by Dr. David Tipene-Leach and Dr. Riripeti Haretuku
Mothering, Issue 114
David Tipene-Leach, MBChB, DcomH, MCCMNZ, is a primary care physician, public health specialist, and medical adviser to the Maori SIDS Prevention Team.
Riripeti Haretuku, DipBus, MEd, NZOM, is director of the Maori SIDS Prevention Team.
The New Zealand National SIDS Study identified three modifiable risk factors in SIDS deaths: prone sleeping position, the absence of breastfeeding, and maternal cigarette smoking.
A prevention campaign was launched across New Zealand, and within a year the national SIDS rate was cut in half. By 1992, bedsharing was being promoted as a fourth modifiable risk factor, and an anti-bedsharing message was included in the SIDS prevention effort.
It soon became quite clear to SIDS workers in the community, and later at a statistical level, that
SIDS deaths among the indigenous Maori, who comprise about 15 percent of the population, had
hardly dropped at all. As a result of this finding, and with some agitation from the Maori health sector, the Maori SIDS Prevention Programme was established in 1994.
High rates of both maternal smoking and bedsharing with infants largely explained the high SIDS rates in Maori communities. Promoting breastfeeding and the back and side sleeping positions did not present any problems, as breastfeeding is prevalent among Maori and has its own status as a traditional behavior. Also, the prone sleeping position is far less common among Maori babies, because they are more likely to be found bedsharing with parents or, when older, with siblings.
Initially, the Maori SIDS Prevention Programme refused to counsel against bedsharing in any way. We stuck to the line that smoking was the risk factor of concern in the Maori community and that we should be working on that area. Instead, we promulgated a "Tips for Safe Bedsharing" message that promoted a lightly covered, breastfed baby, sleeping on its back in a traditionally made flax sleeping basket, between the parents in their double bed. At the same time, we faithfully repeated the antismoking mantra and the promotion of breastfeeding in our Maori radio and television campaigns.
Behind the scenes we debated the approach to the bedsharing/smoking issues with our research and public health colleagues, maintaining that their advertising was effectively backing Maori women into a corner and turning them off all the associated SIDS prevention messages. We lobbied for national SIDS prevention publicity to be free of the anti-bedsharing messages and to focus instead on cigarette smoking.
Constantly reviewing their data, and driven by the above debate, the New Zealand study team
subsequently found that bedsharing and cigarette smoking had a confounding relationship. That is, while bedsharing in the presence of maternal smoking increased the SIDS risk, bedsharing on its own did not. Our strategy was thus vindicated, in that infant bedsharing was, as our old people had said, a safe behavior.
We continued therefore to campaign against smoking by pregnant Maori women and Maori mothers in the belief that elimination of one of these factors eliminated the associated risk. We even developed a smoking cessation program of our own, in which scores of community health workers treated people with auricular mini acupuncture needles. It was a valiant but rather frail effort, given the sheer size of the problem: nearly half of all pregnant Maori women smoke.
Researchers soon found that it was smoking during pregnancy, not environmental cigarette smoke, that was the main culprit in SIDS. Persuading Maori mothers to give up smoking would not reduce the risk to their present infants. Therefore, we had to move to a prohibitive message regarding bedsharing if the mother had smoked during her pregnancy.
There were many such Maori mothers who were clearly interested in reducing the risk to their infants. Our workers advised them that cuddling and feeding together in bed was fine, but that they should avoid actually sleeping together and instead place the baby in a crib to sleep. There remains also a sizeable group of Maori mothers who smoked in pregnancy and who will not, or cannot, provide separate sleeping environments for their infants. They remain at risk, and we advise them to place their babies on the outer part of the bed, swaddled and blanketed separately, in their own sleeping space.
There are two mechanisms of infant death in the bedsharing situation. One, the result of an infant biologically compromised because of maternal smoking in pregnancy, is properly labeled SIDS. The other is accidental suffocation or overlying and is not a SIDS death. Accidental suffocation was not investigated in the New Zealand SIDS study, but has been observed by our workers (and others) as being a factor only when drugs, primarily alcohol, are used by the parent(s) before sleeping with the infant. Consequently, an important part of our message to Maori (and other) parents is: If you've been partying, don't sleep with your baby.
The maintenance of the bedsharing option for those who did not smoke in pregnancy has been a
valuable step for infant care in New Zealand. Without the Maori SIDS Prevention Programme's stand against denigrating this age-old practice, bedsharing might have been altogether discouraged by health authorities. We do not counsel against bedsharing at all where there was a smoke-free pregnancy. If the mother smoked during pregnancy, we advise that the baby can be cuddled and fed in bed but that when the parents go to sleep, the baby should be placed on its back in a crib free of potential suffocation hazards, such as pillows, bumpers, and loose blankets.
Bedsharing is now recognized as a risk for infant death only in the presence of smoking in pregnancy and alcohol or drug intake by parents. The traditional behavior of sleeping with infants still remains a viable and safe option for many families.