institute of Jamaica, data from the records of Victoria Jubilee Hospital, and University of the West Indies library holdings, as well as interviews with nurse-midwives and with women using Kingston prenatal clinics [171. THE ORIGINS
OF INSTITUTIONAL
MATERNITY
CARE
The years 1867-1897 represented a period of development of public health laws and regulations in the wake of cholera and smallpox epidemics in 1850, 1861, and 1874 [18, 191 and the foundation of island medical services emerged in this era. Jamaica, at this time, was a British colony, featuring plantation production of sugar, primarily using African slave labor. According to Roberts, Jamaican maternity care during the 18th and 19th centuries was extensively managed by the ‘grandy’, or nana, a woman who cared for women in pregnancy and at delivery and also provided child health care [19, p. 2391. Prior to emancipation in 1834, plantations had included a minimal range of medical services [18, p. 71 and the nana served as the primary health resource for reproductive complaints and maternity care [19]. Prior to the late 18th century, neither the administration nor plantation owners emphasized a self-reproducing slave population, preferring to import new cohorts of
adult slaves. However, from the early 19th century, the decline in the slave trade led to enhanced interest among Jamaican planters in slave reproduction. It might well be that the role of the nana increased in importance during this period [20]. In a discussion of reproduction and health status among slave populations, Roberts reports descriptions of reductions in work loads for pregnant women on the estates. He also notes that “about 14 days before delivery they were sent to a woman operating a midwifery establishment” [19, p. 2391. His data suggest that the lay midwife held a respected role on the plantation, in contributing to the wellbeing of slave women of reproductive age. By the turn of the century, however, emergent government health policy took the position that the care provided by these midwives was of dubious competence. The Handbook of Jamaica from 1894 states that “it was felt by those best able to judge that great hardship and a large mortality resulted from want of midwives who could undertake even the most simple care of labor” [21]. Accordingly, the Victoria Jubilee Lying-In Hospital was established in 1894 with 12 beds, to commemorate Queen Victoria’s Jubilee [21]. This institution was initially intended to serve the needs of elite women [22] while lay midwives continued to attend most births. These developments in Jamaica paralleled the evolution of maternity care in Britain. The 19th century in England witnessed the establishment of lying-in hospitals, the recognition of obstetrics as a medical specialty, and the growing control of birth by male doctors [4, p. 1381. Correspondingly, female midwives came to serve primarily the poorest women, while middle and upper-class women increasingly relied on the services of male physicians [23, p. 1711. By the late 19th century, trained hospital midwives, supervised by physicians, staffed English lying-in hospitals [4, p. 1581. To provide a source of certified midwives in Jamaica hospitals, Victoria Jubilee provided a midwifery training program for “respectable women of good character and strong constitution” [24]. Women desiring to be trained as midwives received instruction leading to a certificate in midwifery. The colonial government showed increasing concern with maternal health as is evident in the Midwifery Law of 1919 providing for the registration of midwives and establishing criteria for qualification, however, only a minority of midwives trained in the hospital program. Others apprenticed under private physicians while the majority of midwives in practice were the nanas, trained by apprenticeship to other midwives [25]. In general, public health policy throughout the 19th and early 20th century was oriented to the containment of epidemic diseases such as cholera and smallpox [18, p. 81; concern with control of epidemic disease led to the organization of the central and local Parochial Boards of Health. However, the increasingly centralized organization of island-wide public
Transformations
in maternity
health services and regulations did not appear to extend to maternal and child health. Policy statements in this domain reflect a concern with the incompetence of the lay midwife [21, p. 61 and periodically address the inadequacies of the ‘female wards’ of Kingston Public Hospital, described in one report as being “as wretched an apology for a Hospital as can be well conceived” with a “death rate. . . more than double what it has been in the Male Hospital” [26, pp. 8-91. Subsequent to the construction of Victoria Jubilee Hospital, annual reports indicate less concern with the hospital facility and its impact on mortality and morbidity than with the perceived relationship between mortality and the social attributes of the population. In this regard, the Annual Report of Kingston Public Hospital for 1902 discusses high infant mortality rates with reference to “the violation of moral laws” by the female sex [27, p. 81 stating that Examination of the statistics has hitherto shown that in those districts where the highest infant death rate obtains, there also has the highest illegitimate rate been registered, pointing to the conclusion that in the presence of unsatisfactory birth surroundings the maternal parent is either indifferent or unequal to the fulfillment of those duties so essential to the life of the offspring. The report also suggests that education for women regarding the moral perils of illegitimacy would contribute to a reduction in infant mortality [28].
