View Article PDF

In 2005, a survey of mostly European mothers who birthed at National Womens Hospital (NWH) in Auckland, New Zealand demonstrated that the benefits of supine sleeping, not smoking, and breastfeeding appeared to be well understood but that more education about keeping the face clear and sleeping in the parents room was needed.1,2 Although these recognized sudden infant death syndrome (SIDS) risk factors have been incorporated into New Zealand health care,3 M ori infants continue to have higher SIDS rates than the general population.4 Living in socioeconomic deprivation and having reduced access to health care has made health promotion more difficult;5,6 in particular, around the issue of bed-sharing/co-sleeping when associated with maternal smoking in pregnancy.6-8 SIDS is the leading cause of preventable death in the post-neonatal period and rates have been falling over the past two decades. Although M ori SIDS rates have fallen from 9.9 per 1000 live births in 1984 to 1.6 per 1000 live births in 2002, 70% of the 40 SIDS deaths in 2005 were M ori and the M ori SIDS rate was five times that of non-M ori, non-Pacific infants.4 In addition, M ori rates of sudden unexpected deaths in infancy have not declined over the 2002-2008 period.9 Information on SIDS-related knowledge and infant care practice by M ori mothers is therefore needed. In 2008 therefore, a 2005 survey protocol that investigated these issues with a largely European sample was repeated with M ori mothers in the Counties Manukau (CM) District Health Board area. Methods In the period 21 July to 31 December 2008, 734 eligible M ori women gave birth in the Counties Manukau region. Mothers were ineligible if they had had a previous SIDS experience or their infants had not yet been discharged from hospital. The mothers demographic details, parity and smoking status and the infants date of birth, National Health Index number, transfer/discharge details, birth-weight and gestation were collected from the birth records. A pathologist checked infant mortality records to ensure none of the infants belonging to listed mothers had died. In order to better recruit M ori mothers to this survey we elected to use a telephone rather than postal contact, to use M ori women as interviewers (second year medical students on Summer Student Research Scholarships) and to home visit if telephone contact was not made. An attempt was made to phone the mothers when the infants were either 6-8 week or 3-4 month of age, as per the 2005 study protocol. If successful, they were given an explanation of the research and were invited to participate either by telephone interview or a home visit. If unsuccessful, they were phoned repeatedly until the babies fell out of the age brackets. Some, who were unable to be contacted, were visited at their home addresses and, if home, were invited to take part. Participants were asked to list all factors that they thought might help reduce the risk of SIDS, and from where and from whom they had received their information. The interviewers enquired about current practices of maternal smoking, breastfeeding and both last night and usual practice infant sleep position and bed sharing. In addition, participants were asked about room sharing, pacifier use, plastic mattress wrapping, head shape concerns and positioning devices. Their concerns about and reasons for using these practices was also surveyed. An information sheet regarding the research project, SIDS prevention pamphlets, and a small token of appreciation (a $20 petrol voucher) were later posted to the mother. The socioeconomic status of each infant was derived from the NZDep2006 code10 based on the mesh block of the place of residence. The survey results from the two age groups were compared and then the overall data were compared to the previous survey in 2005 using the chi-square test. Survival analysis was used to compare breastfeeding cessation differences between the two surveys. To estimate the proportion of bed-sharing in the non-participants, the observed number was extrapolated within socioeconomic categories and then summed to give an estimate of the number sleeping in their own bed. Division of this number by the number of births gave the population proportion. The study received ethical approval from the Auckland Regional Ethics Committee and the Counties Manukau Clinical Board. Results ParticipantsOf the 734 eligible mothers, 315 were able to be contacted via telephone or home visit and of these, 16 declined to participate, leaving 299 (41%) of the cohort who participated. Of those who were not contactable 22% had an invalid telephone number or address, 66% continually did not answer their phone and 12% had babies who fell out of the age range during the contact period. Non-participantsThose who participated in the study were compared with the non-contactable/declined families. Information on geographical location, maternal age, maternal smoking, parity, infant birth weight and gestation was available for the non-participant group. Non-participating mothers were more likely to be smokers (p=0.004), to be multiparous (p=0.04) and were of lower socioeconomic status (p=0.006) than the participants. This difference may have some influence on the estimates derived from the survey, in particular, bed-sharing. In the non-participants this was estimated using geocodes and smoking status, and there was little difference between the participants and the non-participants for either analysis. Participant demographicsThere were no significant differences between the 6-8 week (n=123) and the 3-4 month (n=176) aged infant groups for any of the variables studied and, as in the 2005 survey, the results were pooled. The M ori mothers were younger (26 years, SD 6.5) than the NWH mothers (33 years, SD 5.1). Eighteen percent (1% NWH) were under the age of 20 and 26% (5% NWH) were between 20-24 years of age. Thirty-four percent (48% NWH) were first time mothers. The mean birth weight of the infants was 3362g (3413g, NWH) and 9% (12% NWH) were preterm. Table 1. SIDS prevention factors cited by the mother SIDS prevention factor CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Sleep baby on back* 2020 206 (68.9) 234 (84.2) <0.0001 Dont smoke during pregnancy or around baby* 2020 76 (25.4) 202 (72.7) <0.0001 Avoid bed sharing during sleep* 2020 102 (34.1) 128 (46.0) 0.004 Breastfeed 2020 12 (4.0) 96 (34.5) <0.0001 Keep soft objects/loose bedding out of the cot; keep face clear* 129 (43.1) 77 (27.7) <0.0001 Avoid overheating* 11 (3.7) 74 (26.6) <0.0001 Use a firm sleep surface* 9 (3.0) 47(16.9) <0.0001 Use a pacifier at nap time and bedtime* 5 (1.7) 10 (3.6) 0.19 Sleep in same room as parent* 2020 14 (4.7) 4 (1.4) 0.03 Avoid using secondhand crib mattresses 0 (0.0) 26 (9.4) <0.0001 Other, e.g. avoid alcohol/drugs around baby, wrap mattress in plastic, use natural fibres, use clean bedding, aired sleeping space, new mattress, feet at end, wind well, etc. 76 (25.4) 67(24.1) 0.77 Wrong answer, e.g. side or prone sleeping 1 (5.0) 7 (2.5) 0.13 No risk factors known or listed 35 (11.7) 24 (8.6) 0.27 * AAP guidelines 2005 2020 NZ SUDI prevention guidelines 2008. SIDS prevention knowledge (Table 1)The most common SIDS prevention factor, cited by 69% of the mothers (84% NWH), was to sleep baby on its back. Smoking in pregnancy was mentioned as a risk factor by only 25% of mothers (73% NWH, p<0.0001). As the source of information, 72% of participants cited the midwife (54% NWH) while 56% cited Plunket (27% NWH). Only 6% (40% NWH) of the surveyed population said information came from an antenatal class. Eighty-three percent (70% NWH) however, reported receiving a pamphlet about SIDS prevention from the midwife, Plunket or the hospital (p=0.0002). Table 2. Position or positions in which baby placed to sleep Sleep position CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Last night Back only 210 (71.0) 201 (72.3) 0.65 Side only 56 (18.9) 39 (14.0) 0.14 Front only 18 (6.1) 4 (1.4) 0.004 Side & back 9 (3.0) 34 (12.2) <0.0001 Front +back 1 (0.3) Back+side+front 2 (0.7) Usually Back 170 (56.9) 180 (64.8) 0.06 Side 42 (14.1) 29 (10.4) 0.21 Front 13 (4.3) 8 (2.9) 0.30 Side & back 48 (16.0) 61(21.9) 0.08 Front +back 11 (3.7) Back+side+front 9 (3.0) Side+front 6 (2.0) Sleep position (Table 2)The 201cfront only 201d sleeping position was much more prevalent among M ori (6.1%) than European (1.4%) in the last night category than in the usually category (4 % CM vs 3%NWH). Overall, 13% (3% NWH) usually slept their infants in some combination of sleep positions that included front. The prevalence of usually slept on the side, on the side and back but not the front and the back only positions were similar between groups. Eighty-five percent of mothers choosing the unsafe side and prone positions gave 201cbaby sleeps better 201d as the reason. 201cSafety 201d (68%) and 201crecommended by health professional 201d (28%) were important reasons for the back position. Those who slept baby on the side plus on the back did so for 201cbetter sleep 201d (63%), 201csafety 201d (42%) and 201chead shape concerns 201d (27%). Unexpectedly, 27% of mothers who had cited back sleeping as a preventive factor for SIDS did not sleep the infant on the back. Overall, there were few (n=7) concerns expressed about the choice of sleep position. Table 3. What bed does baby sleep in? Bed CM survey Last night n (%) NWH Survey Last night n (%) CM survey Usually n (%) NWH Survey Usually n (%) Own bed 254 (85.8) 228 (82.3) 244 (81.6) 233 (83.8) Parental bed 27 (9.1) 29 (10.5) 24 (8.0) 24 (8.6) Both own+parental 13 (4.4) 18 (6.5) 28 (9.4) 18 (6.5) Other shared 2 (0.7) 2 (0.7) 3 (1.0) 2 (0.7) Table 4. How long did baby share a bed last night? Time CM survey (n=194) n (%) NWH survey (n=77) n (%) <2 hours 118 (60.8) 33 (42.9) 2-5 hours 38 (19.6) 13 (16.9) >5 hours 38 (19.6) 31 (40.3) Bed sharing/co-sleeping (Table 3 and 4)In response to the question 201cWhat bed does your baby sleep in? 201d most infants in this survey slept in their own bed last night (86%) and usually (82%), but nearly one fifth usually co-slept for some or all of the night. This is similar to the NWH survey. However, when enquiring in a different fashion, i.e. 201cIf baby shared a bed last night, how long did they share for? 201d 65% of mothers (194 of the 299) indicated some bed sharing (NWH 27%) and thirty-nine percent of those (57% NWH) shared for >2 hours. Reasons given for sharing a bed >5 hours varied as follows: 201cprefer closeness 201d (42%), 201cfor breastfeeding 201d (29%), 201cbaby sleeps better 201d (21%), 201ccan keep an eye on baby 201d (18%), 201cfor short naps or settling 201d (11%), and 201cfor cuddles/play/bonding 201d (8%). For mothers in Table 3 who reported usually participating in some bed-sharing, 87% had no concerns, but 9% expressed concerns about the safety of doing so. SmokingIn pregnancy, 53% of mothers had smoked (8% NWH), with a mean of 8 (SD 5.6) cigarettes per day. In the last 24 hours, 51% had smoked. The reported maternal smoking in the M ori mothers was identical to that of M ori women in the NZ Tobacco Use Survey, 2005,11 but the much lower rate reported for European mothers in the 2005 survey was markedly below the known 19% prevalence.11 In other words, European mothers either did not report their smoking in pregnancy or stopped smoking. M ori did not. Worse, 21% of mothers (1% NWH) both smoked in pregnancy and sometimes or always co-slept with their infant. BreastfeedingMothers who reported ever breastfeeding their infants comprised 91%, (97% NWH) although only 74% of 6-8 week infants and 51% of 3-4 month infants were still breastfeeding at the time of the survey. Survival curve analysis of the time of breastfeeding cessation showed that M ori mothers stopped breastfeeding significantly earlier than the 2005 survey mothers (p<0.0001) (Figure 1). When compared with the 2005 survey, Cox regression analysis of other factors associated with earlier cessation of breastfeeding was significant for mothers aged under 20 (p=0.04), maternal smoking during pregnancy (p=0.005), and the use of a pacifier (p=0.0002). Bed sharing was not associated with breastfeeding cessation. Figure 1. Breastfeeding cessation survival curve analysis: M ori survey compared with 2005 survey Positioning devicesWhile 46% of mothers (32% NWH) used a positioning system of some sort, only a few (10%) were of a commercial variety, and 36% of M ori infants had an unsafe homemade positioning system such as a pillow, rolled blanket or tight wrapping. The main reasons for these included 201ckeep baby positioned 201d, 201csafety 201d and 201chelp baby feel secure 201d. Very few mothers had any concerns about positioning systems. Discussion This survey has established for M ori mothers some previously unknown points regarding SIDS related knowledge and infant care practices. It has established the prevalence of M ori infant co-sleeping where there was smoking in pregnancy (21%), an extremely high-risk practice, with a greatly increased SIDS risk, particularly in younger infants,12 with odds ratios ranging from 5 to 29.13 Habitual prone sleeping (13%) and the presence of soft objects in the sleeping environment (36%) have been clearly demonstrated. These are the most commonly reported risk related occurrences in SIDS deaths.4 The survey has also highlighted important differences between M ori and European women and because the European study data is only 3 years older than the present M ori study data, there seems little to preclude such a comparison. Secondly, it seems that these behaviours may well be related to the reported poor knowledge of SIDS related information among M ori mothers. The effectiveness of the national SIDS-related health promotion programme and the relevance of its messages for the known high risk group in New Zealand are therefore bought into question. The early cessation of breastfeeding among M ori mothers and the poor awareness of smoking as a SIDS risk factors are outstanding examples of this. Lastly, we found that participants were far more likely to have heard the information that they did know from a midwife, from Plunket or from the hospital rather than from an antenatal class and this fits well with the known low attendance of antenatal class by M ori women.14 It seems therefore that both the currently mandated formats of imparting infant care related health promotion messages fail M ori mothers. Current smoking cessation programmes are not adequately meeting the needs of M ori women, particularly those who are pregnant15this is despite a recent survey by Wilson et al showing that 85% of M ori smokers wished they had never started smoking.16 Action to urgently support M ori smoking cessation in pregnancy was called for in 2003,17 but no M ori oriented action has eventuated. Stuck in the old public health mode of providing equitably for everyone, we have been unable to grasp the arguably more effective approach of dealing directly with the preventive health needs of the high risk M ori community. In addition, safe sleeping environments messages have revolved around the dont bedshare approach and those at highest risk among this M ori group have rejected this.8 M ori messages need to gain priority. Indeed, a M ori community promoted safe sleeping environment, the wahakura (a woven flax bassinet capable of being taken into the shared bed) takes an alternate approach of attempting to make the bed-sharing/co-sleeping environment more safe.18 Notably, two of the three recommendations of the recent 2009 Child and Youth Mortality Review Committees Fifth Report to the Minister of Health are about smoking in pregnancy and safe sleeping environmentsparticularly pertinent to M ori infants.4 Participation in this survey has been smaller than desiredbut 315 of the potential cohort of 734 were unable to be contacted and transience of members of the lower socioeconomic communities explains this. On the other hand, the 95.5% participation by those able to be contacted, speaks for the success of the sampling strategy, that is, contact by researchers of the same sex and same ethnicity with follow-up by home visiting. Notwithstanding the participation rate of only 41%, the extrapolation analysis from the available data of those non-contactable, reassures us that we have valid data overall. The number of invalid phone numbers again attests to the transiency of residence in this socioeconomic group. Increasing the recruitment would demand a strategy where the research was seen to have arisen from and to be based in the community of interest. Conclusions Despite limitations, this study has highlighted important information about the current state of knowledge among M ori mothers about child care practices and the prevalence of and the reasons for using such practices. The challenge now is to develop health promotion tools that are appropriate in this community and that might improve knowledge and therefore change behaviour, particularly with regard to smoking cessation, safe sleep position, safe sleeping environments, and duration of breastfeeding.

