Issue 112

WELCOME, TENA KOUTOU KATOA, KIA ORANA, TALOFA LAVA, MALO LELEI, FAKAALOFA ATU

In this edition, MSCC has continued to “mine” the data provided by women, to the joint on-line maternity consumer survey undertaken by Women’s Health Action, MSCC, MAMA Maternity and La Leche League.

The 12^th Annual Report of the Perinatal and Maternal Mortality Review Committee (PMMRC) revealed again that maternal suicide is the leading cause of perinatal maternal mortality in AotearoaNZ. In this edition we are going to discuss this committee’s recommendations for maternal mental health screening and treatment. SUDI is a leading cause of neonatal death in babies born >35 weeks gestation and the PMMRC made recommendations related to co-sleeping as a way of reducing infant deaths from this cause. We evaluate the recommendations of the PMMRC on both of these topic with reference to the information provided by some of the 1200+ women who completed the on-line survey of their maternity experience.

Continuing the theme of perinatal maternal mental health, we share a précis of a recently published study which confirmed the importance of partnership between women and their maternity care providers, care planning and informed choice and consent. We also include a review of a resource for care providers published by Perinatal Anxiety and Depression Aotearoa.

MSCC recognizes that each woman’s childbearing experience is unique so we don’t expect that our readers will necessarily agree with everything we write. We do hope, however, that the content of our newsletter is food for thought, discussion and hopefully change in the way women, whanau and their maternity care providers view and experience the maternity services.

We WELCOME input, feedback and suggestions, by: email – [email protected] or to our posts on Facebook @MaternityServicesConsumerCouncil.

Perinatal and Maternal Mortality Review Committee. Twelfth Annual Report, 26 June 2018

The annual reports of the Perinatal and Maternal Mortality Review Committee (PMMRC) continue to report a thorough investigation into, and consideration of, perinatal and maternal mortality in AotearoaNZ.

Perinatal death of mother or baby has a huge impact on both the whanau and care providers. Although this report does not shy away from presenting evidence of “avoidable” mortality or morbidity, this committee rather than blaming, makes recommendations that they believe will help prevent deaths of babies and mothers. In her final introduction as Chair of the PMMRC, Dr Sue Belgrave states: “I strongly believe that it is only with complete accurate data of perinatal and maternal death with informed analysis that we can make recommendations for change and monitor outcomes for women and their babies over time.

We acknowledge the grief of families and whanau who have lost babies and mothers in 2016. Each of the deaths reported represents the tragic loss of a loved child or mother…As well as acknowledging the grief of the families and whanau, we would also like to acknowledge how difficult it is for clinicians who are impacted by the deaths of the women and babies they have cared for.”^[1]

She goes on to state that, “It is no longer possible to publish a comprehensive review of perinatal and maternal mortality on a yearly basis due to budget constraints. The PMMRC has decided to focus on a special topic each year with the publication of basic tables and figures with limited commentary on areas outside the special topic. Maternal mortality will be reviewed in depth every three years.”^[2]

Maternal Mortality

“A maternal death is the death of a woman while pregnant or within 42 days of end of a pregnancy (miscarriage, termination or birth), irrespective of the duration and site of the pregnancy, from any cause related to, or aggravated by the pregnancy or its management. It does not include accidental or incidental causes of death of a pregnant woman.”

Maternities	2006 – 2016
	Number	Percentage
Direct Maternal Death	63	58.9
Pregnancies with abortive outcome	2	1.9
Hypertensive disorders	4	3.7
Obstetric haemorrhage	3	2.8
Pregnancy-related infection	6	5.6
Amniotic fluid embolism	13	12.1
Venous thrombo-embolism	6	5.6
Suicide	28	26.2
Other (Pulmonary embolism & sepsis)	1	0.9
Indirect Maternal Death	39	36.4
Cardiac	10	9.3
Neurological	11	10.3
Infection (not pregnancy related)	8	7.5
Other (endocrine, respiratory, neoplasm, pre-existing medical)	10	9.3
Unknown/Undetermined	5	4.7
Total	107	100

The maternal mortality rate is mercifully low, however tragically, maternal suicide has been one of the leading causes of maternal death since the establishment of the PMMRC in 2006. Since 2010 more mothers have died from suicide than any other single cause. Maori mothers are disproportionately represented in the maternal death statistics, and have a higher rate of death by suicide than mothers in any other ethnic group. In the ten years from 2006 – 2016, 57% of the mothers who died from suicide were Maori.

Maternal and Infant Mental Health Network

The 10^th PMMRC Report, published in 2016, recommended that a multidisciplinary Maternal and Infant Mental Health Network, funded by the MoH, be established to discuss and address perinatal mental health issues. The PMMRC defined the priority areas that this network should investigate as follows:-

1. a stocktake of current mental health services available across New Zealand for pregnant and recently pregnant women to identify both the strengths of services and gaps or inequity in current services and skills in the workforce
2. a national pathway for accessing maternal mental health services, including:
   1. cultural appropriateness to ensure equity of service access and provision
   2. appropriate screening
   3. care for women with a history of mental illness
   4. communication and coordination (p142)

The 11^th Annual Report of the PMMRC (2017) reiterated this recommendation and added further, detailed recommendations from their Maori Caucus to address and reduce, the over-representation of Maori women in the perinatal death by suicide data.