EXPANSION
OF HOSPITAL
OBSTETRICS
The period 1921-1950 represents a phase of increasingly effective control over a wide range of epidemic and endemic diseases as well as a substantial decline in infant and child mortality, from 192 deaths per 1000 live births in the period 1906-1910 to 85.5 deaths per 1000 live births in the period 19461950 [20, pp. 185-l 871. Roberts presents data indicating that mortality among illegitimate children “is manifestly higher than the legitimate at all times. . . and has obviously widened considerably within recent years” [20, p. 1891. The discrepancy, which exists for both sexes, is lowest for neonatal mortality, suggesting that obstetrical practices are less likely to be implicated in this mortality difference than environmental factors. Unlike the colonial medical reports, however, Roberts’ association of environment and disease implicates features of poverty such as poor sanitation, unemployment, and malnutrition rather than moral status and social irresponsibility as determinants of mortality [29]. With regard to females of childbearing age, the period 1921-1946 registered lesser mortality declines than for males, although declines for females after 1946 were marked largely in response to increased availability of prenatal services, as we will discuss below [19, p. 200, 5, p. 11.
services in Jamaica
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In analyzing maternal health policy in this phase it appears that a gradual increase in reliance on hospital delivery as well as on home deliveries assisted by public health nurses or certified midwives occurred. In 1936, seven district public health nurses under the supervision of district medical officers assumed responsibility for providing some prenatal care services throughout the island. Following the recommendation of the secretary general of the British Social Council in 1935 that prenatal clinics be provided in all hospitals and clinics [3O,p. lo], in 1938 the Midwifery Service was reorganized and expanded to include “maternal and infant hygiene and health education” [31, p. 10, 321. The Moyne Commission Report of the West Indies Royal Commission, established in 1938 to investigate conditions generating labor unrest throughout the region, provides a review of policy concerns regarding maternal and child health issues during this period. The Commission in its report on public health generally emphasized the need to develop preventive health services and for immediate progress in maternal and child welfare [33, pp. 1541561. The recommendations were made in the context of a high rate of unemployment and a decline in food crops in relation to export crops; these conditions were associated with an increase in malnutrition and in the incidence of endemic and deficiency diseases [34, p. 4501. The Commission’s emphasis on maternal and child welfare arose in response to high infant and child mortality rates (137 deaths per 1000 live births, and 33% of deaths occurring among children under five) [34, p. 4541. In its discussion of maternal and child health, the Commission report echoes the theme of the 1902 Annual Report of Kingston Public Hospital, deploring high infant mortality and implicating large families, illegitimacy, and lack of parental responsibility as the causes of infant mortality and morbidity [27, p. 1541. However, the Commission does not specifically address maternity care except to comment that the maternal mortality rate in Jamaica was lower than in most tropical countries [33, p. 1301 and to urge that improved midwifery training be developed throughout the West Indies. Carley, in a report on the development of medical services in Jamaica, offers a more precise insight into the position of the nana and the growth of hospital maternity facilities in the period 1930-1940. She states: Maternity work is another branch of medical work receiving much more attention in recent years, in an endeavour to supersede the ‘Mother Gamps’ or inefficient private midwives of Jamaica. By 1938, 10 hospitals outside Kingston had special maternity wards. To these can be added two more which will be available at the Port Antonio and Spalding hospitals. A large increase in accommodations has been made at the Jubilee Maternity Hospital, the daily average number of patients having increased from 22 in 1921 to 150 in 1939 [18,p. 121.