Summary

Abstract

Aim

M ori have high SIDS rates and relevant information is needed to craft appropriate prevention strategies. The aim of the study was to determine what M ori mothers know about SIDS prevention, and to determine their SIDS-related child care practices.

Method

M ori mothers who gave birth in the Counties Manukau District Health Board area were surveyed about their SIDS related knowledge, and infant care practices and their reasons for using and their concerns about these practices. Results were compared with a similar 2005 survey of a largely European sample.

Results

Knowledge of M ori mothers about SIDS prevention was much lower than for European mothers. More M ori infants slept prone and M ori mothers stopped breastfeeding significantly earlier. Although co-sleeping rates were similar, bedsharing increased to 65% for some part of the night. In addition, more than half of the M ori mothers had smoked in pregnancy and 21% of them were sharing a bed with their infant. Potentially unsafe soft objects such as rolled blankets or pillows were used by a third of mothers to help maintain the sleep position.

Conclusion

M ori mothers have a poorer knowledge of SIDS prevention practices. The high rate of maternal smoking, the early cessation of breastfeeding, and co-sleeping where there was smoking in pregnancy were also areas of concern. Appropriate health promotion measures need to be developed for the high-risk M ori community.

Author Information

David Tipene-Leach, General practitioner, Hauora Heretaunga, Hastings; Lynne Hutchison, Research Fellow, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland; Angeline Tangiora, Research Officer, M ori SIDS, School of Population Health, University of Auckland, Auckland; Charlotte Rea, Medical Student, The University of Auckland, Auckland; Rebecca White, Medical Student, The University of Auckland, Auckland; Alistair Stewart, Biostatistician, School of Population Health, The University of Auckland, Auckland; Edwin Mitchell, Professor of Child Health Research, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland

Acknowledgements

We are indebted to the M ori SIDS Team and the Child Health Research Foundation for the funding they provided for this summer studentship project. Our thanks also go to the mothers who provided the information.

Correspondence

Dr David Tipene-Leach. Hauora Heretaunga, 821 Orchard Rd, Hastings, New Zealand. Fax: +64 (0)6 8704823

Correspondence Email

dtipene@xtra.co.nz

Competing Interests

None.

-  Hutchison L, Stewart A, Mitchell E. Infant sleep position, head shape concerns, and sleep positioning devices. J Paediatr Child Health. 2007;43(4):243-8.--  Hutchison L, Stewart AW, Mitchell E. SIDS-protective infant care practices among Auckland, New Zealand mothers. N Z Med J. 2006;119(1247):U2365.--  Ministry of Health. Preventing sudden unexpected death in infancy: Information for health practitioner. 2008 April 2008.--  Child and Youth Mortality Review Committee. Fifth Report to the Minister of Health: Reporting Mortality 2002-2008. December 2009.--  Mantell CD, Craig ED, Stewart AW, et al. Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 2. Pregnancy outcomes for M ori women. Aust N Z J Obstet Gynaecol. 2004;44(6):537-40.--  Tipene-Leach D, Abel S, Finau SA, et al. M ori infant care practices: implications for health messages, infant care services and SIDS prevention in M ori communities. Pac Health Dialog. 2000;7(1):29-37.--  Tipene-Leach D, Abel S, Haretuku R, Everard C. The M ori SIDS Prevention programme: Challenges and implications for M ori health service development. Soc Policy J NZ. 2000;14:65-77.--  Tipene-Leach D, Haretuku R. Developing messages for M ori New Zealanders. Mothering. July 2002.--  Ministry of Health. Fetal and Infant Deaths 2005. Wellington: Ministry of Health; 2009.http://www.moh.govt.nz/moh.nsf/Files/fetalinfantdeaths/$file/fetal2005-sep09.pdf--  Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation User's Manual. 2007.--  Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; 2007.--  Horsley T, Clifford T, Barrowman N, et al. Benefits and harms associated with the practice of bed sharing: a systematic review. Arch Pediatr Adolesc Med. 2007;161(3):237-45.--  Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-42.--  Dwyer S. Childbirth education: Antenatal education and transitions of maternity care in New Zealand: Families Commission and Parents Centre. 2009.--  McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J. 2003;116(1173):U418.--  Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122(1292):99-100.--  Wilson N, Thomson G, Howden-Chapman P. Supporting smoking cessation in pregnancy--action is urgently needed. N Z Med J. 2003;116(1173):U415.--  Tipene-Leach D, Abel S. The wahakura and the safe sleeping environment. Journal of Primary Health Care. 2010; 2(1): 81.-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