The 2017 PMMRC report also quoted research from the UK that found that, the cost of dealing with the fall-out from perinatal mental health problems, for mother, baby, whanau and community was 5 times more than what it would cost to provide equitable and accessible perinatal mental health services with a nationally standardized pathway for referral. This is undoubtedly true in AotearoaNZ too.

The “Practice Point” recommendations (p149) that the PMMRC makes for the provision of maternal mental health screening and care, are specific and comprehensive and would require both ring- fenced funding and the ability for all practitioners to access each woman’s full medical history. Unfortunately neither sufficient funding for appropriate and equitable nationwide maternal mental health services, nor a universal electronic health record that is accessible to (the individual concerned) and all their healthcare providers, is currently available.

Psychosocial health screening

“Early during a woman’s contact with health services, including request for termination of pregnancy, a comprehensive assessment of her psychosocial health and risk factors should be undertaken. This will involve identifying:

• her current social situation, including relationship with partner/ ex-partner, whanau supports, and social stressors such as financial issues, housing, whether their other children are in care of other people, and phone and transport availability
• any previous and current experience of family violence, sexual abuse and assault
• a history of termination of pregnancy or miscarriage in the previous 12 months
• any past or present mental illness, including self-harm and previous suicide attempts, use of alcohol and other drugs
• any past or present treatment by a specialist mental health service, including in-patient care
• a family history of severe mental illness, including perinatal mental illness or suicide in a first degree relative.” (p149)

There is currently no funding provision for primary maternity providers that would enable them to allocate the amount of time that would be required to meet the above recommendations for screening each of their clients in early

pregnancy. The recommendation for early antenatal screening is further compromised by the fact that many women in the most at risk groups, do not present, either early or regularly, for maternity care and their maternity caregivers are not resourced or assisted to follow-up on this.

Women’s experiences of Maternal Mental Health Services

Responses to the Joint Maternity Survey, demonstrate that access to Maternal Mental Health Services (MMH) varies widely in different parts of the country. Different DHBs have differing referral pathways and there appears to be no consistency in level or range of services provided in different parts of the country. Some women reported receiving excellent care while others struggled to access timely care and necessary support. Several DHBs appear to have capacity issues, leading to delays for women needing to access maternal mental health services.

“After I was signed off from my midwife I developed postnatal depression. My options from the Dr were anti-depressants or nothing. I’m glad this is my second baby and overall I’m a strong person because I feel really let down by the system.”

(2018)

“After my third (baby) I had postnatal depression but it took until he was 10 months old to be seen by someone as they didn’t have enough staff.”

(Ashburton)

“Better support postnatally with a PND diagnosis. I wasn’t referred to anyone after seeing the GP and had no contacts of who I could talk to. My GP said I was too busy with 2 young kids to be considered for counselling.

(Palmerston North 2017)

“Given what was, in hindsight, poor advice from my GP to stop taking anti depressants once I fell pregnant. (I got) Support from midwife for antenatal depression but had trouble engaging with MMH – who were fantastic once they were in the loop.”

(Auckland 2016)

“I also used MMH services and they were wonderful, checking up on me daily, and making sure I had extra help and support”

(North Shore 2017)

“I have also used maternal mental health, through antenatal anxiety and during my 7 weeks in hospital. I have recently been referred for treatment of PTSD due to our time in SCBU. I am amazed that this is all free.”

(Bay of Plenty 2018)

“I was under MMH for both my children. With my first child I was basically brushed off. With my second child I was almost hospitalised (there is no Mother and Baby psychiatric inpatient service in Wellington so I would’ve been in hospital separated from my baby who wouldn’t accept a bottle, so they couldn’t hospitalise me). There was no antenatal support for this second pregnancy from any mental health services, and I didn’t even realise that MMH did antenatal support. I feel that had they touched base and said “hey, if and when you are next pregnant let us know” so that they could keep an eye on me (via GP/LMC communication, or directly with me) then I most likely wouldn’t have ended up in the position I ended up in. They are definitely the “ambulance at the bottom of the cliff” and it took a call to Te Haika and CATT to be taken seriously…”

(Wellington 2016)

“Maternal mental health has been an absolute godsend in helping me to adapt to motherhood. I have had some real mental health issues and this service has always been there for me.”

(Waitakere 2018)

“Maternal mental health is very poor and under resourced in Southland.”

“Maternal mental health turned me down due to me “coping” at this point despite being very high risk due to previous mental health issues. Midwife can’t do direct referrals etc. “

(Dunedin 2018)

“Maternal mental health services were easy to access and provided fantastic support.”