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CAROLYN
SARGENT~~~ JOANRAWLINS
The effort to eradicate indigenous midwifery was furthered by the establishment in 1949 of a government administrative domiciliary midwifery service, which extended the duties of the public health nurse to include birth attendance. In his observations on maternal mortality in Jamaica, Williams notes that maternal mortality rates reflect the standard of obstetrical care available to a population [21, p. 11.Assessing the transformation in maternity care since the establishment of Victoria Jubilee Maternity Hospital in 1894, he remarks on a 60% decline in maternal mortality between 1938 and 1960. He relates this decline both to improved and more accessible prenatal care as well as to an increase in hospital delivery; thus he points to the highest maternal mortality in the parishes of Portland and Hanover, where home births were most common. In contrast, the lowest maternal mortality rates were in Kingston, which had the lowest rate of home delivery. It is clear that Jubilee Hospital played a critical role in hospital delivery; by 1955, 64% of live births in Kingston and St Andrew and 22% of live births in the country occurred at this hospital; these figures also indicate the increasing popularity of hospital, rather than home delivery. The hospital also had a special ‘abortion ward’ and had moved from its initial clientele of elite women to a broader constituency. A 1950 report of the Medical Services of Jamaica indicated that prenatal clinics were now held regularly though the island and at Jubilee Hospital; Jubilee had attracted a growing number of rural admissions leading to “a decided increase in the number of deliveries of babies” at Victoria Jubilee Hospital [35, p. 51. There was a corresponding increase in home deliveries assisted by District Midwives rather than by indigenous midwives. While District Midwives attended 7121 home deliveries in 1950, they attended 10,686 deliveries only 2 yr later and 12,477 deliveries by 1956 [35, p. lo]. Island-wide, home deliveries assisted by District Midwives ranged from 18.7% in the parish of St Elizabeth to 56.7% in Trelawny. However, a cautionary remark in the Medical Report for 1955 notes a tendency for women to attend a prenatal clinic at Jubilee but to deliver elsewhere [36, p. 271. This same report documented excessive overcrowding at Jubilee leading to early discharges of mothers and babies and subsequent complications such as cord infections associated with ‘home remedies’ employed to dress the cord. The following year the Medical Report described ‘formidable problems’ at Jubilee including lack of accommodation for abnormal cases and fluctuation in the number and experience of medical staff but applauded the increasing popularity of prenatal clinics [37, p. 281. The ‘severe and increasing problems’ were attributed to the growing practice of rural patients delivering at Jubilee by claiming to reside in Kingston, thus indicating the growing appeal of hospital birth [37, p. 291.
By 1969, Williams urged rethinking of the need for a home delivery service, due to the widespread acceptance of hospital obstetrics: domiciliary midwifery is both uneconomical in time and effort and unpopular with our patients. It is not only idle but cruel to suggest that a woman be confined in an overcrowded and unsanitary environment. What is needed is small inexpensive units with a resident midwife.
In spite of policy critiquing lay midwifery and emphasizing hospital delivery or at a minimum ‘trained and certified’ midwives to serve as home birth attendants, information on lay midwifery is surprisingly scant. Williams [21, p. 141states that in 1964 midwives were responsible for 68% of deliveries in the country and ‘unqualified attendants’ for 26%; he adds that the role which the unqualified attendant or nana plays in Jamaican midwifery is uncertain. Also uncertain is how much she contributed to maternal morbidity and mortality; while it is gratifying to note the gradual increase in deliveries by midwives and a corresponding gradual decrease in deliveries by unqualified attendants: it will be several years before the unqualified attendant is eliminated. Although an Advisory Council to the Minister of Health recommended an interim program for training and supervision of ‘unqualified’ attendants, until such time as all deliveries could be attended by personnel meeting government standards, this project never materialized. In addition to financial constraints, nurse midwives pressured the Ministry to refrain from implementing programs to train the nanas [29]. By 1962, then, urban residents routinely delivered in hospital and domiciliary midwifery was in decline. Home deliveries, when they occurred, were likely to be attended by district nurse midwives, and govemment policy worked explicitly to decrease the role of lay midwives. In comparison, home delivery was comparatively rare in the U.S. by this time; in England during this period, domiciliary midwifery was also in decline [4, p. 2491, the home delivery rate having dropped to 35.4% by 1957 [4, p. 2501. Only one category of midwife, licensed and regulated by government statute, assisted at hospital or home deliveries in England; physician assisted births had supplanted female midwifery in the U.S. POST INDEPENDENCE
MATERNITY
CARE IN JAMAICA
Jamaica’s independence in 1962 generated a reorganization of medical services in which national staff took on policy making responsibility [38, pp. 451. The Five Year Independence Plan (196331968) emphasized public health efforts such as clinical immunization and clean water supplies but did not diverge dramatically from previous policy regarding the practice of midwifery. At this time, 40.6% of deliveries occurred in hospitals or clinics; in 1964, registered midwives attended 68% of births while 26% of deliveries were attended by a nana or ‘unqualified personnel’ [21, p. 131.