In 2005, a survey of mostly European mothers who birthed at National Womens Hospital (NWH) in Auckland, New Zealand demonstrated that the benefits of supine sleeping, not smoking, and breastfeeding appeared to be well understood but that more education about keeping the face clear and sleeping in the parents room was needed.1,2 Although these recognized sudden infant death syndrome (SIDS) risk factors have been incorporated into New Zealand health care,3 M ori infants continue to have higher SIDS rates than the general population.4 Living in socioeconomic deprivation and having reduced access to health care has made health promotion more difficult;5,6 in particular, around the issue of bed-sharing/co-sleeping when associated with maternal smoking in pregnancy.6-8 SIDS is the leading cause of preventable death in the post-neonatal period and rates have been falling over the past two decades. Although M ori SIDS rates have fallen from 9.9 per 1000 live births in 1984 to 1.6 per 1000 live births in 2002, 70% of the 40 SIDS deaths in 2005 were M ori and the M ori SIDS rate was five times that of non-M ori, non-Pacific infants.4 In addition, M ori rates of sudden unexpected deaths in infancy have not declined over the 2002-2008 period.9 Information on SIDS-related knowledge and infant care practice by M ori mothers is therefore needed. In 2008 therefore, a 2005 survey protocol that investigated these issues with a largely European sample was repeated with M ori mothers in the Counties Manukau (CM) District Health Board area. Methods In the period 21 July to 31 December 2008, 734 eligible M ori women gave birth in the Counties Manukau region. Mothers were ineligible if they had had a previous SIDS experience or their infants had not yet been discharged from hospital. The mothers demographic details, parity and smoking status and the infants date of birth, National Health Index number, transfer/discharge details, birth-weight and gestation were collected from the birth records. A pathologist checked infant mortality records to ensure none of the infants belonging to listed mothers had died. In order to better recruit M ori mothers to this survey we elected to use a telephone rather than postal contact, to use M ori women as interviewers (second year medical students on Summer Student Research Scholarships) and to home visit if telephone contact was not made. An attempt was made to phone the mothers when the infants were either 6-8 week or 3-4 month of age, as per the 2005 study protocol. If successful, they were given an explanation of the research and were invited to participate either by telephone interview or a home visit. If unsuccessful, they were phoned repeatedly until the babies fell out of the age brackets. Some, who were unable to be contacted, were visited at their home addresses and, if home, were invited to take part. Participants were asked to list all factors that they thought might help reduce the risk of SIDS, and from where and from whom they had received their information. The interviewers enquired about current practices of maternal smoking, breastfeeding and both last night and usual practice infant sleep position and bed sharing. In addition, participants were asked about room sharing, pacifier use, plastic mattress wrapping, head shape concerns and positioning devices. Their concerns about and reasons for using these practices was also surveyed. An information sheet regarding the research project, SIDS prevention pamphlets, and a small token of appreciation (a $20 petrol voucher) were later posted to the mother. The socioeconomic status of each infant was derived from the NZDep2006 code10 based on the mesh block of the place of residence. The survey results from the two age groups were compared and then the overall data were compared to the previous survey in 2005 using the chi-square test. Survival analysis was used to compare breastfeeding cessation differences between the two surveys. To estimate the proportion of bed-sharing in the non-participants, the observed number was extrapolated within socioeconomic categories and then summed to give an estimate of the number sleeping in their own bed. Division of this number by the number of births gave the population proportion. The study received ethical approval from the Auckland Regional Ethics Committee and the Counties Manukau Clinical Board. Results ParticipantsOf the 734 eligible mothers, 315 were able to be contacted via telephone or home visit and of these, 16 declined to participate, leaving 299 (41%) of the cohort who participated. Of those who were not contactable 22% had an invalid telephone number or address, 66% continually did not answer their phone and 12% had babies who fell out of the age range during the contact period. Non-participantsThose who participated in the study were compared with the non-contactable/declined families. Information on geographical location, maternal age, maternal smoking, parity, infant birth weight and gestation was available for the non-participant group. Non-participating mothers were more likely to be smokers (p=0.004), to be multiparous (p=0.04) and were of lower socioeconomic status (p=0.006) than the participants. This difference may have some influence on the estimates derived from the survey, in particular, bed-sharing. In the non-participants this was estimated using geocodes and smoking status, and there was little difference between the participants and the non-participants for either analysis. Participant demographicsThere were no significant differences between the 6-8 week (n=123) and the 3-4 month (n=176) aged infant groups for any of the variables studied and, as in the 2005 survey, the results were pooled. The M ori mothers were younger (26 years, SD 6.5) than the NWH mothers (33 years, SD 5.1). Eighteen percent (1% NWH) were under the age of 20 and 26% (5% NWH) were between 20-24 years of age. Thirty-four percent (48% NWH) were first time mothers. The mean birth weight of the infants was 3362g (3413g, NWH) and 9% (12% NWH) were preterm. Table 1. SIDS prevention factors cited by the mother SIDS prevention factor CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Sleep baby on back* 2020 206 (68.9) 234 (84.2) <0.0001 Dont smoke during pregnancy or around baby* 2020 76 (25.4) 202 (72.7) <0.0001 Avoid bed sharing during sleep* 2020 102 (34.1) 128 (46.0) 0.004 Breastfeed 2020 12 (4.0) 96 (34.5) <0.0001 Keep soft objects/loose bedding out of the cot; keep face clear* 129 (43.1) 77 (27.7) <0.0001 Avoid overheating* 11 (3.7) 74 (26.6) <0.0001 Use a firm sleep surface* 9 (3.0) 47(16.9) <0.0001 Use a pacifier at nap time and bedtime* 5 (1.7) 10 (3.6) 0.19 Sleep in same room as parent* 2020 14 (4.7) 4 (1.4) 0.03 Avoid using secondhand crib mattresses 0 (0.0) 26 (9.4) <0.0001 Other, e.g. avoid alcohol/drugs around baby, wrap mattress in plastic, use natural fibres, use clean bedding, aired sleeping space, new mattress, feet at end, wind well, etc. 76 (25.4) 67(24.1) 0.77 Wrong answer, e.g. side or prone sleeping 1 (5.0) 7 (2.5) 0.13 No risk factors known or listed 35 (11.7) 24 (8.6) 0.27 * AAP guidelines 2005 2020 NZ SUDI prevention guidelines 2008. SIDS prevention knowledge (Table 1)The most common SIDS prevention factor, cited by 69% of the mothers (84% NWH), was to sleep baby on its back. Smoking in pregnancy was mentioned as a risk factor by only 25% of mothers (73% NWH, p<0.0001). As the source of information, 72% of participants cited the midwife (54% NWH) while 56% cited Plunket (27% NWH). Only 6% (40% NWH) of the surveyed population said information came from an antenatal class. Eighty-three percent (70% NWH) however, reported receiving a pamphlet about SIDS prevention from the midwife, Plunket or the hospital (p=0.0002). Table 2. Position or positions in which baby placed to sleep Sleep position CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Last night Back only 210 (71.0) 201 (72.3) 0.65 Side only 56 (18.9) 39 (14.0) 0.14 Front only 18 (6.1) 4 (1.4) 0.004 Side & back 9 (3.0) 34 (12.2) <0.0001 Front +back 1 (0.3) Back+side+front 2 (0.7) Usually Back 170 (56.9) 180 (64.8) 0.06 Side 42 (14.1) 29 (10.4) 0.21 Front 13 (4.3) 8 (2.9) 0.30 Side & back 48 (16.0) 61(21.9) 0.08 Front +back 11 (3.7) Back+side+front 9 (3.0) Side+front 6 (2.0) Sleep position (Table 2)The 201cfront only 201d sleeping position was much more prevalent among M ori (6.1%) than European (1.4%) in the last night category than in the usually category (4 % CM vs 3%NWH). Overall, 13% (3% NWH) usually slept their infants in some combination of sleep positions that included front. The prevalence of usually slept on the side, on the side and back but not the front and the back only positions were similar between groups. Eighty-five percent of mothers choosing the unsafe side and prone positions gave 201cbaby sleeps better 201d as the reason. 201cSafety 201d (68%) and 201crecommended by health professional 201d (28%) were important reasons for the back position. Those who slept baby on the side plus on the back did so for 201cbetter sleep 201d (63%), 201csafety 201d (42%) and 201chead shape concerns 201d (27%). Unexpectedly, 27% of mothers who had cited back sleeping as a preventive factor for SIDS did not sleep the infant on the back. Overall, there were few (n=7) concerns expressed about the choice of sleep position. Table 3. What bed does baby sleep in? Bed CM survey Last night n (%) NWH Survey Last night n (%) CM survey Usually n (%) NWH Survey Usually n (%) Own bed 254 (85.8) 228 (82.3) 244 (81.6) 233 (83.8) Parental bed 27 (9.1) 29 (10.5) 24 (8.0) 24 (8.6) Both own+parental 13 (4.4) 18 (6.5) 28 (9.4) 18 (6.5) Other shared 2 (0.7) 2 (0.7) 3 (1.0) 2 (0.7) Table 4. How long did baby share a bed last night? Time CM survey (n=194) n (%) NWH survey (n=77) n (%) <2 hours 118 (60.8) 33 (42.9) 2-5 hours 38 (19.6) 13 (16.9) >5 hours 38 (19.6) 31 (40.3) Bed sharing/co-sleeping (Table 3 and 4)In response to the question 201cWhat bed does your baby sleep in? 201d most infants in this survey slept in their own bed last night (86%) and usually (82%), but nearly one fifth usually co-slept for some or all of the night. This is similar to the NWH survey. However, when enquiring in a different fashion, i.e. 201cIf baby shared a bed last night, how long did they share for? 201d 65% of mothers (194 of the 299) indicated some bed sharing (NWH 27%) and thirty-nine percent of those (57% NWH) shared for >2 hours. Reasons given for sharing a bed >5 hours varied as follows: 201cprefer closeness 201d (42%), 201cfor breastfeeding 201d (29%), 201cbaby sleeps better 201d (21%), 201ccan keep an eye on baby 201d (18%), 201cfor short naps or settling 201d (11%), and 201cfor cuddles/play/bonding 201d (8%). For mothers in Table 3 who reported usually participating in some bed-sharing, 87% had no concerns, but 9% expressed concerns about the safety of doing so. SmokingIn pregnancy, 53% of mothers had smoked (8% NWH), with a mean of 8 (SD 5.6) cigarettes per day. In the last 24 hours, 51% had smoked. The reported maternal smoking in the M ori mothers was identical to that of M ori women in the NZ Tobacco Use Survey, 2005,11 but the much lower rate reported for European mothers in the 2005 survey was markedly below the known 19% prevalence.11 In other words, European mothers either did not report their smoking in pregnancy or stopped smoking. M ori did not. Worse, 21% of mothers (1% NWH) both smoked in pregnancy and sometimes or always co-slept with their infant. BreastfeedingMothers who reported ever breastfeeding their infants comprised 91%, (97% NWH) although only 74% of 6-8 week infants and 51% of 3-4 month infants were still breastfeeding at the time of the survey. Survival curve analysis of the time of breastfeeding cessation showed that M ori mothers stopped breastfeeding significantly earlier than the 2005 survey mothers (p<0.0001) (Figure 1). When compared with the 2005 survey, Cox regression analysis of other factors associated with earlier cessation of breastfeeding was significant for mothers aged under 20 (p=0.04), maternal smoking during pregnancy (p=0.005), and the use of a pacifier (p=0.0002). Bed sharing was not associated with breastfeeding cessation. Figure 1. Breastfeeding cessation survival curve analysis: M ori survey compared with 2005 survey Positioning devicesWhile 46% of mothers (32% NWH) used a positioning system of some sort, only a few (10%) were of a commercial variety, and 36% of M ori infants had an unsafe homemade positioning system such as a pillow, rolled blanket or tight wrapping. The main reasons for these included 201ckeep baby positioned 201d, 201csafety 201d and 201chelp baby feel secure 201d. Very few mothers had any concerns about positioning systems. Discussion This survey has established for M ori mothers some previously unknown points regarding SIDS related knowledge and infant care practices. It has established the prevalence of M ori infant co-sleeping where there was smoking in pregnancy (21%), an extremely high-risk practice, with a greatly increased SIDS risk, particularly in younger infants,12 with odds ratios ranging from 5 to 29.13 Habitual prone sleeping (13%) and the presence of soft objects in the sleeping environment (36%) have been clearly demonstrated. These are the most commonly reported risk related occurrences in SIDS deaths.4 The survey has also highlighted important differences between M ori and European women and because the European study data is only 3 years older than the present M ori study data, there seems little to preclude such a comparison. Secondly, it seems that these behaviours may well be related to the reported poor knowledge of SIDS related information among M ori mothers. The effectiveness of the national SIDS-related health promotion programme and the relevance of its messages for the known high risk group in New Zealand are therefore bought into question. The early cessation of breastfeeding among M ori mothers and the poor awareness of smoking as a SIDS risk factors are outstanding examples of this. Lastly, we found that participants were far more likely to have heard the information that they did know from a midwife, from Plunket or from the hospital rather than from an antenatal class and this fits well with the known low attendance of antenatal class by M ori women.14 It seems therefore that both the currently mandated formats of imparting infant care related health promotion messages fail M ori mothers. Current smoking cessation programmes are not adequately meeting the needs of M ori women, particularly those who are pregnant15this is despite a recent survey by Wilson et al showing that 85% of M ori smokers wished they had never started smoking.16 Action to urgently support M ori smoking cessation in pregnancy was called for in 2003,17 but no M ori oriented action has eventuated. Stuck in the old public health mode of providing equitably for everyone, we have been unable to grasp the arguably more effective approach of dealing directly with the preventive health needs of the high risk M ori community. In addition, safe sleeping environments messages have revolved around the dont bedshare approach and those at highest risk among this M ori group have rejected this.8 M ori messages need to gain priority. Indeed, a M ori community promoted safe sleeping environment, the wahakura (a woven flax bassinet capable of being taken into the shared bed) takes an alternate approach of attempting to make the bed-sharing/co-sleeping environment more safe.18 Notably, two of the three recommendations of the recent 2009 Child and Youth Mortality Review Committees Fifth Report to the Minister of Health are about smoking in pregnancy and safe sleeping environmentsparticularly pertinent to M ori infants.4 Participation in this survey has been smaller than desiredbut 315 of the potential cohort of 734 were unable to be contacted and transience of members of the lower socioeconomic communities explains this. On the other hand, the 95.5% participation by those able to be contacted, speaks for the success of the sampling strategy, that is, contact by researchers of the same sex and same ethnicity with follow-up by home visiting. Notwithstanding the participation rate of only 41%, the extrapolation analysis from the available data of those non-contactable, reassures us that we have valid data overall. The number of invalid phone numbers again attests to the transiency of residence in this socioeconomic group. Increasing the recruitment would demand a strategy where the research was seen to have arisen from and to be based in the community of interest. Conclusions Despite limitations, this study has highlighted important information about the current state of knowledge among M ori mothers about child care practices and the prevalence of and the reasons for using such practices. The challenge now is to develop health promotion tools that are appropriate in this community and that might improve knowledge and therefore change behaviour, particularly with regard to smoking cessation, safe sleep position, safe sleeping environments, and duration of breastfeeding.

