SUDI prevention: a review of Maori safe sleep innovations for infants


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SUDI prevention: a review of Maori safe sleep innovations for infants
  󰁔󰁈󰁅 󰁎󰁅󰁗 󰁚󰁅󰁁󰁌󰁁󰁎󰁄 󰁍󰁅󰁄󰁉󰁃󰁁󰁌 󰁊󰁏󰁕󰁒󰁎󰁁󰁌   Journal of the New Zealand Medical Association NZMJ 2 August 2013, Vol 126 No 1379; ISSN 1175 8716 Page 1 of 9 URL:  ©NZMA SUDI prevention: a review of M ā ori safe sleep innovations for infants Sally Abel, David Tipene-Leach   Abstract: Recent research and policy around sudden unexpected death in infancy (SUDI) have emphasised the place of safe sleeping practices within SUDI prevention strategies. M ā ori SUDI prevention workers have focussed on innovations around the safe sleep environment for some time now, as they have grappled with difficult to change and disproportionately high M ā ori SUDI rates. The wahakura  (a flax bassinet modelled on a traditional M ā ori infant sleeping item) was developed in 2006 aiming to mitigate some of the risks of bedsharing with vulnerable infants, in particular infants exposed to maternal smoking in pregnancy. Early wahakura projects in Gisborne and Hawke’s Bay showed high acceptability, effectiveness as an infant health promotion vehicle but difficulty maintaining a low/no cost supply for vulnerable families. The Hawke’s Bay project revealed two pathways forward: the need for robust research to ensure the safety of the wahakura and the exploration of financially viable and more readily available alternatives. Work on both pathways is currently in progress around the country, signalling New Zealand’s ongoing contribution to SUDI prevention and its potential contribution to knowledge and practices applicable to indigenous and other marginalised communities worldwide. Recommendations by New Zealand coroners 1  and recent publications in the New Zealand Medical Journal 2,3  have highlighted the urgency of ensuring that strategies to prevent sudden unexpected death in infancy (SUDI) are well understood and effectively implemented by parents and caregivers of young babies. In addition, in June 2012, the Health Quality & Safety Commission (HQSC) wrote to all District Health Boards urging them to prioritise SUDI prevention strategies and making a number of recommendations in this regard. 4  The issue of infant bedsharing has come in for particular attention, with recommendations to ensure consistent safe sleep messages are given and to provide safe sleep options where necessary to families with vulnerable babies. This focus on the infant safe sleep environment has been central to M ā ori SUDI prevention workers for the last seven years as they have grappled with difficult to change and disproportionately high M ā ori SUDI rates. In this viewpoint article we review the development of M ā ori initiated innovations for safer infant sleep environments, and suggest that these and other local safe sleep initiatives and research have the potential to keep New Zealand at the forefront of international SUDI prevention research and advice. Sudden infant death syndrome (SIDS) has been defined as “the sudden unexpected death of an infant <1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including    NZMJ 2 August 2013, Vol 126 No 1379; ISSN 1175 8716 Page 2 of 9 URL:  ©NZMA performance of a complete autopsy and review of the circumstances of death and the clinical history.” 5  The broader term SUDI describes “any sudden and unexpected death, whether explained or unexplained (including SIDS), that occurs during infancy. After case investigation, [SUDIs] can be attributed to suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, and trauma (accidental or non accidental).” 6  New Zealand has the highest SUDI rate in the industrialised world. 7  Over the period 2003 to 2007 there was an average of 65 SUDI deaths per year or a rate of 1.1 deaths per 1,000 live births. 8  It is the main cause of post neonatal mortality in infants up to 1 year of age in New Zealand and although dramatic reductions in SIDS and SUDI occurred throughout the 1990s, since 2002 post-neonatal SUDI death rates have remained static. Deaths classified as SIDS still predominate in SUDI figures but the proportion of SUDI attributed to accidental suffocation/strangulation increased steadily over the period 2005 to 2009 and was particularly high for very young babies, accounting for 61% and 38% of SUDI deaths in babies aged 0-3 weeks and 4-7 weeks respectively. 