(Auckland 2017)

“Mental health support is poor. I have the baby blues but no assessment of whether I am right about that or whether it is more serious and it’s been 3 wks so far.”

(Taranaki 2018)

“…mental health services (need improving) it took 13weeks to get any meaningful help,”

(2017)

“Mental health took ages to get seen and had to go through the referral process 3 times.”

(Rotorua 2017)

More support from maternal mental health, not being left 3 weeks after referral until someone contacts you.”

(2017)

“No-one picked up or offered extra info on postnatal depression (which got diagnosed at 5 months after reading something on Facebook). All and all my whole birthing experience has left me feeling traumatized and belittled and deprived of support and education.”

(2016)

“There needs to be way more support with mental health for mums with families on 1 wage and over 25 and not Maori or Pacific Island. Like seeing counselors and professionals. They are too expensive. Mothers with mental health issues don’t always need antidepressants.”

(Capital and Coast 2017)

“Twice after my first I reached out as I was spiraling down and mentally wasn’t coping … my GP at the time told me she thought it how I felt was “situational dependent” and that I’d be ok… the second time I drove to the nearest after hours clinic burst into tears and couldn’t speak I was so beyond it all… doctor told me there was nothing she could do… I seriously wanted to crawl into a hole and die. I felt like I was screaming out for help but no one was listening … my plunket nurse was the only person to listen (midwife care had finished by the time things got bad).”

(Tauranga)

A handful of women commented favourably about non-DHB maternal mental health support programmes and groups.

“I attended the adjustment to parenthood group which was amazing.”

(Taranaki 2015)

“I developed very bad postnatal depression and the team at PPAP (Plunket Postnatal Adjustment Programme) were amazing and got me back to a good place. Postnatal mental health is a huge thing and needs to be more accessible for all as the waitlists are so long it is ridiculous.”

(Christchurch 2017)

“Maternal mental health connected me with some amazing services including Mothers Matter.”

(Rotorua 2017)

Waitemata DHB’s maternal mental health service was great, as were the Walsh Trust – He Kakano Ora and the La Leche League.”

( Waitemata 2017)

Some women reported receiving inadequate mental health support and/or felt anxious about the termination date of their allocation maternal mental health services. One would hope that it is standard practice for service providers to make referrals to appropriate ongoing support services and to communicate with individual women about this, well before MMH services end.

“I had a couple of sessions with Procare after birth as I had PTSD and would cry over it but they felt rushed. Wish I had have been able to access regular emotional support better.”

(Auckland 2018)

“Maternal mental health saved my life, and maybe my babies life. Need more resources for maternal mental health. I will shortly be discharged from there and I am worried as still suffering ptsd and pnd.(obstectric trauma, an infected episiotomy, 8.5 months later am still suffering.”

(2018)

“Maternal Mental Health needs to see you for longer – it takes more than 3 meetings for you to be able to build that trust so you can open up.”

(2018)

“Maternal Mental Health Team were great. Wish their services went further than babies 1st birthday.”

(Whangarei 2016)

“Further support with breastfeeding, and mental health post 7months would have been well received.”

(Waikato 2017)

Midwives attend a mandatory Practice Day once every three years as part of the Midwifery Council’s Recertification Programme at which one of the key topics included is maternal mental health. This focuses on the midwifery role of screening, identifying and referring women with mental health concerns.

One of the difficulties is the lack of standardization in both the MMH services available in different DHBs and the referral pathways for these. Several DHBs will not allow LMC midwives to refer women directly into their service meaning that distressed mothers have to have an additional consult with a GP (who has often had no prior involvement in the woman’s maternity care) who may or may not make a referral to MMH. In addition there are different community and NGO providers in different areas – which must make it difficult for midwives to have information about which provider offers which type of service. Clearly some LMC midwives manage this process better than others.

“A stronger focus on screening for PND. I can clearly see its beginnings for me but the midwife (back up) that provided postnatal care missed it over and over…I feel she failed me/us and seemed solely focused on baby (who was doing great).”

(2015)

“I have a history of PND so my midwife organised for me to start seeing someone while I was still pregnant. They were really supportive.”

(Palmerston North 2017)

“Maternal mental health turned me down due to me “coping” at this point despite being very high risk due to previous mental health issues. Midwife can’t do direct referrals etc. “

(Dunedin 2018)

“Mental health was a huge issue for me and I wasn’t diagnosed with PND until my daughter was 7 months old. It was a horrific time for me and my back up midwife was absolutely awful. Had it not been for my parents, my daughter and I wouldn’t still be here.”

(Palmerston North 2015)

“My midwife was very supportive during the pregnancy, and during the postnatal period. She helped put additional supports in place in the months after the birth.