Summary

Abstract

Aim

M ori have high SIDS rates and relevant information is needed to craft appropriate prevention strategies. The aim of the study was to determine what M ori mothers know about SIDS prevention, and to determine their SIDS-related child care practices.

Method

M ori mothers who gave birth in the Counties Manukau District Health Board area were surveyed about their SIDS related knowledge, and infant care practices and their reasons for using and their concerns about these practices. Results were compared with a similar 2005 survey of a largely European sample.

Results

Knowledge of M ori mothers about SIDS prevention was much lower than for European mothers. More M ori infants slept prone and M ori mothers stopped breastfeeding significantly earlier. Although co-sleeping rates were similar, bedsharing increased to 65% for some part of the night. In addition, more than half of the M ori mothers had smoked in pregnancy and 21% of them were sharing a bed with their infant. Potentially unsafe soft objects such as rolled blankets or pillows were used by a third of mothers to help maintain the sleep position.

Conclusion

M ori mothers have a poorer knowledge of SIDS prevention practices. The high rate of maternal smoking, the early cessation of breastfeeding, and co-sleeping where there was smoking in pregnancy were also areas of concern. Appropriate health promotion measures need to be developed for the high-risk M ori community.

Author Information

David Tipene-Leach, General practitioner, Hauora Heretaunga, Hastings; Lynne Hutchison, Research Fellow, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland; Angeline Tangiora, Research Officer, M ori SIDS, School of Population Health, University of Auckland, Auckland; Charlotte Rea, Medical Student, The University of Auckland, Auckland; Rebecca White, Medical Student, The University of Auckland, Auckland; Alistair Stewart, Biostatistician, School of Population Health, The University of Auckland, Auckland; Edwin Mitchell, Professor of Child Health Research, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland

Acknowledgements

We are indebted to the M ori SIDS Team and the Child Health Research Foundation for the funding they provided for this summer studentship project. Our thanks also go to the mothers who provided the information.

Correspondence

Dr David Tipene-Leach. Hauora Heretaunga, 821 Orchard Rd, Hastings, New Zealand. Fax: +64 (0)6 8704823

Correspondence Email

dtipene@xtra.co.nz

Competing Interests

None.

