Research devoted to reducing sudden unexpected death in infancy (SUDI) among Māori leads to Royal Society Te Apārangi prize

Professor David Tipene-Leach, Māori and Indigenous Research Professor at the Eastern Institute of Technology (EIT), public health physician and former GP, is working to reduce infant exposure to risk factors for SUDI and thereby reduce infant mortality rates. He is currently rolling out stage three of his project and its associated research in Hawkes Bay.

The SIDS Prevention Campaign

In stage one of the project Tipene-Leach led a Māori SIDS (Sudden Infant Death Syndrome) prevention campaign in the mid-1990s. The main issues targeted were back-sleeping and the promotion of breast feeding. After three years of intense engagement with Māori communities, mostly mothers and grandmothers, Māori SIDS rates had fallen dramatically – although not on par with Pākehā rates. The two other significant risk factors identified at the time were bedsharing and maternal smoking. Bed-sharing had many perceived benefits and therefore an anti-bed-sharing message was rejected and cessation of smoking during pregnancy was only a small part of the programme given the difficulty of achieving change.

By the mid-2000s, the drop in Māori SIDS (now called SUDI) related deaths had plateaued and it had been clearly identified that bed-sharing per se did not contribute significantly to SUDI. Instead, it was the combination of bed-sharing and smoking during pregnancy that increased the risk. A survey was undertaken to compare SIDS related knowledge and practice in South Auckland to that in central Auckland, which was considered lower risk.

‘We were able to demonstrate that bed-sharing, when coupled with smoking in pregnancy, was 20 times more common in South Auckland, which reinforced that the combined factors were the problem for at risk mothers,’ says Tipene-Leach.

A case review of 221 SUDI deaths between 2000 and 2009 was completed to identify main contributing factors. Bed-sharing data was identified but there was no data available on smoking during pregnancy.

‘We found that 83% of the deaths were from Māori and Pasifika whānau, and that two thirds of them were bed-sharing at the time,’ says Tipene-Leach.

The Wahakura – a flax bassinet

These observations led to stage two of the project – working with the bed-sharing part of this duplex risk factor.

‘Why can’t we have a safe sleeping device in a shared bed and make it out of flax, so it is attractive to Māori women?’ asks Tipene-Leach.

A group of Ngāti Porou weavers worked with Tipene-Leach to create a woven safe sleep environment – like a Moses basket. The design was wider and completely flat-bottomed to ensure it couldn’t accidentally turn over. The wahakura – a flax bassinet that could be taken into the adult bed – had been created. It was trialled in 2007 by Ngā Maia Māori Midwives collective on the East Coast with great success.

Two years later, it became clear that wahakura were difficult to make and that supply was going to be a problem. Wānanga teaching of wahakura weaving, along with the development of a new and easier design helped. However, the team were also looking around for anything that ‘did the same thing as a wahakura’ but wasn’t made of flax. A colleague of Tipene-Leach, Stephanie Cowan, had identified a plastic box of similar size to the wahakura.

Soon after, in 2011, the 22 February Christchurch earthquake struck and approximately 1500 pēpi (babies) were left homeless and bed-less. The Christchurch domiciled Cowan rolled out the ‘little sister of the wahakura’ in Christchurch to provide a sleeping space for pēpi wherever they might be. The now nationally renowned Pēpi-Pod was born.

In late 2011 the now ‘much-more-available’ Pēpi-Pods were distributed in partnership with the Hawkes Bay DHB to whānau assessed as having risk factors contributing to SUDI. Precedence was given to smoking during pregnancy.

‘It's a story that starts off with a bright idea, add in some tikanga Māori, and then push it out to Māori and weaving circles as well as mainstream hospital and health circles, and we see a dramatic result,’ says Tipene-Leach.

A significant amount of further research was required along the way, firstly to demonstrate that the wahakura was in fact attractive to Māori women. A qualitative study of twelve Māori women who had used the wahakura and ten key stakeholders, such as midwives, was undertaken to scope opinions about the wahakura.

‘They thought it was easy to use and liked that it was practical and portable. From a cultural aspect, the respondents said it was an expression of them as Māori mums. Midwives told us that they usually struggled to make or maintain contact with at risk Māori mothers, but with the wahakura everybody is interested. They also reported that the mothers were more receptive to safety messages regarding the flax bassinet and their pregnancy in general,’ says Tipene-Leach.