(Waitemata 2017)

“More help with anxiety- this really set me back in the weeks after birth to the point of going on medication. I wish I’d been put on it earlier and put in touch with maternal mental health services (as my midwife said she would and never did) knowing my level of anxiety”

(Waikato 2017)

“…my postnatal care was so thorough, my midwife got onto my mental health issues straight away. I felt supported and listened too. Maternal Mental Health was also amazing, they kept in touch and made me feel as though I could rely on them if I needed more.”

(Waihi 2016)

“PND care poor – midwife uninterested, GP only offered drugs. Didn’t know where to go.”

(Hutt Valley 2017)

Well -resourced women/whanau who are well enough, may be able to request care, seek out available services, self refer and receive the care they need. However, our search through DHB websites to find information about DHB funded and provided maternal mental health services revealed a bewildering range of results, from very good, (with the pathways for referral and self-referral explained- some even had a link to the Edinburgh Screening Tool for initial self assessment) to absolutely useless – only a few lines of information or complicated flow charts to describe referral processes and pathways.

(Mothers need) “more information about what to do if you think you have PND, who to talk to”

(Auckland 2018)

“(Needed) Easily accessible support for someone to talk to about new Mum struggles – what’s normal to worry about, when it might be a good idea to see GP etc”

(Hutt Valley 2016)

In our January newsletter we reported on women’s experience of, often inadequate, maternity care during and after miscarriage. They reported that; access to services often involved delays, sometimes required them to share space with mothers with new babies, and that some care providers lacked compassion. The absence of funded post birth care from their LMC midwives added to their grief and trauma. Many reported that they experienced anxiety and depression following miscarriage and felt that they should have been offered access to maternity care and MMH services.

“1st Pregnancy ended in late miscarriage at 15+6 weeks – I got little to no help support wise from my midwife or from hospital midwives at the women’s clinics (they all felt sorry for me but no one actually recommended any counseling)”

(Wellington)

“During my miscarriage/birth at 17 weeks gestation I would have preferred to be under the care of my midwife rather than the gynaecology department. It would also have been great to have the full 6 weeks postnatal care and to have access to maternal mental health.”

(2015)

“Miscarriage support is absolutely lacking. After a loss at 8 weeks that sent me spiraling into deeper PND there was no support at all to help with this experience.“

“More support after our missed miscarriage and after our still born would have been amazing. Never offered counseling, never offered help or information about who to go to for help.”

MSCC looks forward to hearing that the proposed Network has been established and has defined a nationally consistent pathway to access DHB funded MMH services that are accessible and appropriate for all women living in their catchments. DHBs should be required to post easily accessible, consumer friendly information on their websites about the MMH services they offer and include a self-referral pathway. Progress so far however, has been SLOW. In the two plus years since the PMMRC first made this recommendation, the MoH has only managed to formulate the service specifications for a Maternal and Infant Mental Health Network.

Ask for help – your needs are normal and valid.

SIDS/SUDI and Neonatal Deaths

Neonatal death is defined as the death of any baby who is born at 20+ weeks gestation, weighs 400+gms and shows signs of life, but dies any time between birth and midnight of the 27th day of life. The neonatal death rate was 2.6/1000 live births in 2007 and 2.5/1000 live births in 2016.

From 2007 to 2016, for 68 babies who died before they were 4 weeks old, the cause of death was recorded as, sudden unexpected death in infancy (SUDI). During this period SUDI was the second most common cause of death of babies who were born at >35 weeks gestation with no congenital anomalies.

Sleeping risk factors among SUDI deaths from 35 weeks gestation 2007–2016 (p56)

	Number	Percentage
Location of sleep at event or death
Home	56	82
Family or friend’s home	8	12
Hospital	4	6
Stated place of sleep at event or death
Cot	8	12
Pepi –pod	1	1
Single bed	5	7
Double/Queen Bed	46	68
Couch/Chair	6	9
Not stated	2	3
Other persons sleeping with baby at event death
Adults	36	53
Adults and siblings	18	26
Other sleep risk factors identified at event or
death
Pillow in bed	8	12
Rolled blankets in bed	1	1
Sleep position at time of death
Back	39	57
Side	9	13
Front	2	3
Not stated	18	26

Apparently, only six of the 68 babies who died with a diagnosis of SUDI were in an “approved” low-risk sleeping place and position at the time of death. (p21)

MSCC believes that it is unhelpful that SUDI has become the classification for both SIDS deaths (deaths where no cause is able to be established) and SUDI (deaths that are the result of accident or trauma). We believe that parents are much more empowered to evaluate risk and enhance safety when they understand that the majority of SUDI deaths are accidental (SUDI), rather than inexplicable (SIDS) . Babies of Maori and Pasifka mothers were statisticallyover-represented in SUDI deaths with 66% of the babies who died having a Maori mother, and 18% a Pasifika mother.