-  Hutchison L, Stewart A, Mitchell E. Infant sleep position, head shape concerns, and sleep positioning devices. J Paediatr Child Health. 2007;43(4):243-8.--  Hutchison L, Stewart AW, Mitchell E. SIDS-protective infant care practices among Auckland, New Zealand mothers. N Z Med J. 2006;119(1247):U2365.--  Ministry of Health. Preventing sudden unexpected death in infancy: Information for health practitioner. 2008 April 2008.--  Child and Youth Mortality Review Committee. Fifth Report to the Minister of Health: Reporting Mortality 2002-2008. December 2009.--  Mantell CD, Craig ED, Stewart AW, et al. Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 2. Pregnancy outcomes for M ori women. Aust N Z J Obstet Gynaecol. 2004;44(6):537-40.--  Tipene-Leach D, Abel S, Finau SA, et al. M ori infant care practices: implications for health messages, infant care services and SIDS prevention in M ori communities. Pac Health Dialog. 2000;7(1):29-37.--  Tipene-Leach D, Abel S, Haretuku R, Everard C. The M ori SIDS Prevention programme: Challenges and implications for M ori health service development. Soc Policy J NZ. 2000;14:65-77.--  Tipene-Leach D, Haretuku R. Developing messages for M ori New Zealanders. Mothering. July 2002.--  Ministry of Health. Fetal and Infant Deaths 2005. Wellington: Ministry of Health; 2009.http://www.moh.govt.nz/moh.nsf/Files/fetalinfantdeaths/$file/fetal2005-sep09.pdf--  Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation User's Manual. 2007.--  Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; 2007.--  Horsley T, Clifford T, Barrowman N, et al. Benefits and harms associated with the practice of bed sharing: a systematic review. Arch Pediatr Adolesc Med. 2007;161(3):237-45.--  Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-42.--  Dwyer S. Childbirth education: Antenatal education and transitions of maternity care in New Zealand: Families Commission and Parents Centre. 2009.--  McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J. 2003;116(1173):U418.--  Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122(1292):99-100.--  Wilson N, Thomson G, Howden-Chapman P. Supporting smoking cessation in pregnancy--action is urgently needed. N Z Med J. 2003;116(1173):U415.--  Tipene-Leach D, Abel S. The wahakura and the safe sleeping environment. Journal of Primary Health Care. 2010; 2(1): 81.-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