Transformations
in maternity services in Jamaica
With regard to Kingston maternity services, continuing reports of problems plaguing Jubilee hospital emerged in relation to the expanding clientele. For example, Kitzinger [9, p. 197, conducting research in 1965 describes obstacles confronting hospital nurses, midwives and clients: Between 35 and 40 women were delivered in each of two eight-bedded delivery rooms every 24 hr. Equipment was
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to the establishment of this paraprofessional category of personnel, the government proposed to increase the number of district midwives and to involve these personnel in the training and supervision of traditional birth attendants [39, p. 1121. However, this proposal suffered the fate of previous plans to involve the nanas in the national health system as the plan was never implemented.
always in short supply and was not reordered until it had
run out. Sterilization of swabs took 48 hr. There was no hot water after early morning, no isolation ward and no means of effectively communicating up the staff hierarchy. Kitzinger [9, p. 1971 reports overt conflicts between staff and laboring women over expectations for behavior during delivery, as “doctors and nurses are engaged in a struggle to acquire and maintain control over their patients”. In the ongoing effort to move from home delivery to viable institutional maternity care, significant efforts at transforming the health service occurred in the proposal by the People’s Nationalist Party government under the leadership of Michael Manley in 1974 for comprehensive health care in the context of Democratic Socialism. It is beyond the scope of this paper to assess in its entirety Manley’s health scheme. Rather, we note specific elements of the health program: (1) more emphasis on family planning within maternal and child health services; (2) a shift from construction of large public general hospitals to local health centers and clinics; (3) mandatory health insurance; (4) requirements for medical graduates to work in rural health care centers [39, pp. 81-831. Following upon this initial set of policy proposals, the National Health Plan of Jamaica for 1978-1983 selected as a high priority total maternal and child health care coverage focusing on pregnancy, childbirth, and early childhood health concerns such as gastroenteritis and malnutrition [40, p. 1061. To meet the objectives of the comprehensive health plan, efforts were made to restructure health care delivery to extend primary coverage throughout the population. That restructuring proposed four categories of clinic differing in size, service, category of staff and target population. The Type I clinic was to provide a district midwife, health aides and a custodian, and offer prenatal, postnatal and child health clinics; among the duties of the district midwife was attendance at home deliveries. Following the model of the Barefoot Doctors of People’s Republic of China, the Plan proposed a category of Community Health Aides, or primary health workers to provide a link between the community and the health system. With regard to maternal and child health, these aides were to offer basic care in the home and advice regarding such concerns as prenatal care, nutrition and family planning, as well as to screen and refer complicated cases. In addition
CONTEMPORARY MATERNITY SERVICES
A consideration of maternity services in the 1980s contributes to an assessment of the extent to which the Manley National Health Plan generated enduring changes in the delivery of midwifery services to Jamaican women, especially those residing in Kingston and St Andrew. Government reports assessing the health care system throughout the 1980s reflect a concern with shortage of personnel in all categories-nurses, physicians, and midwives: the 1980 Economic and Social Survey noted that in the context of political strife between supporters of the People’s Nationalist Party and the Jamaica Labor Party “the delivery of health services especially in the Kingston metropolitan area was made more difficult. . by high levels of violence and industrial action. . . economic instability, and a shortage of health staff’ [41, p. 16.11. Attendance at health facilities such as prenatal clinics also declined during this period [41, p. 16.81 and the Victoria Jubilee Hospital experienced a critical shortage of nurses. Similarly, from 1984-1986, prenatal and family planning visits declined so that the average number of prenatal visits per pregnant woman was 2.5 in 1984 and 1.7 by 1986. In the period 1984-1986, under the leadership of Edward Seaga and the