The PMMRC conducted an in depth investigation into all neonatal deaths for this 12^th Annual report and formulated two recommendations relating to SUDI. Between 2007 and 2014, 4 of the 68 SUDI babies died prior to discharge from hospital prompting the following recommendation:-

The PMMRC recommends that the Ministry of Health and DHBs have a responsibility to ensure that midwifery staffing ratios and staffing acuity tools:

a. enable active observation of mothers and babies who are undertaking skin-to-skin contact in the postnatal inpatient period

b. allow for the identification of, and additional needs of, mothers who have increased risk factors for sudden unexpected death in infancy (SUDI).

MSCC is concerned that the PMMRC has chosen to make a recommendation that cannot practically be achieved without severely restricting opportunities for skin-to- skin contact between mothers and their babies in the immediate postnatal period. Even if our postnatal wards were adequately staffed (which most are not currently), “active observation” of any mother and baby pairs having skin – to-skin contact is unachievable (except in the immediate postbirth period) and conjures up images of 1960s and 70s breastfeeding regimens, where babies were brought to mothers at prescribed times and allowed to feed for 5 minutes on each breast before being removed from their mother’s arms! We think that it is essential that we remember that SUDI is rare, that the overwhelming majority of mothers do not accidentally suffocate their babies.

We totally agree that, “mothers are less able to ensure a safe environment for breastfeeding or sleeping when they have experienced a long or complicated labour and birth, are under the influence of medications, or have some medical conditions.” (p27) Improved midwife:mother/baby ratios in the postnatal wards would go some way to reducing this risk (and adequate pay scales for midwives would assist in achieving this).

“After my c section – almost 1am – I was taken to my room but my partner wasn’t allowed to stay. I felt very alone and as I still hadn’t regained movement in my legs from the spinal block I had to stay on my own completely exhausted after 36+ hrs of labour and then the c section. I felt vulnerable not being able to tend to baby without someone having to get her out of her cot to pass her to me and spending my first night as a mum alone.”

(2017)

“Bub was born with meconium in the waters and we were required to wait 6 hours for monitoring prior to transferring to Rangiora Birth Centre. We ended up being there 7 hours and only saw someone twice during that time.”

(2016)

“I shared my room with a smoker which was foul, and easily went 8 hours without seeing anyone which is terrible. I’m a nurse and I would never not see a patient for that long.”

(2017)

“The hospital was short staffed and no one brought in a bassinet, forcing me to hold my baby all night and not sleep a wink. When I asked about it I was told to sleep with her in my hospital bed. I didn’t trust myself to do so safely as I was exhausted so I stayed awake until a shift change of staff.”

(2018)

“The midwives at the hospital were very obviously stretched. It was our first child and sometimes we didn’t see a midwife on the ward all day. They would come and introduce themselves and then we wouldn’t see a midwife again until the next one came to introduce themselves that evening.”

(2018)

We cannot help but note that our knowledge about what is important for mothers/parents and babies in the first few days after birth is in no way facilitated by the design, furnishing and operation of most postnatal wards in our hospitals.

MSCC recommends that when new maternity facilities are being built or existing facilities are being refurbished, there should be a requirement for single postnatal rooms making it possible for the second parent or a support person to stay overnight to support the mother and baby. It’s been over 40 years since the benefits of having the father/other parent/support person present during the labour and birth were recognised and accommodated, providing postnatal facilities that support the benefits of keeping the new family together in the early postnatal period, is long overdue. It is unlikely that the DHBs will ever be able to fund staffing levels that would allow “active observation” of mothers and babies, but having the second parent or a support person rooming-in with the new mother would go a long way to ensuring that women are supported to have safer skin-to-skin time with their babies

“Partners weren’t allowed to stay so I spent the first night alone with my son. I really struggled getting him to latch so would buzz for help, someone would eventually come and latch him and then would rush off saying they would be back to check in 10 mins and then wouldn’t come back for an hour – my son of course had come off as soon as they left the room. I was too scared to sleep with my son in my bed but I couldn’t get him to settle in the bassinet so I stayed awake the whole night.”

(2018)

“The night after my baby was born (his first night) was truly awful for me. As is usual with newborns, he didn’t want to be put down, he just wanted to be held. This meant I didn’t sleep for close to 48hrs (having laboured through the previous night) and I would have greatly benefited from my husband being able to stay the night to help me with our son. The midwives and nurses were good but they were simply stretched too thin.”

(2017)

“When calling for assistance it would take 30 mins for anyone to arrive, (during the days were better). My husband had to leave overnight, which I fully understand. However having a c-section I was unable to pick up my child when crying in her crib, bend over to get a new nappy etc and with busy staff I felt uneasy calling them asking for help.”

(2018)

“Would be fantastic if partners could stay all night with you after a c-section. I couldn’t move to pick up my crying baby and the nurses were busy took ages for them to come distressed mum and baby that didn’t need to happen.”