In 2005, a survey of mostly European mothers who birthed at National Womens Hospital (NWH) in Auckland, New Zealand demonstrated that the benefits of supine sleeping, not smoking, and breastfeeding appeared to be well understood but that more education about keeping the face clear and sleeping in the parents room was needed.1,2 Although these recognized sudden infant death syndrome (SIDS) risk factors have been incorporated into New Zealand health care,3 M ori infants continue to have higher SIDS rates than the general population.4 Living in socioeconomic deprivation and having reduced access to health care has made health promotion more difficult;5,6 in particular, around the issue of bed-sharing/co-sleeping when associated with maternal smoking in pregnancy.6-8 SIDS is the leading cause of preventable death in the post-neonatal period and rates have been falling over the past two decades. Although M ori SIDS rates have fallen from 9.9 per 1000 live births in 1984 to 1.6 per 1000 live births in 2002, 70% of the 40 SIDS deaths in 2005 were M ori and the M ori SIDS rate was five times that of non-M ori, non-Pacific infants.4 In addition, M ori rates of sudden unexpected deaths in infancy have not declined over the 2002-2008 period.9 Information on SIDS-related knowledge and infant care practice by M ori mothers is therefore needed. In 2008 therefore, a 2005 survey protocol that investigated these issues with a largely European sample was repeated with M ori mothers in the Counties Manukau (CM) District Health Board area. Methods In the period 21 July to 31 December 2008, 734 eligible M ori women gave birth in the Counties Manukau region. Mothers were ineligible if they had had a previous SIDS experience or their infants had not yet been discharged from hospital. The mothers demographic details, parity and smoking status and the infants date of birth, National Health Index number, transfer/discharge details, birth-weight and gestation were collected from the birth records. A pathologist checked infant mortality records to ensure none of the infants belonging to listed mothers had died. In order to better recruit M ori mothers to this survey we elected to use a telephone rather than postal contact, to use M ori women as interviewers (second year medical students on Summer Student Research Scholarships) and to home visit if telephone contact was not made. An attempt was made to phone the mothers when the infants were either 6-8 week or 3-4 month of age, as per the 2005 study protocol. If successful, they were given an explanation of the research and were invited to participate either by telephone interview or a home visit. If unsuccessful, they were phoned repeatedly until the babies fell out of the age brackets. Some, who were unable to be contacted, were visited at their home addresses and, if home, were invited to take part. Participants were asked to list all factors that they thought might help reduce the risk of SIDS, and from where and from whom they had received their information. The interviewers enquired about current practices of maternal smoking, breastfeeding and both last night and usual practice infant sleep position and bed sharing. In addition, participants were asked about room sharing, pacifier use, plastic mattress wrapping, head shape concerns and positioning devices. Their concerns about and reasons for using these practices was also surveyed. An information sheet regarding the research project, SIDS prevention pamphlets, and a small token of appreciation (a $20 petrol voucher) were later posted to the mother. The socioeconomic status of each infant was derived from the NZDep2006 code10 based on the mesh block of the place of residence. The survey results from the two age groups were compared and then the overall data were compared to the previous survey in 2005 using the chi-square test. Survival analysis was used to compare breastfeeding cessation differences between the two surveys. To estimate the proportion of bed-sharing in the non-participants, the observed number was extrapolated within socioeconomic categories and then summed to give an estimate of the number sleeping in their own bed. Division of this number by the number of births gave the population proportion. The study received ethical approval from the Auckland Regional Ethics Committee and the Counties Manukau Clinical Board. Results ParticipantsOf the 734 eligible mothers, 315 were able to be contacted via telephone or home visit and of these, 16 declined to participate, leaving 299 (41%) of the cohort who participated. Of those who were not contactable 22% had an invalid telephone number or address, 66% continually did not answer their phone and 12% had babies who fell out of the age range during the contact period. Non-participantsThose who participated in the study were compared with the non-contactable/declined families. Information on geographical location, maternal age, maternal smoking, parity, infant birth weight and gestation was available for the non-participant group. Non-participating mothers were more likely to be smokers (p=0.004), to be multiparous (p=0.04) and were of lower socioeconomic status (p=0.006) than the participants. This difference may have some influence on the estimates derived from the survey, in particular, bed-sharing. In the non-participants this was estimated using geocodes and smoking status, and there was little difference between the participants and the non-participants for either analysis. Participant demographicsThere were no significant differences between the 6-8 week (n=123) and the 3-4 month (n=176) aged infant groups for any of the variables studied and, as in the 2005 survey, the results were pooled. The M ori mothers were younger (26 years, SD 6.5) than the NWH mothers (33 years, SD 5.1). Eighteen percent (1% NWH) were under the age of 20 and 26% (5% NWH) were between 20-24 years of age. Thirty-four percent (48% NWH) were first time mothers. The mean birth weight of the infants was 3362g (3413g, NWH) and 9% (12% NWH) were preterm. Table 1. SIDS prevention factors cited by the mother SIDS prevention factor CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Sleep baby on back* 2020 206 (68.9) 234 (84.2) <0.0001 Dont smoke during pregnancy or around baby* 2020 76 (25.4) 202 (72.7) <0.0001 Avoid bed sharing during sleep* 2020 102 (34.1) 128 (46.0) 0.004 Breastfeed 2020 12 (4.0) 96 (34.5) <0.0001 Keep soft objects/loose bedding out of the cot; keep face clear* 129 (43.1) 77 (27.7) <0.0001 Avoid overheating* 11 (3.7) 74 (26.6) <0.0001 Use a firm sleep surface* 9 (3.0) 47(16.9) <0.0001 Use a pacifier at nap time and bedtime* 5 (1.7) 10 (3.6) 0.19 Sleep in same room as parent* 2020 14 (4.7) 4 (1.4) 0.03 Avoid using secondhand crib mattresses 0 (0.0) 26 (9.4) <0.0001 Other, e.g. avoid alcohol/drugs around baby, wrap mattress in plastic, use natural fibres, use clean bedding, aired sleeping space, new mattress, feet at end, wind well, etc. 76 (25.4) 67(24.1) 0.77 Wrong answer, e.g. side or prone sleeping 1 (5.0) 7 (2.5) 0.13 No risk factors known or listed 35 (11.7) 24 (8.6) 0.27 * AAP guidelines 2005 2020 NZ SUDI prevention guidelines 2008. SIDS prevention knowledge (Table 1)The most common SIDS prevention factor, cited by 69% of the mothers (84% NWH), was to sleep baby on its back. Smoking in pregnancy was mentioned as a risk factor by only 25% of mothers (73% NWH, p<0.0001). As the source of information, 72% of participants cited the midwife (54% NWH) while 56% cited Plunket (27% NWH). Only 6% (40% NWH) of the surveyed population said information came from an antenatal class. Eighty-three percent (70% NWH) however, reported receiving a pamphlet about SIDS prevention from the midwife, Plunket or the hospital (p=0.0002). Table 2. Position or positions in which baby placed to sleep Sleep position CM Survey (n=299) n (%) NWH Survey (n=278) n (%) P value Last night Back only 210 (71.0) 201 (72.3) 0.65 Side only 56 (18.9) 39 (14.0) 0.14 Front only 18 (6.1) 4 (1.4) 0.004 Side & back 9 (3.0) 34 (12.2) <0.0001 Front +back 1 (0.3) Back+side+front 2 (0.7) Usually Back 170 (56.9) 180 (64.8) 0.06 Side 42 (14.1) 29 (10.4) 0.21 Front 13 (4.3) 8 (2.9) 0.30 Side & back 48 (16.0) 61(21.9) 0.08 Front +back 11 (3.7) Back+side+front 9 (3.0) Side+front 6 (2.0) Sleep position (Table 2)The 201cfront only 201d sleeping position was much more prevalent among M ori (6.1%) than European (1.4%) in the last night category than in the usually category (4 % CM vs 3%NWH). Overall, 13% (3% NWH) usually slept their infants in some combination of sleep positions that included front. The prevalence of usually slept on the side, on the side and back but not the front and the back only positions were similar between groups. Eighty-five percent of mothers choosing the unsafe side and prone positions gave 201cbaby sleeps better 201d as the reason. 