2nd August 2013, Volume 126 Number 1379

Sally Abel, David Tipene-Leach

Recommendations by New Zealand coroners1 and recent publications in the New Zealand Medical Journal2,3 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 Māori SUDI prevention workers for the last 7 years as they have grappled with difficult to change and disproportionately high Māori SUDI rates.

In this viewpoint article we review the development of Māori 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 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 Zealand10 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 1 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 1 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.11However, it has not been as effective amongst Māori, whose babies are now significantly over-represented.

In the period 2003 to 2007, 62% of SUDI deaths were Māori. 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-Māori, 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 Māori women. A recent Auckland study found that 53% of Māori mothers smoked in pregnancy14 compared to just 8% of a mostly European sample,15 confirming the relatively poor success of smoking cessation programmes among pregnant Māori women.16

Although some commendable efforts have been made regarding tobacco policy and Māori smoking rates,17 the pervasive marketing of tobacco alongside the difficultiesof 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 Māori 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 Māori 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 Māori 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.

Māori have been shown to feature prominently in these figures, with the latest data showing that between 2002 and 2009 the Māori death rate from suffocation in the place of sleep was 8.22 times the European rate.10

Bedsharing is relatively common amongst Māori. The two Auckland studies14,15 found that 65% of Māori 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 6 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 Māori is both a culturally valued behaviour20 and an infant sleeping practice that is prevalent in resource-poor homes.

The issue for Māori 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 Māori product called the pōrakaraka,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 Māori over the currently promoted bassinet beside the bed. In particular, the traditional origin and the ‘Māori flavour’ of the flax construction are designed to appeal to the Māori mother who might otherwise reject advice not to bedshare in an unsafe fashion.

Figure 1. Wahakura (Photo credit: Kath Allen)

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The development of the wahakura prototype and a trial of its production and distribution were the focus of a Te Puni Kōkiri 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 Māori midwifery service to mothers of vulnerable Māori babies.

Two significant outcomes identified in the project audit22 were the high level of acceptability of the wahakura by whānau (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 whānau 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 Māori 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 Māori babies, a number of weavers around the country continue to make wahakura and Whakawhetu continues to promote them.24

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 Wānanga 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 Māori communities producing a sustainable supply of wahakura without major external funding.

Four sites of production/distribution were trialled - a Māori midwifery practice in Hastings, a Māori 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 evaluation25 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 whānau 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 Māori 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 3-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 Māori 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 infant sleep time, and whether there is greater maternal and whānau baby mindedness’ (the ability of the mother/whānau to observe and think about her baby’s thoughts, feelings and needs) in the assigned device.

In addition, an Eastern Institute of Technology Hawke’s Bay wahakura qualitative study, funded by a Lottery Health Research Grant, was initiated in 2012. It sits beside the KISS study and is exploring in depth Māori views about and experiences of the wahakura, including contemporary understanding of historical precursors, and how the wahakura is used in normal practice.

Alternative infant sleeping spaces

The other pathway that became obvious following the findings of the Tu Meke PHO project was the development of alternative infant sleeping spaces that were relatively simple and cheap to procure.

The term pēpi-pod was originally conceived by Nicola McDonald, then from the Māori SIDS team, to denote any device not made of flax that served the ‘safer sleep environment’ function of a wahakura.

It was the dramatic upheaval in Christchurch homes following the February 2011 earthquake resulting in a sudden emergence of “increased risks to babies posed by disrupted living and sleeping conditions”,26 that prompted child health advocacy programme, Change for our Children (CFOC), to mount a pēpi-pod response after identifying a relatively cheap item in the Plastic Box store.

The pēpi-pod, considered a “sister to the wahakura”,26 is made from the bottom section of a plastic clothes container and comes with an attractive cover, a simple mattress and a sheet/merino blanket set, along with comprehensive safe sleep education resources and instruction. It is considerably cheaper than the wahakura.

Figure 2. Pēpi-pod (Photo credit: CFOC)

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Change for our Children distributed 642 pēpi-pods in the 5 months following the Christchurch earthquake and found they were very well received by the 100 families surveyed, many of whom valued the capacity for ‘safer bed sharing’.26

Later that year the Hawke’s Bay District Health Board (HBDHB) also launched a pēpi-pod intervention. The HBDHB Safe Sleep Action Project provides enhanced antenatal safe sleep education and a safe sleeping environment audit, with the provision of pēpi-pods for families of vulnerable babies.