Jamaica Labor Party, health policy focused on “rationalization and alternate financing to insure more cost efficient and effective delivery of health care services” [42, p. 20.11 with rationalization defined as reduction of hospital beds, regionalization of specialist services, and improvement of quality of care. Pregnant women throughout the island relied heavily on hospital midwifery services: while approx 20% of births occurred in institutions in 1950, by 1985 77% of deliveries were in hospitals [12, p. 1901. Certain rural parishes such as Trelawny, St Elizabeth, Clarendon and Westmoreland continued to show the highest rate of home deliveries assisted by a nana. By 1987 the Ministry of Health reported that 21.5% of deliveries in rural areas occurred at home while c 5 % of Kingston births were home deliveries. However, a closer examination of maternity care in Table I. Birth assistance in 1985 Type of assistance
%
Public hospital birth/Kingston Public hospital birth/island Domiciliary births/certified midwife ‘Unqualified attendants’ Private hospital
85 71 I3 10 6
1230
CAROLYN SARGENT and JOAN RAWLINS
Kingston indicated that at the Victoria Jubilee Hospital, where 25% of all deliveries in Jamaica occur, 65% of deliveries were unattended; in other words, women selecting to give birth in the hospital delivered without attendance of a midwife or physician [42]. This situation reflects an economic context in which budget reductions for both recurrent and capita1 expenditures exacerbated problems in health service delivery. In a review of the Jamaican economy during this period, Boyd [43, p. 1221 states that the total expenditure by the government for health care fell from J$70.00 per person in 1981 to JS47.00 per person in 1985. The decline in government expenditure “coincided with significantly poorer personal service as patients frequently had to take their own linen and in some cases food, as hospital supplies became increasingly unreliable and poor. This was in addition to the increasing difficulty of obtaining treatment”. CONCLUSION We then return to our opening discussion concerning the dissatisfaction of pregnant women attempting to obtain prenatal care at Jubilee. A historical perspective on the development of maternity services in Jamaica has indicated the evolution of the current crisis. Colonial policy consistently worked towards the abolition of the lay midwife, the mainstay of rural maternity care from the 19th century. A comparison of the development of maternity services in Jamaica, England and the U.S.A. suggests a similar move from female, midwife-assisted home delivery, to medicalized, hospital births. While midwifery has been largely eradicated in the U.S. (although experiencing a revival), England has retained state certified midwives to serve primarily as assistants at hospital births. Similarly, in Jamaica, certified midwives continue to staff public maternity hospitals but have ceased to perform an urban domiciliary function. In spite of intermittent policy statements proposing training programs for lay midwives in Jamaica to enable them to provide an additional alternative for birth assistance, these efforts never materialized. In this regard, Jamaica contrasts markedly with other former colonies in the Third World where a more laissez-faire attitude prevailed with regard to midwifery and where independence has been accompanied by a resurrection and glorification of indigenous medicine in the context of nationalism. A number of sub-Saharan African states, for example, have established training sessions for lay midwives as well as for herbalists and other categories of healers in efforts to integrate indigenous medicine with national health systems [44]. While the colonial period in Africa did witness measures to eradicate dimensions of indigenous medicine-for example the Witchcraft Suppression Act of 1899 in Northern Rhodesia-in the post-independence period, indigenous healers have generally retained legitimacy. In some cases the state has legally recognized such
healers [44, p. 351 and associations of healers have emerged. In contrast, the nationalist movement in Jamaica did not glorify this dimension of African tradition; as Lewis [45, p. 1781 points out “it is impossible to restore a. . . continuity violently broken for more than two hundred years”. Similarly, with regard to Jamaican perspectives on indigenous medicine, Kitzinger [9, p. 1891 noted that “for many members of the Jamaican middle class, nanas are evil old busybodies who kill almost as many as they help and who are opposed to every benefit conferred on Jamaica by science and medicine, embarrassing symbols of customs associated with slavery and subjugation”. Further, the decline of lay midwifery was hastened by the establishment of hospital-based midwifery services as well as by the involvement of public health nurses in domiciliary midwifery in rural Jamaica. While Jamaican women increasingly give birth in hospitals, the delivery of services has deteriorated. The demonstration of pregnant women at the Gleaner Newspaper offices indicates the intensification of dissatisfaction with contemporary maternity care. These women articulated the views of many other low-income women in Kingston, discussing their antagonism towards hospital midwives, to whom they attributed responsibility for the inadequate service. They also protested the unsanitary conditions at Jubilee, as well as lack of bed linen, inedible food and staff indifference. Many women had delivered at Jubilee unattended by a midwife, a situation they attributed to ‘rude’ personnel but which midwives themselves explained in terms of staffing shortages. While broader economic contingencies have indeed contributed to a deterioration in maternity services, we see in the orientation of hospital personnel the theme explicit among the colonial elite equating poverty, immorality, and ill health. Thus midwives, though cognizant of organizational problems affecting the hospital, attribute to women social irresponsibility leading to ill advised pregnancy and health complications. This cultural construction of illegitimacy and maternity manifest in colonial documents and in contemporary medical practice is a dimension of class relations that has had an impact on health policy and on delivery of maternity services in Jamaica throughout its history. Thus while analyses of the transformation in maternity care in England and the U.S. have emphasized the relegation of midwifery to a “secondary status health profession” [l, p. 13, 5, p. 51, in Jamaica an additional issue is the secondary status of the public hospital in the national health system, as well as class-based tensions between doctors, hospital midwives, and their clients [46]. Yet in spite of the prevalence of unassisted births in hospital, urban women did not favor home deliveries. As one woman explained “You could die if you stayed home”. From the client perspective, then, we see the perception that home delivery is no longer a
Transformations
in maternity services in Jamaica
viable option. As in Europe and the U.S., women have come to view birth as requiring medical supervi-
sion, preferably in a hospital setting [5, pp. 133, 1531. For working class and indigent women, however, structural problems facing the primary public maternity hospital in Kingston have reduced its viability as an alternative to home delivery whether assisted by a certified or indigenous midwife.
14.
Acknowledgement-We
15.
are grateful to Dennis Cordell, Department of History, Southern Methodist University, for his assistance with data analysis.
16. REFERENCES
1. Ehrenreich B. and English D. Witches, Midwives, and Nurses. A History of Women Healers. The Feminist Press, Old Westbury, New York, 1973. Oakley A. Women Confined. Towards a Sociology of Child&b. Schocken Books, New York, 1980. _- _ Michaelson K. L. (Ed.) Childbirth in America. Berain and Garvey, South‘Hadley, MA, 1988. Towler J. and Bramall J. Midwives in History and Society. Croom Helm, London, 1986. Wertz R. W. and Wertz D. C. Lying-In. A History of Childbirth in America. The Free Press, New York, 1977. 6. Rothman B. K. Awake and aware, or false consciousness: the cooption of childbirth reform in America. In Childbirth: Alternatives to Medical Control (Edited by Romalis S.), pp. 150-181. University of Texas Press, Austin, 1981. 7. Romalis S. Overview. In Childbirth: Alternatives to Medical Control (Edited by Romalis S.), pp. 3-33. University of Texas Press, Austin, 1981. 8. Sargent C. Maternity, Medicine and Power. University of California Press, Berkeley, 1989. 9. Kitzinger S. The social context of birth: some comparisons between childbirth in Jamaica and Britain. In Ethnography of Fertility and Birfh (Edited by MacCormack C.), pp. 181-205. Academic Press, New York, 1982. 10. Cosminsky S. Childbirth and change: A Guatemalan study. In Ethnography of Fertility and Birth (Edited by MacCormack C.), pp. 2055231. Academic Press, New York, 1982. 11. Kay M. (Ed.) Anthropology of Human Birth. Davis, Philadelphia, 1982. 12. Samuels A. Health sector review. Ministry of Health, Kingston, 1987. 