201cSafety 201d (68%) and 201crecommended by health professional 201d (28%) were important reasons for the back position. Those who slept baby on the side plus on the back did so for 201cbetter sleep 201d (63%), 201csafety 201d (42%) and 201chead shape concerns 201d (27%). Unexpectedly, 27% of mothers who had cited back sleeping as a preventive factor for SIDS did not sleep the infant on the back. Overall, there were few (n=7) concerns expressed about the choice of sleep position. Table 3. What bed does baby sleep in? Bed CM survey Last night n (%) NWH Survey Last night n (%) CM survey Usually n (%) NWH Survey Usually n (%) Own bed 254 (85.8) 228 (82.3) 244 (81.6) 233 (83.8) Parental bed 27 (9.1) 29 (10.5) 24 (8.0) 24 (8.6) Both own+parental 13 (4.4) 18 (6.5) 28 (9.4) 18 (6.5) Other shared 2 (0.7) 2 (0.7) 3 (1.0) 2 (0.7) Table 4. How long did baby share a bed last night? Time CM survey (n=194) n (%) NWH survey (n=77) n (%) <2 hours 118 (60.8) 33 (42.9) 2-5 hours 38 (19.6) 13 (16.9) >5 hours 38 (19.6) 31 (40.3) Bed sharing/co-sleeping (Table 3 and 4)In response to the question 201cWhat bed does your baby sleep in? 201d most infants in this survey slept in their own bed last night (86%) and usually (82%), but nearly one fifth usually co-slept for some or all of the night. This is similar to the NWH survey. However, when enquiring in a different fashion, i.e. 201cIf baby shared a bed last night, how long did they share for? 201d 65% of mothers (194 of the 299) indicated some bed sharing (NWH 27%) and thirty-nine percent of those (57% NWH) shared for >2 hours. Reasons given for sharing a bed >5 hours varied as follows: 201cprefer closeness 201d (42%), 201cfor breastfeeding 201d (29%), 201cbaby sleeps better 201d (21%), 201ccan keep an eye on baby 201d (18%), 201cfor short naps or settling 201d (11%), and 201cfor cuddles/play/bonding 201d (8%). For mothers in Table 3 who reported usually participating in some bed-sharing, 87% had no concerns, but 9% expressed concerns about the safety of doing so. SmokingIn pregnancy, 53% of mothers had smoked (8% NWH), with a mean of 8 (SD 5.6) cigarettes per day. In the last 24 hours, 51% had smoked. The reported maternal smoking in the M ori mothers was identical to that of M ori women in the NZ Tobacco Use Survey, 2005,11 but the much lower rate reported for European mothers in the 2005 survey was markedly below the known 19% prevalence.11 In other words, European mothers either did not report their smoking in pregnancy or stopped smoking. M ori did not. Worse, 21% of mothers (1% NWH) both smoked in pregnancy and sometimes or always co-slept with their infant. BreastfeedingMothers who reported ever breastfeeding their infants comprised 91%, (97% NWH) although only 74% of 6-8 week infants and 51% of 3-4 month infants were still breastfeeding at the time of the survey. Survival curve analysis of the time of breastfeeding cessation showed that M ori mothers stopped breastfeeding significantly earlier than the 2005 survey mothers (p<0.0001) (Figure 1). When compared with the 2005 survey, Cox regression analysis of other factors associated with earlier cessation of breastfeeding was significant for mothers aged under 20 (p=0.04), maternal smoking during pregnancy (p=0.005), and the use of a pacifier (p=0.0002). Bed sharing was not associated with breastfeeding cessation. Figure 1. Breastfeeding cessation survival curve analysis: M ori survey compared with 2005 survey Positioning devicesWhile 46% of mothers (32% NWH) used a positioning system of some sort, only a few (10%) were of a commercial variety, and 36% of M ori infants had an unsafe homemade positioning system such as a pillow, rolled blanket or tight wrapping. The main reasons for these included 201ckeep baby positioned 201d, 201csafety 201d and 201chelp baby feel secure 201d. Very few mothers had any concerns about positioning systems. Discussion This survey has established for M ori mothers some previously unknown points regarding SIDS related knowledge and infant care practices. It has established the prevalence of M ori infant co-sleeping where there was smoking in pregnancy (21%), an extremely high-risk practice, with a greatly increased SIDS risk, particularly in younger infants,12 with odds ratios ranging from 5 to 29.13 Habitual prone sleeping (13%) and the presence of soft objects in the sleeping environment (36%) have been clearly demonstrated. These are the most commonly reported risk related occurrences in SIDS deaths.4 The survey has also highlighted important differences between M ori and European women and because the European study data is only 3 years older than the present M ori study data, there seems little to preclude such a comparison. Secondly, it seems that these behaviours may well be related to the reported poor knowledge of SIDS related information among M ori mothers. The effectiveness of the national SIDS-related health promotion programme and the relevance of its messages for the known high risk group in New Zealand are therefore bought into question. The early cessation of breastfeeding among M ori mothers and the poor awareness of smoking as a SIDS risk factors are outstanding examples of this. Lastly, we found that participants were far more likely to have heard the information that they did know from a midwife, from Plunket or from the hospital rather than from an antenatal class and this fits well with the known low attendance of antenatal class by M ori women.14 It seems therefore that both the currently mandated formats of imparting infant care related health promotion messages fail M ori mothers. Current smoking cessation programmes are not adequately meeting the needs of M ori women, particularly those who are pregnant15this is despite a recent survey by Wilson et al showing that 85% of M ori smokers wished they had never started smoking.16 Action to urgently support M ori smoking cessation in pregnancy was called for in 2003,17 but no M ori oriented action has eventuated. Stuck in the old public health mode of providing equitably for everyone, we have been unable to grasp the arguably more effective approach of dealing directly with the preventive health needs of the high risk M ori community. In addition, safe sleeping environments messages have revolved around the dont bedshare approach and those at highest risk among this M ori group have rejected this.8 M ori messages need to gain priority. Indeed, a M ori community promoted safe sleeping environment, the wahakura (a woven flax bassinet capable of being taken into the shared bed) takes an alternate approach of attempting to make the bed-sharing/co-sleeping environment more safe.18 Notably, two of the three recommendations of the recent 2009 Child and Youth Mortality Review Committees Fifth Report to the Minister of Health are about smoking in pregnancy and safe sleeping environmentsparticularly pertinent to M ori infants.4 Participation in this survey has been smaller than desiredbut 315 of the potential cohort of 734 were unable to be contacted and transience of members of the lower socioeconomic communities explains this. On the other hand, the 95.5% participation by those able to be contacted, speaks for the success of the sampling strategy, that is, contact by researchers of the same sex and same ethnicity with follow-up by home visiting. Notwithstanding the participation rate of only 41%, the extrapolation analysis from the available data of those non-contactable, reassures us that we have valid data overall. The number of invalid phone numbers again attests to the transiency of residence in this socioeconomic group. Increasing the recruitment would demand a strategy where the research was seen to have arisen from and to be based in the community of interest. Conclusions Despite limitations, this study has highlighted important information about the current state of knowledge among M ori mothers about child care practices and the prevalence of and the reasons for using such practices. The challenge now is to develop health promotion tools that are appropriate in this community and that might improve knowledge and therefore change behaviour, particularly with regard to smoking cessation, safe sleep position, safe sleeping environments, and duration of breastfeeding.

