Plunket staff share their work with colleagues.

Sessions for the 400 clinical staff and workshops for the more than 600 volunteers were a feature of the second day of the centenary conference. There were 14 concurrent sessions for clinical staff, held over two time slots during the second day.

The session on family violence heard Whakatane-based Plunket clinical manager Marianne Grant outline the development of a "community collaborative family violence network" involving 19 agencies in the Bay of Plenty and funded through the Ministry of Social Development. Since it was established, agencies were working more closely together, there was increased access to training and development, and there was a collective vision to reduce family violence and to change the social climate to ensure family violence was no longer tolerated.

Former Te Runanga 0 Aotearoa NZNO chair and current Plunket Maori clinical educator Sharon Morunga dedicated her korero to "all the children we have lost". In the final year of her masters research, her focus is barriers to Maori health workers identifying family violence in Maori families. Using a kaupapa Maori approach, Morunga outlined the seven principles underpinning her research.

Challenges for Plunket staff

She asked why just four percent of Plunket's workforce was Maori, and she challenged Plunket staff to be open to working with Maori communities, to review policies and decision-making to ensure they promoted affirmative practices; to draw on Maori organisations and channels to find out who to consult; to draw on the skills and support Maori can offer the organisation; and to encourage new migrants to learn about Maori culture.

Many in the audience were moved to tears by Morunga's presentation, with one vowing to "work harder to help our people and support them".

The last speaker in the family violence session was Plunket policy analyst Cathy Kern who presented some results from a range of international research studies linking animal abuse and family violence. Fear of what might happen to pets was a barrier for some women in leaving a violent relationship. She said screening for animal abuse should be a part of every assessment procedure.

One Plunket nurse in south Auckland told the session that vicious dogs were a barrier to accessing families, as nurses would not enter a property if dogs were not confined. One day, dog control officers took away 40 dogs from one street in south Auckland and, on rubbish days, dogs often attacked Plunket workers.

Sudden infant death syndrome 

In the child health and well-being session, Hutt Valley Plunket nurse Bettina Symes outlined the latest research into sudden infant death syndrome (SIDS): that it was a multiaetiologic phenomenon, rather than having a single cause; the vulnerable age was one to eight months, peaking at two to four months; the current SIDS rate was 0.89/1000 live births, with the Maori rate at 2/1000 live births. Eighty percent of SIDS now occurred in lower socioeconomic groups.

She canvassed the non-modifiable risk factors, eg male, preterm and low birth weight babies, and young mothers; and the modifiable risk factors, eg maternal smoking, especially prenatally, sleeping on soft surfaces with loose bedding, and on couches, and late or no prenatal care. Protective factors included room sharing in the first six months; pacifier use when settling to sleep, breastfeeding and immunisation.

Health professionals had a responsibility to be aware of the changing face of SIDS, take detailed assessments to assess the degree of risk for vulnerable infants, respect client choice and use/refer to appropriate resources, Symes said. The family support manager for Heart Children, a support organisation for children born with congenital heart defects, Shona Harvey, outlined the development and structure of the organisation; and the mothers of two heart children shared their stories. Karen Hand, who is now a regional family support co-ordinator for Heart Children in Christchurch, praised her Plunket nurse for picking up that her son, now 12, had a congenital heart defect, a fact missed by all the other health professionals involved in his care. Told he only had a month to live, she said the Plunket nurse visited her every day "and made me feel like I had a normal baby". She urged Plunket nurses to keep on doing "your great work."

The final part of the concurrent session looked at attachment relationships. Plunket clinical adviser for Otago/Southland and a counsellor, Jocelyn Johnstone, outlined the development of attachment theory, current research which looked at the effects on a child's, and subsequently on the adult's emotional development, if the attachment between mother and infant is compromised or disrupted.

Government may need to set more realistic breastfeeding targets, especially for Maori and more deprived communities, according to South Island clinical adviser Trinie Moore at the session on breastfeeding trends.

"How do we increase breastfeeding rates for those in higher areas of deprivation?" Moore asked. "The Ministry of Health wants a 90 percent exclusive breastfeeding rate by six weeks of age, but this is a huge leap from where we are currently." Dunedin Family Centre community Karitane Jill Moore took a very different approach in her part of the workshop, donning various hats and reading breastfeeding stories from a large scrapbook. The three stories she read were all written from the baby's perspective and were designed to increase women's breastfeeding knowledge in a supportive and accessible way.