DHBs could enhance safety for mothers and babies by providing either, sidecar bassinets that attach to the mother’s bed or by providing wider, lower beds that would allow space for a wahakura or pepi- pod, in all postnatal rooms. Either of these options would make it easier for new mothers to access their babies for breastfeeding and skin-to- skin comfort, then return them to a safe sleeping space without fear of either, dropping the baby or falling out of the bed.

“More side car cots should be available/offered.”

(Taranaki 2015)

“Option to have a cosleeper – it was unbelievably difficult to care for a newborn when I could barely move post c-section.”

The PMMRC recommends that lead maternity carers (LMCs) and DHBs ensure that every baby will have access to a safe sleep place on discharge from the hospital or birthing unit, or at home, that is their own place of sleep, on their back and with no pillow. If they do not have access to a safe sleep place, then a wahakura or Pepi-Pod®2 must be made available for the baby’s use prior to discharge from hospital.

Every baby does need a safe sleeping place but this does not mean that it is not possible for mothers to safely co -sleep with their babies. MSCC supports the recommendation that LMCs and hospital staff check to see whether new mothers have been able to arrange a safe bed for their babies and that easy access to a wahakura of Pepi-Pod is available when needed.

We believe the current blanket prohibition on mothers co-sleeping with their babies is unhelpful and causes unnecessary stress and anxiety for new mothers. Although the table above shows that the highest percentage of babies who died were in an adult bed, many of these babies were also exposed to additional factors that are known to make co-sleeping risky.

“The majority of mothers were known to have smoked in pregnancy 48 (71 percent). Smoking status in the postnatal period was unknown for 43 mothers as the smoking status was not recorded. However, 20 mothers were noted to smoke in the postnatal period… In 17 cases (25 percent), whanau were known to be smoking postnatally in the home. Twelve caregivers (18 percent) were known to have been consuming alcohol on the night of the baby’s death. Two caregivers (3 percent) were known to use illicit drugs at the time of death. Methamphetamine was found on routine toxicology testing of three babies…At the time of the event or death, 56 babies (82 percent) were at home, eight babies (12 percent) were at a family or friend’s home, and four babies (6 percent) were in hospital… The majority were sleeping with an adult and/or siblings (79 percent), and just over half were reported as having their own (unshared) usual sleeping place…Family violence was documented in the maternal history of five SUDI deaths, but there was no information on screening for family violence for 25 women (37 percent). In four cases, Child, Youth and Family/Oranga Tamariki was involved with child protection at the time of death.” (pp55 – 57)

The linking of co -sleeping with SIDS/SUDI has been challenged by whanau in AotearoaNZ and internationally since it emerged in the 1990s. Co-sleeping is normal mammalian behaviour, breastfeeding and co -sleeping are evolutionary survival behaviours. Evolution wouldn’t favour a practice that led to either suffocation or the sudden and inexplicable death of infants (and parents would have noticed long before now if co-sleeping was killing their babies! Indeed, would the human species have survived if co- sleeping killed babies?) . Most mothers who choose to or end up co -sleeping with their babies do so because it facilitates breastfeeding and there is ample evidence that breastfeeding reduces the risk of SIDS. Research reveals that approximately 50% of breastfeeding mothers co-sleep with their babies for some of the night or all night^[3][4] but most do not admit this to their caregivers for fear of being judged as reckless or accused of putting their comfort ahead of their babies’ safety.

Why is it, that the one factor that is known to reduce the risk of SUDI/SIDS was not recorded in the risk table?- i.e. breastfeeding^[5][6] We are not told whether any of the babies who died with a diagnosis of SUDI while co- sleeping were sleeping with their mothers and were fully or exclusively breastfed. This information is essential if parents are to make an informed decision about co-sleeping.

Up until the 20^th century, mamas breastfed, they did not birth by c-section and take post-operative pain relief, they didn’t smoke cigarettes, drink alcohol or use recreational drugs. We’re not suggesting that new families debunk to the nearest cave, but to safely co- sleep in the 21 ^st century, the new mama, and anyone else in the bed does need to be drug, alcohol and tobacco free; ideally the baby needs to be breastfed; the mattress needs to be firm enough that there is no possibility of the baby rolling into an adult body, onto it’s face on the mattress or getting wedged between mattress and wall or pillows; the bedding should be made from natural fibres that breathe – micro-fleece sheets and polyester duvets plus one or two adult bodies can make for a very hot bed – hyperthermia has been a known risk factor for SUDI for decades; and free from any bedding, toys etc that could cause suffocation or strangulation. If in doubt, a sidecar arrangement, a wahakura or a pepi-pod can allow a mother to safely keep her newborn close at night. It is not appropriate or helpful, to threaten or demonize the mothers who have made an informed choice to co -sleep and have organised a safe co-sleeping arrangement.

Many mothers find themselves accidentally co-sleeping, often in completely unsafe situations, because they have been following the recommendation not to bed share. Individual care providers need to be permitted to discuss individual risk factors and safe and responsible co- sleeping strategies with those mothers who instinctively or practically feel that bedsharing may be beneficial. Health authorities and health care providers do families a great disservice when they issue blanket prohibitions that close down these conversations.