Summary

Abstract

Aim

M ori have high SIDS rates and relevant information is needed to craft appropriate prevention strategies. The aim of the study was to determine what M ori mothers know about SIDS prevention, and to determine their SIDS-related child care practices.

Method

M ori mothers who gave birth in the Counties Manukau District Health Board area were surveyed about their SIDS related knowledge, and infant care practices and their reasons for using and their concerns about these practices. Results were compared with a similar 2005 survey of a largely European sample.

Results

Knowledge of M ori mothers about SIDS prevention was much lower than for European mothers. More M ori infants slept prone and M ori mothers stopped breastfeeding significantly earlier. Although co-sleeping rates were similar, bedsharing increased to 65% for some part of the night. In addition, more than half of the M ori mothers had smoked in pregnancy and 21% of them were sharing a bed with their infant. Potentially unsafe soft objects such as rolled blankets or pillows were used by a third of mothers to help maintain the sleep position.

Conclusion

M ori mothers have a poorer knowledge of SIDS prevention practices. The high rate of maternal smoking, the early cessation of breastfeeding, and co-sleeping where there was smoking in pregnancy were also areas of concern. Appropriate health promotion measures need to be developed for the high-risk M ori community.

Author Information

David Tipene-Leach, General practitioner, Hauora Heretaunga, Hastings; Lynne Hutchison, Research Fellow, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland; Angeline Tangiora, Research Officer, M ori SIDS, School of Population Health, University of Auckland, Auckland; Charlotte Rea, Medical Student, The University of Auckland, Auckland; Rebecca White, Medical Student, The University of Auckland, Auckland; Alistair Stewart, Biostatistician, School of Population Health, The University of Auckland, Auckland; Edwin Mitchell, Professor of Child Health Research, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland

Acknowledgements

We are indebted to the M ori SIDS Team and the Child Health Research Foundation for the funding they provided for this summer studentship project. Our thanks also go to the mothers who provided the information.

Correspondence

Dr David Tipene-Leach. Hauora Heretaunga, 821 Orchard Rd, Hastings, New Zealand. Fax: +64 (0)6 8704823

Correspondence Email

dtipene@xtra.co.nz

Competing Interests

None.

-  Hutchison L, Stewart A, Mitchell E. Infant sleep position, head shape concerns, and sleep positioning devices. J Paediatr Child Health. 2007;43(4):243-8.--  Hutchison L, Stewart AW, Mitchell E. SIDS-protective infant care practices among Auckland, New Zealand mothers. N Z Med J. 2006;119(1247):U2365.--  Ministry of Health. Preventing sudden unexpected death in infancy: Information for health practitioner. 2008 April 2008.--  Child and Youth Mortality Review Committee. Fifth Report to the Minister of Health: Reporting Mortality 2002-2008. December 2009.--  Mantell CD, Craig ED, Stewart AW, et al. Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 2. Pregnancy outcomes for M ori women. Aust N Z J Obstet Gynaecol. 2004;44(6):537-40.--  Tipene-Leach D, Abel S, Finau SA, et al. M ori infant care practices: implications for health messages, infant care services and SIDS prevention in M ori communities. Pac Health Dialog. 2000;7(1):29-37.--  Tipene-Leach D, Abel S, Haretuku R, Everard C. The M ori SIDS Prevention programme: Challenges and implications for M ori health service development. Soc Policy J NZ. 2000;14:65-77.--  Tipene-Leach D, Haretuku R. Developing messages for M ori New Zealanders. Mothering. July 2002.--  Ministry of Health. Fetal and Infant Deaths 2005. Wellington: Ministry of Health; 2009.http://www.moh.govt.nz/moh.nsf/Files/fetalinfantdeaths/$file/fetal2005-sep09.pdf--  Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation User's Manual. 2007.--  Ministry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; 2007.--  Horsley T, Clifford T, Barrowman N, et al. Benefits and harms associated with the practice of bed sharing: a systematic review. Arch Pediatr Adolesc Med. 2007;161(3):237-45.--  Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-42.--  Dwyer S. Childbirth education: Antenatal education and transitions of maternity care in New Zealand: Families Commission and Parents Centre. 2009.--  McLeod D, Pullon S, Cookson T. Factors that influence changes in smoking behaviour during pregnancy. N Z Med J. 2003;116(1173):U418.--  Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122(1292):99-100.--  Wilson N, Thomson G, Howden-Chapman P. Supporting smoking cessation in pregnancy--action is urgently needed. N Z Med J. 2003;116(1173):U415.--  Tipene-Leach D, Abel S. The wahakura and the safe sleeping environment. Journal of Primary Health Care. 2010; 2(1): 81.-

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE