The death of a newborn could have been prevented if a sleeping capsule had been delivered 24 hours earlier, a coroner has found.
The death has led to a recommendation that funding be considered to provide all mothers of newborns with one of the safe sleeping capsules at birth.
It’s not the first time a coroner has recommended prioritizing the use of pēpi pods in infants to prevent parents from suffocating their babies while co-sleeping, with a whopping 12 recommendations dating back to 2008.
Coroners labeled the problem a “hidden epidemic”, but a 2016 Weekend herald investigation found that a health ministry contract to fund the cribs was suspended despite the death of about 50 babies a year from sudden unexpected deaths in infancy [Sudi]†
In the latest tragedy, baby Eli Edwards-Te Rangi died in his mother’s bed in June last year, the night before her midwife was due to bring a pēpi pod to sleep in.
The mother woke up during the night to find her four-week-old baby face down and unresponsive.
Coroner Alexander Ho advised the health ministry to consider automatically giving all newborns a pēpi pod or wahakura, a woven flax crib, at birth.
“It is not enough for new parents to simply be ‘presented’ with such a device at birth,” coroner Ho said in his statement on the baby’s death.
“Many new moms are tired and overwhelmed after giving birth. They don’t want to make another decision.
“If there is a serious public health desire to reduce infant mortality from Sudi, simple steps must be taken to prevent deaths before they are necessary.”
Deputy Chief Coroner Anne Tutton said it was alarming that coroners continued to investigate deaths that could have been prevented.
She endorsed the comments of former chief medical examiner, Judge Deborah Marshall, who said this was why coroners continued to make the recommendations in hopes the message would get through.
“The evidence is pretty clear about the dangers of co-sleeping without any protection for the baby,” Marshall said in 2016.
“Babies are safest in a separate crib or crib, but if that wasn’t possible, the pēpi pod or wahakura was the next best option.”
Between September 2018 and June 2020, the number of Sudi suspected deaths rose to 64.
In 2020, the ministry ordered an investigation resulting in three reports released last month to understand the reasons behind the number of babies dying from Sudi.
It found that Māori babies were eight and a half times more likely to die from Sudi than non-Māori.
“The number of babies in New Zealand who die from Sudi each year is not declining and social inequality means the percentage of Sudi is higher for babies who are Māori, or who live in areas of high deprivation,” the ministry’s chief clinical adviser of child and youth health, wrote Dr. Tim Jellyman.
In the case of baby Eli, the maternity ward offered his mother a pēpi pod, but she declined because she already had a crib at home.
The coroner noted that she smoked and the midwife reminded her to sleep safely to avoid the risk of Sudi, as baby Eli had been exposed to cigarette smoke during pregnancy.
Coroner Ho said the mother declined a prenatal referral to smoke-free services, but he was sympathetic to her decision to sleep with her baby.
“Motherhood is exhausting. I appreciate the circumstances in which a sleep-deprived mother, who is often awakened at night to breastfeed, can choose to have a baby in her bed rather than back in the bed.” cradle.”
New Zealand College of Midwives chief executive Alison Eddy said pēpi pods should be available to anyone who wanted one, not just those who smoked during pregnancy.
“Premature birth and low birth weight are also risk factors. People seem to forget this,” Eddy said.
“Sudi is linked to health and social inequality and is more experienced by people living in poverty.
“We need to get to the root of the problem. This goes beyond us and the Ministry of Health. The entire industry and society must work on this to ensure that all families with new babies have good housing.”
Housing and poverty were some of the issues identified in the Health Ministry reports released on May 31.
Other concerns included the need for involvement in whānau, smoking during pregnancy, sick babies and the mother’s mental health.
The need for a bicultural framework within a national Sudi prevention program that recognized the significance and effectiveness of Māori leadership was recognized, along with the need for culturally anchored programs and safe sleep messages.
A health ministry spokesperson told Open Justice any Sudi death was unacceptable, but stopped short on the issue of funding pēpi pods for all newborns.
Instead, he said that pēpi pods could not be financed in isolation because they had to be provided with appropriate safe sleep messages for māmā and whānau.
This included smoking cessation programs, 16 of which were funded nationwide.
The spokesman said the ministry was concerned about Sudi’s current tariffs, especially the high tariffs on Māori and Pacific babies.
“We recognize that the current inequalities are unacceptable and we continue to pay close attention to the persistent percentages of Sudi for Māori and how to better address this in the future,” he said.
He said funding from the ministry, the National Sudi Prevention Service and Interim Health New Zealand, has paid for the 8,500 safe baby sleeping beds provided to newborns every year since 2017.
“This will provide sleep-safe beds for 15 percent of babies born each year nationally and equals the currently reported proportion of mothers who smoke during pregnancy.”
The advice for safe sleeping remains to avoid all types of smoke, with babies sleeping on their backs and on a flat surface with their faces clear.
Breastfeeding newborns was found to create a stronger immune system.