Cultural perspectives on breastfeeding

Nine presenters, from nine different cultural groups in Auckland, took the last section of the session, each one describing both traditional and changing attitudes to breastfeeding from their own cultural perspectives.

"People are socialised to breastfeed or not to breastfeed, with knowledge and practice passed down from mother to daughter. Staff who understand the role of culture in breastfeeding will be able to provide more culturally sensitive support and information to mothers from their own and other cultural heritages," said lead presenter Margaret Wong.

Many of the presenters spoke of the pressures on women from other cultures to give up breastfeeding and use formula, in order to get back to work. Lack of family support was another factor in the poorer breastfeeding statistics among Asian, Pacific, Middle Eastern women and teenage mothers.

Shobna Singh, a Fijian Indian, spoke of the importance of privacy while breastfeeding for women from her culture. "Nurses should also be aware that many decisions will be made by the mother-in-law as well as the mother, so nurses must make sure they speak to both. In New Zealand, mothers will often turn to bottle feeding and let the inlaws take over the baby care." Singh said.

Rezwana Nazir from Iran described the use of wet nurses, often family members, in her culture. Kaiawhina Kura Marsters, who works primarily with teenage mothers, spoke of the social and peer pressures these women faced. "Don't go and tell teenagers what to do. Go and listen to them to understand the pressures they are under."

Diagnosing postnatal depression 

In a presentation entitled "Don't mention the D word!" Plunket educator Liz Banks spoke of the prevalence of postnatal depression (PND) and the questions well child/tamariki ora nurses should ask in order to diagnose this condition. "PND affects approximately 13 percent of women in the first year of motherhood, with one New Zealand study identifying a 20 percent rate," she said. "Many cases of PND go undetected, despite these women having contact with health care services. If undetected and untreated, PND can adversely affect a mother's functioning, as well as her infant's development."

Universal screening

Women might not realise that what they were experiencing was not normal, said Banks, and they might not want to admit to a health provider they were struggling. She promotes universal screening of mothers in the first year, as even those who appear to be doing well may not be. She believes well child/tamariki ora nurses are in the best position to do this screening. "Nurses need to be able to identify the risk factors for PND. These include previous episodes of depression, partner difficulties, not breastfeeding, an unplanned pregnancy and anxiousness about the parenting rote. Screening needs to take account of New Zealand's cultural diversity and be committed to improving the health of vulnerable groups, particularly Maori.

"Nurses can ask a mother neutral questions about how she is sleeping and eating. They can also ask her about her mood and whether the reality of motherhood is what she expected. Ask about her relationship with her partner and whether she has thought about harming herself or her baby. If a woman is assessed as struggling and possibly depressed, she should be referred to her family doctor."

Nurses and kaiawhina who deliver Plunket's postnatal adjustment programme believe the adjustment phase to pregnancy, parenting and the first year of a child's life has not been significantly acknowledged, even, at times, over-looked. A member of the programme's Canterbury team, Robyn Aitken, spoke of the well recognised detrimental effect of PND on the emotional development of infants.

"The well-being of the infant and the mother is totally intertwined," she said. "The crucial experiences a baby needs are face-to-face interactions, eye contact and physical closeness. They need an emotional relationship with a specific person, involving soothing, comforting and pleasure. Women who are anxious and depressed may have less positive expectations of their children. It is also possible that difficult infants will result in the mother experiencing anxiety and depression."

Secure vs insecure toddlers

In her one-to-one assessment work in the community, Aitken observes how toddlers behave when separated from their mothers. "A toddler who is secure will explore their environment, but will seek out the parent and find comfort on reunion with that parent. An insecure child will be distressed on being separated from their parent and stow to settle when the parent returns. How mothers treat their babies and the relationship they have with them are the keys to a child's mental health in later life," she said. Other concurrent sessions included an overview of working in partnership with families, for Plunket clinical and management staff run by child psychologist Hilton Davis (see p12); the Ministry of Social Development's strategies for kids, information for the parents' (SKIP) programme; child protection, which featured paediatrician Patrick Kelly on shaken baby syndrome and Plunket's national clinical adviser (nursing) Brenda Hynes and senior nursing-lecturer at Auciland University of Technology rSharon Valiant who presented on their family violence research; practice development, Plunket nurse development, and education.