PEDIATRICS Vol. 118 No. 2 August 2006, pp. e243-e250 (doi:10.1542/10.1542/peds.2005-2517)
ARTICLE |
Barriers to Following the Supine Sleep Recommendation Among Mothers at Four Centers for the Women, Infants, and Children Program
a Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
b Data Coordinating Center
c Department of Epidemiology, School of Public Health
e Department of Pediatrics, School of Medicine, Boston University, Boston, Massachusetts
d Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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ABSTRACT |
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OBJECTIVES. The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers.
DESIGN/METHODS. We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: "ever" (meaning usually, sometimes, or last night) put infant in the prone position for sleep and "usually" put infant in the supine position to sleep.
RESULTS. Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position.
CONCLUSIONS. We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.
Key Words: SIDS • behavior • black • low income • barriers
Abbreviations: SIDS—sudden infant death syndrome • WIC—Women—Infants—and Children
Sudden infant death syndrome (SIDS) remains the leading cause of postneonatal death in the United States.1 Although the cause of SIDS is unclear, studies have shown that placing infants to sleep in the supine position decreases the risk for SIDS.2,3 The Back to Sleep campaign began in 1994 and highlighted the importance of placing infants in the supine position for sleep. Since then, more caregivers report placing their infants in the supine position for sleep (27% in 1994 vs 70% in 2004).4 There has been a concomitant decrease of 
50% in the incidence of SIDS.5,6
Despite this decrease, racial differences in the incidence of SIDS continue; black infants are twice as likely to die from SIDS compared with white infants. In 2002, 0.6 per 1000 white infants died from SIDS compared with 1.1 per 1000 black infants.7 Furthermore, black infants are less likely to be placed in the supine position for sleep compared white infants and more likely to be placed in the prone position for sleep.5,6,8–11 On the basis of data from the National Infant Sleep Position Study during the years 2000–2004, 13% of white infants were placed in the prone position for sleep compared with 20% of black infants, and 72% of white infants were placed in the supine position for sleep compared with 54% of black infants.4 Research has shown that these are linked. That proportionately more black infants are placed in the prone position for sleep at least partially explains the increased incidence of SIDS.11
For this reason, we sought to gain a deeper understanding about the choices that mothers, particularly black mothers, make regarding infant sleeping position. In addition, we sought to include mothers with low incomes because infants who live in low-income households are at increased risk for SIDS. Researchers who examined the US Linked Birth/Infant Death data sets found that the risk for SIDS in infants from low-income families has increased since the Back to Sleep campaign began.12 Those who live in low-income households also have been found to be more likely than those in higher income households to place their infants in other than the supine position for sleep.13
As preliminary work to guide our current study, we conducted focus groups of low-income, primarily black caregivers to identify potential barriers to following the Back to Sleep recommendations. From these focus groups, we identified themes that are important to mothers when choosing the sleeping position for their infants. These themes included their beliefs about infant safety, their beliefs about infant comfort, advice that mothers received about how to place their infants to sleep, their main sources of trusted advice, and their own knowledge about reducing the risk for SIDS.14 Through these focus groups, we found that mothers worried about the safety of placing their infants to sleep in the supine position. Specifically, they worried that the infants could choke in this position. Some also believed that infants were more comfortable in the prone position for sleep. Mothers sought and received advice about infant sleeping position from many sources, especially female friends and relatives. Health care providers were not a uniformly trusted source of advice. Finally, they had not universally heard about the Back to Sleep recommendations, including the importance of placing their infants in the supine position for sleep, and had varying opinions about how to keep their infants safe when asleep.14 With these themes in mind, the objective of this study was to quantify the degree to which these barriers that were identified in our focus groups were associated with the choice of infant sleep position in a larger group of primarily black, low-income mothers.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Study Population
Between June and October 2004, we conducted face-to-face interviews with 671 mothers of infants at Women, Infants, and Children (WIC) program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. The WIC Supplemental Nutrition Program is a federally funded program for low-income women who are pregnant, breastfeeding, and/or postpartum and for children who are younger than 5 years and are from low-income families. The data analysis was performed on the 671 participants who were the mothers of the infants because we believed that this would be a more homogeneous group who generally had the most consistent contact with the infants. Mothers were eligible to participate in the study when they received benefits from WIC, had an infant who was younger than 8 months, and spoke English. The WIC centers were chosen on the basis of the center's geographic location, availability, and willingness to participate. Each WIC center had to serve at least 50% black clients. Before beginning the study, we discussed current programs or interventions at the WIC sites with the WIC directors. We are not aware of any formal SIDS educational initiatives that were occurring at any of the WIC centers during or before our interviews.
