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Why is NZ's infant death rate still so comparatively high?

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Our rate of sudden unexpected death in infancy is about 0.75 deaths per 1000 babies, compared with just 0.1 per 1000 in the Netherlands.

During the 1990s, cot death – or what’s now known as sudden unexpected death in infancy (Sudi) – was big news in New Zealand. Red Nose Day, an annual event, was so popular that vast numbers of people, pets and even cars sported red plastic noses sold to help raise funds for research to reduce our cot-death rate, which was then one of the highest in the developed world.

Thanks to a successful public-health campaign encouraging parents to put babies to sleep on their backs, rather than their stomachs, the number of Kiwi infants dying from Sudi fell dramatically, from a rate of one in every 250 in 1988 (a total of 254 deaths) to about one in 1000 a decade later. By the late 90s, cot death had started to slip from the public consciousness.

“Back to sleep” campaigns have had similar results in other countries, saving many thousands of parents from the anguish of having their apparently healthy baby die unexpectedly.

But Sudi rates continue to be relatively high in New Zealand – about 0.75 deaths per 1000 babies, compared with just 0.1 per 1000 in the Netherlands, for example. That’s about 50 babies a year, of whom about two-thirds are Māori.

“Sudi now occurs predominantly in Māori and Pacific populations living in situations of deprivation,” says long-time Cure Kids Sudi researcher and Auckland GP Christine McIntosh.

What differentiates these babies is not just their socio-economic background but two risk factors that, when combined, mean they are 32 times more likely to die from Sudi: maternal smoking and bed sharing.

About 31% of Māori women smoke while pregnant, compared with 13.5% of Pacific Island women and 6.8% of Pākehā women. According to McIntosh, exposure to the effects of maternal smoking during pregnancy lowers oxygen levels in the uterus and affects a baby’s brain development. Once born, these babies are less likely to respond if oxygen levels fall while they are asleep.

Dr Christine McIntosh. Photo/Supplied

Sharing a bed increases the likelihood of vulnerable babies experiencing breathing problems if, for example, their face gets too close to a sleeping adult or covered with bedding, or they end up slumped with their chin resting on their chest. Rather than waking up, they are more likely to stay asleep and, potentially, die from Sudi.

“We’re talking about babies who don’t stir and wake up and alert their parents to the problem,” says McIntosh.

The national Sudi prevention programme is now tackling these two risk factors with the goal of reducing our Sudi rate to less than 0.1 per 1000, or about six deaths a year.

In an ideal world, all pregnancies would be smoke-free. “If we got rid of maternal smoking, Sudi rates would plummet,” says McIntosh.

However, smoking levels, among young Māori women in particular, remain stubbornly high despite many years of anti-smoking campaigns. That means a large focus of the Sudi-prevention programme is also on safe sleeping – making sure babies sleep on their backs and in their own beds.

This can be a bassinet or cot, which should have a firm mattress, a fitted bottom sheet and a woollen (rather than synthetic) blanket. But a key element of the Sudi-prevention programme is promoting the use of “safe-sleep baby beds” – either Pēpi-Pods (plastic sleeping boxes) or wahakura (woven flax bassinets) – that can be placed on the parents’ bed to provide a separate sleeping space for their baby. This significantly reduces the risks associated with bed sharing.

The Ministry of Health has allocated $5.1 million a year so district health boards can provide education and 8500 safe-sleep beds for babies at higher risk of Sudi. Their parents are encouraged to use the beds every time their baby sleeps.

McIntosh says wahakura are particularly important because they embrace tikanga Māori in Sudi protection. And as Fay Selby-Law, general manager of the National Sudi Prevention Coordination Service, points out, they’re also more sustainable. She’d like to see wahakura being used more widely, regardless of a baby’s risk of Sudi, to help normalise them.

“They are an Aotearoa solution to safe sleeping, not just a Māori solution. It’s not just Māori who love natural products, and it’s not just Māori who want a solution that is Aotearoa-based.”

This article was first published in the July 6, 2019 issue of the New Zealand Listener.