An evaluation of the first 14 months, during which 345 pēpi-pods were distributed primarily to Māori and Pacific families, reported on pēpi-pod usage and retention of safe sleep knowledge and behaviours with the device.

Like Cowan et al.’s (2012) Christchurch evaluation, it found high levels of acceptability, with many mothers appreciating being able to confidently have their baby close by, in or on the parental bed.27

In early 2013 the pēpi-pod was being actively deployed in five regions: Christchurch, Hawke’s Bay, Waikato, Rotorua and Otara.28 Research to ascertain the safety of the pēpi-pod has yet to be undertaken, however a study involving the pēpi-pod is currently underway in South Auckland.

The Haumaru moe o te pēpi study, funded by Cure Kids and the Auckland Medical Research Foundation, is a randomised control trial comparing outcomes from an enhanced safe sleep education programme that uses pēpi-pods with those from a standard safe sleep education programme. The research is expected to be completed by the end of 2013.29

A less complex method of making a wahakura has recently been developed and is currently being utilised in a safe sleep intervention by Northland DHB. The wahakura waikawa, an equally robust but perhaps artistically less appealing item, is woven from untreated flax. With preparation and weaving time being significantly reduced, the cost of the item will likely make it considerably easier to access.

Conclusion

Over the past few years Māori and other SUDI prevention workers’ promotion of infant safer sleeping devices that can be used in the parental bed has taken place within an environment in which SUDI prevention advice has often been very anti-bedsharing. More recently there is increasing acknowledgement that blanket warnings against bedsharing are unlikely to be successful when there are well understood parental and infant benefits from this practice.18

With many Māori (and other) parents and caregivers now using a wahakura or pēpi-pod, often in the shared bed, there needs to be a distinction made when reporting on infant sleeping practices between ‘direct bedsharing’ (without an infant safe sleeping device) and ‘bedsharing with an infant safe sleeping device’.

More work is needed to refine our understanding of safety and lack of safety within the shared bed. Results from the current KISS Study in Hawke’s Bay may yield useful information in this regard. In addition, a nation-wide Health Research Council funded case control study aims, amongst other things, to explore the infant/parent shared sleeping environment closely30possibly identifying safer ways to bedshare.

Earlier New Zealand research that determined the prone sleeping position as the primary risk for sudden infant death syndrome,11 was a major contributor to international SIDS prevention advice that subsequently saw a dramatic decline in post-neonatal mortality in the developed world.

The persistently high rates of SIDS and SUDI deaths in largely Māori communities, however, highlight the continued significance of other SUDI risk factors, such as smoking in pregnancy, unsafe bedsharing practices and social deprivation.

A traditional Māori infant sleeping device has been revived in an attempt to mitigate some of these risks. The work to provide robust evidence for its safety is in progress as is the exploration of similar alternatives. This work is directed at ensuring that babies most vulnerable to SUDI have access to a safer sleep environment without (undue) cost.

The extent of bedsharing with vulnerable infants and Māori efforts to find a solution to this problem make New Zealand an ideal place to grapple with the ‘tail of the SIDS epidemic’.

The practical approach of utilising and adapting indigenous infant sleeping methods may be equally applicable in other countries where SIDS/SUDI persists in indigenous and other marginalised communities.

Abstract

Recent research and policy around sudden unexpected death in infancy (SUDI) have emphasised the place of safe sleeping practices within SUDI prevention strategies. Māori 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 Māori SUDI rates. The wahakura (a flax bassinet modelled on a traditional Māori 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.

Author Information

Sally Abel, Senior Research Fellow, EIT Hawke’s Bay, Napier; David Tipene-Leach, GP, Te Taiwhenua o Heretaunga, Hastings

Acknowledgements

We thank the former Tu Meke First Choice PHO and Health Hawke’s Bay PHO for funding support as well as Heather Sutton, author of the Tu Meke First Choice PHO Wānanga Wahakura project evaluation. We are also grateful to the two anonymous NZMJ reviewers for their helpful comments.

Correspondence

Dr Sally Abel, Senior Research Fellow, Faculty of Health Sciences/Te Manga Māori, 501 Gloucester Street, Taradale, Napier 4142. Fax: +64 (0)6 9748910

Correspondence Email

sabel@orcon.net.nz

Competing Interests

Nil.

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