Demonstrating that the wahakura was in fact safe was more complex.

‘People in the SIDS environment were saying you're mad, how can you possibly suggest that the way to prevent something that is caused by bed-sharing is to promote bed-sharing?’ recounts Tipene-Leach.

A three-year randomised controlled trial in collaboration with researchers at the University of Otago led by Professors Barry Taylor and Tipene-Leach along with Professor Sally Baddock from Otago Polytechnic was commenced. It featured two different groups made up of Hawke’s Bay mothers of Māori infants, with 100 pēpi sleeping in wahakura, and a control group of 100 sleeping in traditional bassinets. Later, a third wing of 45 pēpi sleeping in a Pēpi-Pod was added. No significant behavioural or physiological differences related to SUDI risk were noted in the pēpi in different sleeping environments. This meant the wahakura and Pēpi-Pod could reasonably be considered safe sleeping devices.

Finally, it had not been shown that wahakura and Pēpi-Pod use was linked to the drop in SUDI deaths. This changed with an ecological study undertaken by world SUDI expert Professor Ed Mitchell along with Cowan and Tipene-Leach which observed that a 30% drop in the infant mortality rate had occurred among Māori pēpi in areas where the wahakura and Pēpi-Pods were distributed. They determined that no other changes could account for the improvement. Subsequently, the devices were incorporated into the National SUDI Prevention Programme.

The House of Weaving

Tipene-Leach has now commenced stage three of the project.

Called ‘Te Whare Pora O Hine-te-iwaiwa’ (house of weaving), it is a ‘clinic’ for pregnant women, staffed by weavers, not medical personnel. It is based at Te Taiwhenua o Heretaunga, an iwi health provider, in Flaxmere, Hawkes Bay.

‘Hine-te-iwaiwa is the deity of weaving and childbirth, so it is kind of like a women's business house,’ explains Tipene-Leach.

With this wānanga concept, the first set of pregnant women began weaving wahakura for their unborn pēpi at the clinic this year. The idea of the clinic is to use the wahakura and weaving to attract women who might normally only visit a midwife quite late in their pregnancies. The wahine weave several items for their pregnancy over an eight-week period, including a muka (flax fibre) umbilical tie, an ipu whenua and ipu pito (container for placenta and belly button), a kete (basket) for nappies and their own wahakura. 

Through this process the women emotionally and spiritually connect with their own pregnancy and with other mums. As a result, they often feel confident to link into other health networks earlier, like midwives. The Taiwhenua Māori maternal health programmes like breastfeeding support and smoking cessation are then much easier to make contact with.

‘Like the initial wahakura project, it is about finding an attractive intervention to allow women who might not have made good use of antenatal services to be in contact with providers that reduce the risk of their pregnancy and baby’s infancy by increasing their exposure to mātauranga Māori and kaupapa Māori services,’ says Tipene-Leach.

The initiative is funded for four years and Tipene-Leach is leading a research project to determine whether, how and why the mātauranga Māori Te Whare Pora service increases wahine Māori accessing of midwifery services at an earlier stage than usual in their pregnancy. His next goal is to replicate the Te Whare Pora model through Māori health primary care providers throughout New Zealand.

In November this year, Tipene-Leach was awarded the inaugural Tahunui-a-Rangi Award from the Royal Society Te Apārangi for the wahakura and its role in creating a safer sleep environment for the prevention of SUDI among Māori.

• The Te Whare Pora O Hine-te-iwaiwa project has received funding from Auahatanga Hauora Māori and Manatū Hauora (the Ministry of Health).
  
  
• Professor David Tipene-Leach MNZM (Ngāti Kere, Ngāti Manuhiri), is a former GP and current Professor of Māori and Indigenous Research at the Eastern Institute of Technology in the Hawke’s Bay. He has spent his working life promoting Māori health. In 2004 he was made a Fellow of the Royal New Zealand College of General Practitioners and gained Distinguished status in 2016. He was also made an Honorary Fellow of the New Zealand College of Public Health Medicine in 2015 and obtained a full Fellowship in 2017. In 2018 he was made a Member of the New Zealand Order of Merit for services to Māori and health. Email David Tipene-Leach. 
  
  
• Visit the EIT's website.