9  The most recent publication on accidental suffocation in New Zealand 10  reported that, amongst the 50 deaths from suffocation in a place of sleep recorded between 2002 and 2009, the most common age of death was one month or under. While the age range of the deaths in this report was 0-24 years of age, 48% of these were infants under one year of age. Much of SUDI prevention research and advice has been focussed on SIDS prevention, although it is believed that SIDS prevention practices can also help prevent suffocation/strangulation in bed. 10  The classic approach to preventing SIDS deaths has been to define the risk factors, devise the appropriate messages and then design and implement an information-sharing health promotion campaign. Indeed, this has worked very well in mainly middle class, white communities in which advice to change from the prone to the back sleeping position was associated with a huge decrease in post-neonatal death in the 1990s. 11  However, it has not been as effective amongst M ā ori, whose babies are now significantly over-represented. In the period 2003 to 2007, 62% of SUDI deaths were M ā ori. This equates to approximately 40 deaths per annum, a rate of 2.3 deaths per 1000 live births, which is four and a half times that of Other (non-M ā ori, non-Pacific, non-Asian) infants whose rate is 0.52 per 1,000. 8  The risk of SIDS increases significantly with maternal smoking in pregnancy and with bed-sharing where the mother smoked in pregnancy. 12  SIDS is also associated with high socio-economic deprivation. 13  In New Zealand high rates of smoking in pregnancy persist amongst M ā ori women. A recent Auckland study found that 53% of M ā ori mothers smoked in pregnancy 14  compared to just 8% of a mostly European sample, 15  confirming the relatively poor success of smoking cessation programmes among pregnant M ā ori women. 16  Although some commendable efforts have been made regarding tobacco policy and M ā ori smoking rates, 17  the pervasive marketing of tobacco alongside the difficulties      NZMJ 2 August 2013, Vol 126 No 1379; ISSN 1175 8716 Page 3 of 9 URL:  ©NZMA of dealing with smoking addiction in poorly resourced communities have made progress in this area very challenging. Consequently efforts to reduce smoking in pregnancy, including exploration of new innovative approaches, should remain a primary aim of health authorities, along with strategies that take a wider approach to SUDI prevention. For several years now M ā ori SIDS prevention workers have recognised that the phenomenon of ‘bedsharing where the mother smoked in pregnancy’ is deserving of specific attention. The Auckland studies showed that 21% of M ā ori mothers had both smoked in pregnancy and ‘always’ or ‘sometimes’ co-slept with their baby, compared with only 1% of the mostly European mothers. 14,15  Considering the difficulty of effecting smoking cessation amongst M ā ori women during pregnancy, attention moved towards how to increase infant sleep environment safety without necessarily banning bedsharing, the closeness of which is heralded as beneficial both for bonding and promoting breastfeeding. 18,19  Also speaking to the importance of working with safety issues around bedsharing are infant deaths from accidental suffocation, which have continued to increase over time. M ā ori have been shown to feature prominently in these figures, with the latest data showing that between 2002 and 2009 the M ā ori death rate from suffocation in the place of sleep was 8.22 times the European rate. 10  Bedsharing is relatively common amongst M ā ori. The two Auckland studies 14,15  found that 65% of M ā ori mothers had bedshared for some period the night before, compared with 27% of the mainly European mothers. Neither health promotion advice nor coroners’ frequent urging of parents to avoid bedsharing with infants less than six months of age appear to have impacted significantly on this behaviour. In addition to the bonding and breastfeeding benefits it affords, it seems that bedsharing amongst M ā ori is both a culturally valued behaviour 20  and an infant sleeping practice that is prevalent in resource-poor homes. The issue for M ā ori SUDI prevention health workers therefore became how to find a ‘safer sleep environment’ that was both culturally acceptable and practical. The wahakura (flax bassinet) A first expression of this ‘safer sleeping environment’ emerged in Gisborne in 2006. Similar to a pre-European M ā ori product called the p ō rakaraka, 21  the wahakura  (‘waha’ to carry, ‘kura’ precious little object) is an approximately 72 x 34 cm bassinet-like object woven from harakeke (New Zealand flax). It comes with a thin foam mattress and a set of ‘rules’ that promote back sleeping; keeping the wahakura free of pillows, bumpers, loose blankets or toys; keeping the baby’s environment smoke-free; and banning the proximity of tired or inebriated adults, alongside the promotion of ‘every time, every place, every sleep’ usage, a return to the wahakura after feeding and sharing the ‘rules’ with every possible caregiver. The wahakura seeks to provide a safer sleeping place for infants, particularly within a shared parental or caregiver bed. This form of maintaining closeness with baby is likely to find favour with M ā ori over the currently promoted bassinet beside the bed. In particular, the traditional srcin and the ‘M ā ori flavour’ of the flax construction are    NZMJ 2 August 2013, Vol 126 No 1379; ISSN 1175 8716 Page 4 of 9 URL:  ©NZMA designed to appeal to the M ā ori mother who might otherwise reject advice not to bedshare in an unsafe fashion. Figure 1. Wahakura (Photo credit: Kath Allen) The development of the wahakura prototype and a trial of its production and distribution were the focus of a Te Puni K ō kiri funded project in Gisborne in 2006 and 2007. The prototype development phase determined the appropriate design and size and the type of harakeke needed to ensure sturdy sides and durability. Eighty-five wahakura were distributed through a M ā ori midwifery service to mothers of vulnerable M ā ori babies. Two significant outcomes identified in the project audit 22  were the high level of acceptability of the wahakura by wh ā nau (extended family), and that participating midwives found it invaluable to successfully deliver a range of antenatal and infant health promotion messages (such as, smoke-free environments for babies and the promotion of breastfeeding) within a culturally conducive paradigm. Most of these wahakura were subsequently either distributed for use amongst other wh ā nau members expecting babies or became the ‘security blankets’ of the growing infant. The inability to reclaim them back into the project, therefore, led to a problem with sustainability of supply. The Gisborne project itself stalled around the expense of making further wahakura. In the attempt to boost production skills and thereby supply, the making of wahakura was promoted by the M ā ori SIDS Prevention Programme (now known as Whakawhetu) as an important focus of their national SIDS prevention work from 2008. 23  They ran a number of meetings around the country aimed at training and up-skilling weavers and health promoters around the production and use of the wahakura and subsequently regional wahakura projects developed in Northland, Auckland and Waikato. Although these projects did not translate into a sustainable supply of wahakura for vulnerable M ā ori babies, a number of weavers around the country continue to make wahakura and Whakawhetu continues to promote them. 24      NZMJ 2 August 2013, Vol 126 No 1379; ISSN 1175 8716 Page 5 of 9 URL:  ©NZMA The Hawke’s Bay Tu Meke First Choice PHO Project Building on the Gisborne wahakura work, a Hawke’s Bay Ministry of Health funded project was initiated in late 2008 by Hawke’s Bay’s former Tu Meke First Choice Primary Health Organisation (Tu Meke PHO). The W  ā nanga Wahakura – Weaving Our Way to the Future  project had two objectives: to further investigate the wahakura as a vehicle for antenatal health promotion delivery and to explore the viability of M ā ori communities producing a sustainable supply of wahakura without major external funding. Four sites of production/distribution were trialled - a M ā ori midwifery practice in Hastings, a M ā ori Women’s Welfare League/urban marae in Napier, a Primary Health Organisation in Wairoa and a single weaver working with community networks of her own in the high deprivation Flaxmere community. Each site confirmed that using the wahakura and its associated educational resources as a focus for delivering antenatal infant health promotion messages was very successful. The project was, however, unable to demonstrate an approach that could produce wahakura from the community in an economically sustainable fashion. The project evaluation 25  found a number of reasons why this was difficult. The high degree of weaving skill required and the length of time it took to make a wahakura militated against easy and ready construction. Any chance of a supply evolving without ongoing external funding was clearly not viable. In addition, there was a paucity of people with these particular weaving skills and some constraints around supply of the appropriate types of long flax. This meant that, although mothers who had reasonable financial means or weavers in the wh ā nau had a good chance of obtaining a wahakura, those who had neither, usually those whose babies were most vulnerable, were unlikely to be able to access one unless production was funded. The Tu Meke PHO project was pivotal in clarifying the way forward for further development of M ā ori safer sleeping environments by determining two onward pathways. Wahakura research The first pathway determined by the Tu Meke PHO project was the development of research that might establish the safety or otherwise of the wahakura as an infant sleep environment. Consequently, collaboration between Hawke’s Bay researchers and researchers from the University of Otago and Otago Polytechnic led to the development of the Kahungunu Infant Safe Sleep (KISS) study, a Health Research Council funded three year project which was initiated in Hawke’s Bay in 2011. This study is randomising approximately 240 mothers who attend Hawke’s Bay midwifery services with many M ā ori clients, to either a wahakura or bassinet as a sleeping environment, and then seeking to determine the safety and other benefits, or harm, of each. It is designed to examine thermal environment, hypoxic events, head covering/uncovering episodes, mother-infant interaction including breastfeeding and
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