Interviews
All of the interviews were conducted by research assistants who lived in the area where the WIC centers were located. They were trained at the site by 2 of the investigators (A.M. and E.R.C.). The training was based on a manual that was developed specifically for the training. Each assistant received and read the manual, and then training sessions with practice interviews were conducted followed by several pilot interviews at each site. The pilot interviews were observed by the researchers (A.M. and E.R.C.). Interviewers were trained to ask the mothers to use a doll for demonstrating the sleeping position for their infants. Key interview questions that were asked to obtain the relevant data are in Table 1. After the interview, all participants received information about the current recommendations for safe infant sleep following the Back to Sleep guidelines. Institutional Review Board approval was obtained for all sites. All participants gave informed consent and received a $10 gift certificate at the end of the interview.
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Statistical Analysis
Descriptive statistics, including frequencies and percentages, were calculated. Univariate and logistic regression analyses were conducted to identify and quantify factors that were associated with choice of infant sleeping position. Univariate analyses were used to select factors that were significantly associated with mothers’ choice of infant sleep position. Initial independent variables were chosen on the basis of previous research that identified factors that were associated with choice of infant sleeping position (race, education, infant age, previous child-rearing experience, and hospital position)5,6,9,10,15 as well as factors that were identified in the focus groups (advice, trust, comfort, safety, and knowledge).14 All variables selected were forced into the multivariate analysis. The multivariate logistic regression models were built to calculate adjusted odds ratios for 2 main outcome variables: "ever" (meaning usually, sometimes, or last night) put infant in the prone position to sleep and "usually" put infant in the supine position to sleep in the past 2 weeks. All variables that were included in the models are in Tables 2 and 3. All analyses were conducted with SAS 8.2 software (SAS Institute, Cary, NC);
for all tests was set at .05.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Demographics
A total of 1013 caregivers met eligibility criteria and were approached for interview. Of those, 203 (20%) refused to participate. Demographic data are not available on those who refused. Of those who consented to participate, 2 interviews were partially completed and 808 interviews were completed (for a response rate of 80%). Data analysis was performed on 671 mothers of the infants. The majority, 64%, were black. They were evenly distributed between the sites (Table 4).
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Choice of Sleeping Position
Of the participants, 396 (59%) reported that they usually placed their infants in the supine position for sleep, 169 (25%) usually on the side, 101 (15%) usually in the prone position, and 5 (1%) other. Of note, 231 (34%) reported that they ever (meaning that they responded that they usually, sometimes, or last night) placed their infants in the prone position for sleep in the past 2 weeks. Demographic data that were associated with choice of infant sleeping position are in Table 2.
Themes
Advice
Figure 1 shows the advice that the mothers reported receiving from a nurse, from a doctor, and from a female friend or relative. Seventy-two percent of the mothers reported receiving advice from a nurse, 53% from a doctor, and 38% from an important female family friend or relative. Just 42% of the 671 participants reported that they were told by a nurse to place their infants in the supine position, 36% by a doctor, and 15% by a female friend or relative. Of those who received advice from a nurse, 58% reported being advised to place their infants in the supine position; 10% in the side position; 31% in other positions, which was a combination of positions (eg, side and supine); and only 1 prone. Of those who reported receiving advice from a doctor, 68% reported being advised to place their infants in the supine position, 6% in the side position, 26% other, and only 1 prone. Of those who reported receiving advice from a female friend or relative, 38% reported being advised to place their infants in the supine position, 24% in the side position, 20% in the prone position, and 18% other. Sixty percent of the mothers reported seeing their infants placed in the supine position during the postpartum hospital stay. None reported that the infants were placed in the prone position. Receiving advice from a nurse, doctor, and female friend or relative was associated with choice of infant sleeping position. Trusting the opinion of a doctor or a nurse and trusting ones’ own opinions also were associated with choice of infant sleeping position (Table 3). Of note, only 60% of participants reported that they trusted the opinion of a doctor or a nurse most about infant sleeping position.
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Comfort
Thirty–six percent of the mothers reported that they believed that infants were more comfortable in the prone position. Opinions about infant comfort were associated with the choice of infant sleeping position (Table 3).
Safety/Knowledge
Of the participants, 50% reported that they believed that their infants were more likely to choke in the supine position, and 29% reported that they believed that placing their infants to sleep with an adult would help prevent SIDS. Mothers were told that black infants were more likely to die from SIDS. Only 43% reported that they believe that infant sleeping position is related to SIDS in black infants. Concerns about infant safety and knowledge or lack of knowledge about reducing the risk for SIDS were associated with the choice of infant sleeping position (Table 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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It has been more than a decade since the American Academy of Pediatrics and other organizations announced recommendations to place infants in the supine position for sleep to decrease the risk for SIDS. In our study of 671 low-income, primarily black mothers of infants, we have demonstrated that there are several key themes that are both common and important predictors of noncompliance with sleep position recommendations. We also observed that nonsupine sleep position was very common among study participants and that more than one third of the participants reported that they "ever" (meaning usually, sometimes, or last night) placed their infants in the prone position for sleep during the past 2 weeks.
Each of the themes that we had identified previously from focus groups (advice, comfort, and safety/knowledge) were confirmed as important in this large sample of WIC clients. Advice from an important female friend or relative and the position perceived as most comfortable were the most influential (ie, associated with adjusted odds ratios from 4.25 to 5.84), both in association with usual supine when the advice or perceived comfort was in favor of the supine and in association with prone sleeping when the advice or perceived comfort was in favor of the prone position. Advice from doctors and nurses to place the infants in the nonsupine position also was significantly associated with position but less strongly than advice from an important female friend or relative. The importance of advice from female friends and relatives has been suggested indirectly by other studies. One study, conducted in Washington, DC, found that infants with a grandmother living in the home were more likely to be placed in the prone position for sleep.10
Health care providers were not uniformly trusted sources of advice. However, when the mothers in the study did trust a doctor or a nurse about placing their infants to sleep, they were more likely to place them in the supine position. This suggests that although not uniformly trusted sources of advice, health care provider recommendations to place infants in the supine position remain important. The importance of the extent to which mothers trust those who provide advice was not assessed previously in relation to sleep position. Previous studies showed that mothers who thought that their infants were more comfortable sleeping in the prone position were more likely to choose this position.10
Choking was identified previously as a concern that may influence parents’ choice of sleep position for infants. Analyzing data that were collected as part of the National Infant Sleep position study, Willinger et al6 found that mothers who were concerned about their infants’ choking were less likely to place their infants in the supine position. Brenner et al10 found that caregivers sited concerns about choking as a common reason for choosing the sleep position for their infants.
Although maternal race often has been a factor associated with placing infants in the prone position for sleep, we found, when adjusting for other variables, including location, infant age, and advice, that race of the mother did not play a significant role in choice of position. In some previous studies, Hispanic families were more likely than black families to choose the supine position for sleep.4,6 Hispanic participants in this study were a heterogeneous group, some living on the east coast and some on the west coast, and likely from families who originated in various Spanish-speaking countries. Factors that are related to geographic location as well as country of origin may account for differences between our study and previous studies with regard to infant sleeping position reported by Hispanic mothers.
Differences that are based on location could be a marker for differing cultural beliefs by location or the differences in education and permeation of recommendations by location. The potential impact of education is suggested by the frequent misconceptions about SIDS reported in this study. This may reflect inconsistent education that parents receive about how to decrease the risk for SIDS. Many mothers did not believe that there is a connection between infant sleeping position and SIDS, and approximately one quarter of the mothers also thought that they could prevent SIDS by having their infants sleep with an adult.
The degree to which the barriers that were identified through the face-to-face interviews can be generalized may be limited by the fact that the data collection occurred in only 4 cities and by the fact that the sample was restricted to WIC clients. In addition, it always is possible that the mothers reported what they thought that they should say rather than what they actually did at home (reporting bias). We tried to minimize reporting bias by conducting face-to-face interviews, using a doll for a model, and asking about the usual, sometimes, and last-night sleeping positions. Also, the information about advice from doctors was specific to that received during and after the postpartum period. It is possible that we missed information about advice during the prenatal period. For future studies, it might be important to broaden the time frame for advice that is received from health care providers. However, it is reassuring that the proportion of infants who usually are placed in the supine position in this study is similar to that found in the 2004 National Infant Sleep Position telephone survey, in which 60% of black caregivers reported usually placing their infants in the supine position for sleep and 16% usually in the prone position.4
This study does provide new insights into the prevalence and the importance of key barriers that lead to the frequent choice of nonsupine sleep position within this largely black, low-income population. These barriers include lack of advice or getting the wrong advice; lack of trust in health care providers; concerns about safety, especially choking, and comfort; and lack of knowledge among participants about reducing the risk for SIDS. These finding could be used to inform better the design of interventions to get more infants on their back to sleep. Additional studies should be conducted to identify interventions that best can address these barriers.
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ACKNOWLEDGMENTS |
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This study was supported by funds from the National Institute of Child Health and Human Development grant U10 HD029067-09A1C.
We thank Deborah Diehl and the staff at the WIC center in New Haven, Rhonda Dickson and the staff at the WIC center in Boston, Karen Newsome and the staff at the WIC center in Dallas, and Judy Gomez and the staff at the WIC center in Los Angeles. We also thank Marian Willinger for review of the manuscript.
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FOOTNOTES |
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Accepted Feb 13, 2006.
Address correspondence to Eve R. Colson, MD, 333 Cedar St, PO Box 208064, New Haven, CT 06520. E-mail: eve.colson{at}yale.edu
This research was presented in part at the annual meeting of the Pediatric Academic Societies; May 14–17, 2005; Washington, DC.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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