13. Rawlins J. and Sargent C. Factors influencing prenatal care use among low-income Jamaican women. International Center for Research on Women Report No. 14, Washington, D.C., 1990. More detailed analyses of these data will be presented in forthcoming publications such as [15]. Briefly, we summarize that research involving 125 women attending prenatal clinic and 100 postnatal patients at Victoria Jubilee Hospital has elicited opinions regarding care received at the Hospital. In addition, 50 women have been interviewed in a lowincome Kingston neighborhood, regarding health care experiences. Approximately 25% of the prenatal patients interviewed expressed some negative comment in direct response to questionnaire items eliciting information on trust in midwife, and concerns about labor, delivery or hospital. However, 25 community women interviewed both with structured and unstructured interview schedules were uniformly negative in their retrospective histories of prenatal and delivery experiences at VJH. These women reported incidents such as being yelled at or “handled rough” by nurses, delivering
17.
18. 19. 20.
21. 22. 23. 24. 25.
26.
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unattended, and complained of hospital shortages in such supplies as bedsheets, cutlery, dishes, and appropriate food. Clinic patients when asked explicitly if they had heard such reports indicated they had, and often had similar experiences but did not translate these observations into a negative comment on staff or hospital. Reluctance to do so may be a product of the interview setting, given the widespread critiques of the hospital in mo& informal circumstances. _ Jefferv R. The Politics of Health in India. D. 20. University of California Press: Berkeley, 1988.’_ Sargent C. and Rawlins J. Factors influencing prenatal care among Jamaican women. Human Organ. 50(2), 179-188. The World Health Organization has suggested use of the term ‘Traditional Birth Attendant’ to avoid confusion with biomedically trained nurse-midwives. Here the term lay midwife or the local term nana will be used for those trained by apprenticeship, and nurse-midwife will refer to those midwives who are government certified and employed in the hospital system. The research presented here was financed by the International Center for Research on Women through Cooperative Agreement No. DAN-lOlO-A-O&-70614 with the Office-of Nutrition and Health of the U.S. Agency for International Development, and by the National Science Foundation. BNS-8703627. Carey M. M. Medical Services in Jamaica. Institute of Jamaica, Kingston, 1943. Roberts G. W. The Population of Jamaica. The Conservation Foundation, University Press, Cambridge, 1957. It would be interesting to assess the transformation of lay midwifery over the past century; however, there seem to be very few detailed descriptions of the nana’s work. Possible changes in midwifery practice are suggested in research by Kitzinger, who interviewed a number of nanas in the 1960s; several had daughters studying to be certified midwives in England. The nanas studied their daughters’ midwifery texts to update their practice [9, pp. 103-1051. The nanas observed by Kitzinger customarily advised on prenatal care (diet, massage), provided delivery and postpartum assistance, infant care, and emotional support, resulting in “a prototype of family and home-centered maternity care” [9, p. 1071. Older Kingston women interviewed in Sargent’s research [15, 17] report that few urban women recall or practice prenatal and postpartum ritual observances such as those described by Kitzinger’s informants, and mentioned in Carol MacCormack and Alizon Draper’s Social and cognitive aspects of female sexuality in Jamaica. In The Cultural Construction of Sexuality (Edited by Pat Caplan), pp. 143-165. Tavistack, London, 1987. Williams L. L. Some observations on maternalmortality in Jamaica. West Ind. Med. J. 22, l-14, 1973. Matron C. Stuart Victoria Jubilee Hospital, pers. commun. Leavitt J. W. Brought lo Bed. Childbearing in America. Oxford Universitv Press. New York, 1986. Dann N. History-of Victoria Jubilee.Hospital or Lying in Hospital, Kingston, Jamaica. Inservice Education, Victoria Jubilee Hospital, 1974. Towler and Bramall present a detailed history of midwifery in England including statutory acts regulating the practice of midwifery, training alternatives for midwives during the 19th and 20th centuries, and tracing the decline of domiciliary midwifery. While no available texts explicitly link the growth of hospital-based midwifery in England with the development of maternity care in Jamaica, many parallels are evident. Anonymous. The report of the ordinary and resident medical officers and the annual report of the inspector
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27. 28.
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33. 34. 35.
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CAROLYNSARGENTand JOAN RAWLINS
and director of the public hospital for 1864. Levy, Kingston, Jamaica, 1865. Anonymous. Annual report, Kingston Public Hospital, Kingston, 1902. Similarly, in the late 19th century in the U. S., doctors and patrons urged impoverished young girls to deliver in hospitals, wishing to rescue them from “degenerating into depravity” [S, p. 1331; Towler and Bramall also address the role of maternity hospitals in 18th century England, as a response to the needs of women in circumstances of distress, in industrial towns (p. 128). Roberts G. Personal communication, September, 1988. Wedderburn C. C. The development of public health in Jamaica. Unpublished report, Department of Social and Preventive Medicine, University of the West Indies. Diggory H. J. P. The history of public health in the Carribean. Unpublished report, Department of Social and Preventive Medicine, University of the West Indies. Prenatal care in England drew greater clinic attendance subsequent to the Maternal and Child Welfare Act of 1918, but was not widely recognized as necessary until the 1930s [25, pp. 200,224]; thus the attention of the British Social Council in Jamaica to the need for prenatal care paralleled the growing legitimacy of prenatal care in England. West India Royal Commission report. Her Majesty’s Stationary Office, London, 1945. Williams E. From Columbus to Castro. The History of the Caribbean 1492-1969. Deutsch, U.K., 1970. Medical department. Report of the medical services of Jamaica and its dependencies for 1950. The Medical Department, Kingston, 1950. Ministry of health. Report of the medical services of Jamaica and its dependencies for 1950. Ministry of Health, Kingston, 1955. Ministry of health. Report of the medical services of Jamaica and its dependencies for 1956. Ministry of Health, Kingston, 1956.
38. Standard Sir K. Development of Public Health in the Commonwealth Caribbean. Department of Social and Preventive Medicine. Universitv of the West Indies. Kingston, 1973. 39. Barrett I. R. The delivery of health care in Jamaica and its implications for public policy. MSc. thesis, Department of Government, University of the West Indies, 1979. 40. Economic and Social Survey Jamaica. National Planning Agency, Kingston, 1981. 41. Planning Institure of Jamaica. Economic and Social Suruey Jamaica. Planning Institute of Jamaica, Kingston, 1987. and morbidity 42. Ministry of health. Perinatal mortality survey. Report of the preliminary findings. Ministry of Health, University of the West Indies, Kingston, 1987. 43. Boyd D. A. C. Economic Management, Income, Distribution, and Poverty in Jamaica. Praeger, New York, 1988. 44. Last M. and Chavunduka G. L. (Eds) The Professionalisation of African Medicine. Manchester University Press, Manchester, 1986. 45. Lewis G. R. The Growth of the Modern West Indies. Monthly Review Press, New York, 1968. has been described as having problems of 46. Jamaica economic development and social injustice which include a rigid class system, extremes of wealth and poverty, and a deteriorating economy dominated by bauxite and sugar. Correspondingly, the health care system is characterized by a maldistribution of services favoring the urban elite, as well as by inadequate financing and infrastructure for facilities targeting low income populations (see, for example, Manley M., Jamaica. Struggle in the Periphery, pp. 5, 49-50. Third World Media Limited, Oxford, 1982; Bolles L. A. Kitchens hit by priorities: employed working-class Jamaican women confront the IMF. In Women, Men and the Infernational Division of Labor (Edited by Nash J. and Fernandez-Kelly M. P.), p. 139. State University of New York Press, Albany, 1983.