“I’m all for empowering parents with information about how to set up a safe bed sharing space. It’s so frustrating that some parents still hear the “bed-sharing is not safe, don’t do it” message. Before I knew better, that message meant I dozed on the couch with my baby in order to avoid sleeping in bed together!! (Couch sleeping is much less safe than planned, informed bed-sharing!)”

“I found Plunket largely a waste of time. Their advice was so black and white, and out dated. I wanted to love Plunket but their advice around solids, allergens, bed sharing and babywearing needs updating. My concern is for parents who don’t have the resources to make other arrangements, or who (e.g.) don’t get good advice on bedsharing because Plunket doesn’t discuss how to make it safer.“

(Waikato 2016)

“Also being given safe sleeping advice about bed sharing /co sleeping instead of Plunketscaremongering parents into thinking your baby will die of SIDS automatically if you bedshare.”

“Mainly the way people talk about co sleeping – I don’t appreciate nurses telling me I’ll be killing my baby.”

(2017)

“Breastfeeding mother-infant dyads are biologically designed (emotionally, socially and physiologically) to sleep next to each other, and the fact that their proximity settles infants, increases sleep for both, and enhances breastfeeding makes this arrangement hard for parents to steadfastly avoid.”^[7]

Book Review

Are you OK? …Really?
A resource about perinatal mental health for providers
Published by Perinatal Anxiety and Depression Aotearoa (PADA) April 2018
The “Foreword” in this book states that, “More than one in every ten women in NZ will develop a mental illness during pregnancy or within the first year of having a baby.” and prefaces 250+ pages of densely packed information to assist providers to diagnose and treat, or refer women for treatment.

This is not a book to sit down and read from cover to cover, but all maternity care providers, as well as individuals and organisations who provide services to women during their childbearing years, would benefit from having access to this book. It provides assistance with recognising perinatal anxiety, depression and psychosis.

Each chapter is written by a different author or organization and I think that this is important to remember when reading – each is an expert in their own area and fully conversant of how the service they offer operates, but many appeared not to have a thorough understanding of how the maternity services are provided, the work and workload of LMC midwives. (It was gratifying to find the inclusion of a chapter on “Caring for the carers”).

There are chapters on risk factors including; pre-existing mental illness (including the risks and benefits of psychiatric medications during pregnancy etc), a history of loss and grief, PTSD, sexuality, maternal age, ethnicity, migrant status etc. Chapters that describe the relationship between sleep, breastfeeding and maternal wellbeing. There is even a chapter on the pressures of, and support provided by, access to online information and social media, which tells us that many new mothers spend up to 3 hours per day online! Father/partners are not forgotten, they have their own chapter but also feature in many of the other chapters. Most of the chapters conclude with a helpful list of resources – contact details for appropriate care and support providers or resources for gathering more information.

Although there is a bibliography and references section at the end of the book, I would have preferred that references were footnoted and available at the end of each chapter. I found that this book has a stronger focus on recognizing and treating maternal mental health in individuals than on prevention (e.g. I would have liked to see a chapter on diet, lifestyle and exercise). I also think we/society need to have a much broader conversation about how 21^st century lifestyle (the lack of access to practical support from extended family and the “village”) is contributing to poor mental health outcomes generally, and maternal mental health in particular given the intergenerational impact that this is going to have. That aside, this is a valuable local resource for maternity care and service providers. Much needs to be done, at every level, to assist women to make a healthy transition to mothering.

Reviewed by Brenda Hinton

Available for $35 +$5p&p from Perinatal Anxiety and Depression Aotearoa (PADA)

Research

Psychosocial factors that mediate the association between mode of birth and maternal postnatal adjustment: findings from a population-based survey. Alderdice F, Henderson J, Opondo C et al BMC Women’s Health201919:42 https://doi.org/10.1186/s12905-019-0738- x

This study used information provided by 2139 first time English mothers, who gave birth during a 2 week period in January 2014, and responded to a questionnaire when their babies were between 12 and 52 weeks old.

The authors assessed how mode of birth impacted maternal satisfaction with their births, their assessment of postnatal wellbeing and their sense of connection with their babies. Less than half (48%) of the women had a SVD, a quarter had an instrumental birth (forceps or ventouse assisted), and just over a quarter (27%) had a c-section (8.6% prelabour: 18.28% in labour).

Instrumental birth (forceps or ventouse assisted) and both planned and unplanned c- section were associated with lower maternal postnatal wellbeing scores when compared to those of women who had had a spontaneous vaginal birth (SVD). Women who had an instrumental birth and those who had an unplanned c-section also reported lower satisfaction with their care during labour than women who had a SVD. This analysis found no association between mode of birth and maternal/infant sense of belonging/connection.

The authors then looked at how five psychosocial experiences during labour and birth, influenced women’s assessment of their satisfaction with their intrapartum care and their postnatal wellbeing. Women were asked about:-

1. Perceived control – i.e. their ability to make informed decisions about their birth experience.
2. Level of confidence in, and support received from, their Health Care Providers (HCPs) during labour/birth.
3. Expectations – how well their birth experience matched their pre-labour expectations.
4. How soon after the birth they held their babies and for how long.
5. Whether or not their baby had any health problems postnatally.

“Perceived control” had the strongest mediating effect – i.e. women who felt that they had been an active participant in the decision -making about their labours and births, reported higher levels of postnatal wellbeing and satisfaction with their birth experience, regardless of whether they had a SVD, instrumental birth or an in labour c-section. (Most women who had a prelabour c-section felt that they had had the opportunity to participate in this decision and reported positive wellbeing postnatally.)

Holding the baby soon after birth had the second highest positive impact followed by maternal confidence in and perceived support from her HCPs. Infant health postnatally did not appear to have any significant mediating effect on satisfaction or postnatal maternal wellbeing related to mode of birth, in this study.

Getting back to our 2018 joint survey… results clearly showed that satisfaction with the maternity experience was highest when women had been able to form a trusting relationship with their LMCs antenatally and had their choices for care respected and supported. LMC midwives were generally rated highly for respect, support and partnership. Many women, however, reported that secondary care providers seemed to have little understanding of informed choice and consent and little desire to facilitate this. Given the percentage of women suffering postnatal distress and anxiety and the knowledge that “perceived lack of control” during birthing contributes to compromised maternal wellbeing, MSCC recommends that DHBs institute a compulsory study day annually for all employed caregivers, to support them to ensure that they are facilitating partnership and informed decision-making. Although it is now 25 years since the passing of the Health and Disability Commissioner Act and its appended Code of Health and Disability Consumer Rights, we know that many maternity care providers don’t know the difference between informed choice and informed compliance. Blanket statistical risk assessments are used to frighten women into compliance, rather than treating women as individuals and offering options for the management in non-emergency situations.

“Baby was induced unnecessarily with no signs of distress to fit with hospital schedule. I wasn’t given the option to say no or ask questions.”

(Auckland)

“Being pressured into being induced when there was no direct risk to baby. Also being pressured into a c section after only 12 hours of labour.”

(Wellington)

“Having obstetricians who work more collaboratively would have improved my experience. They were very pushy and keen to speed up my induction instead of letting my body work its magic. I opted for the least invasive induction process first (foley catheter) and it worked. Obstetricians definitely have room for improvement around respecting the birthing person’s autonomy.

(Christchurch)

“Hospital doctors and midwives should respect a woman’s right to make choices and not be disrespectful and hold them to ransom that you have to do everything their way if you want any help from them. I still feel so angry and upset at my treatment and things I felt forced into and it was over 2 years ago. Hospital staff breached so many of the Code of Rights and think they have the right to.”

(Auckland)

“I didn’t feel very supported during my labour and birth I was induced and felt as though it all just happened to me. Did not feel very informed.”

(Taranaki)

“ Midwives need more support and not to be ignored by some hospital staff. My midwife and I had 8 months to build a relationship and to have my opinion ignored and then her ignored when she tried to back me up was horrible.”

“My birth in the North Shore Hospital and my treatment there was horrible. It still makes me want to cry and makes me angry 5 years later. No informed consent. No communication. No respect for any of my birth decisions/plans. I was restricted to move and I was offered a c- section with a smile several times for no reason. The machine doing the fetal monitoring broke down. Everyone hit it and banged it until it worked again .when it came back to life I was sent for a crash csection. Nobody knows if it was actually working at all. More honest communication. More information about pros and cons.”

“Obstetrician was horrible – my baby was breech and the OB was wanting me to book in a c-section but I wanted to wait until I went into labour in case the baby turned, her response was “so you’d rather wake up six people at 2am for an emergency c-section? Well I hope I’m not one of those people.” Appalling.”

(Tauranga )

“The attitude of obstetricians and hospital midwives – in general, I felt that even asserting a low level of informed choice was dismissed and I was made to feel like a problem.”

(Dunedin)

“The hospital midwife telling us anecdotal horror stories of her vkdb-affected sister to pressure us when we had made an informed choice to refuse vitamin k for our baby.”

(Middlemore )

For assistance with understanding and facilitating informed choice and consent, get a copy (or more) of our resource @ www.maternity.org.nz

MSCC Steering Group Meetings

We welcome interested maternity consumers to our monthly meetings.

If you are interested in –

• finding out more about the work of the MSCC
• participating in providing information to maternity care consumers
• monitoring the provision of maternity services
• making improvements

PLEASE COME ALONG

Birthcare Meeting Room,
Level 2, 20 Titoki Street Parnell.
2^nd Tuesday of each month from 10:00am – 12:00pm
Next Meeting Tuesday 9 April or email [email protected]