by Amy Spangler
June 07, 2011

It’s been nearly 20 years since the American Academy of Pediatrics (AAP) first recommended that babies be laid down to sleep on their backs. During that time, rates of sudden infant death syndrome (SIDS) have declined 50 percent. But it’s a spotty success story. African American babies are still twice as likely to die of SIDS as Caucasian babies. Not coincidentally, they are also twice as likely to sleep on their tummies. Why aren’t all babies being put to sleep on their backs? Researchers at Children’s National Medical Center in Washington, D.C. aimed to find out.

Research
Trained facilitators conducted focus groups and individual interviews with 83 African American mothers with infants 0–6 months of age living in the Washington, D.C. area. Broad open-ended questions were followed by more specific, probing questions to clarify responses. All interviews were videotaped, audio-recorded, and transcribed by the authors. To ensure accuracy and minimize bias, three authors reviewed each transcript. The results of the interviews were published in the Journal of the National Medical Association in a two-article series. One article addressed sleep position (prone or supine); the second addressed sleep space (crib or adult bed).

Results
Ninety percent of the mothers reported sharing a room with their babies. Their reasons for doing so were space (no room for crib or no crib), comfort, convenience, or safety. Safety concerns included SIDS, breathing difficulties, and vomiting/choking.

Thirty percent of the mothers reported sharing a bed with their babies, citing similar reasons. Although breastfeeding has, in other studies, been shown to influence bedsharing, here, no relationship was found. The majority of mothers (63 percent) either never breastfed or started breastfeeding but stopped early. Only 18 percent were breastfeeding exclusively and 19 percent breastfeeding partially at the time of the initial interview.

While the parents generally were aware of the risks of bedsharing (e.g., overlaying by a parent in the bed, entrapment, or wedging between the bed and the headboard or wall), many chose to do so anyway, so they could better monitor the baby and prevent other harmful outcomes. Worries about insects, rodents, stray gunfire, and random kidnapping were some of the other reasons cited for bedsharing.

The debate over bedsharing’s potential risks and proven benefits is longstanding (you can read about the controversy on baby gooroo here).

The AAP recognizes the need for infants to sleep in close proximity to their parents, but stops short of recommending bedsharing. Their 2005 policy statement on SIDS calls for “the infant’s crib or bassinet [to] be placed in the parents’ bedroom,” stating that “when placed close to their bed, [this] will allow for more convenient breastfeeding and contact.”

Bedsharing, according to the AAP, can be risky if not done properly—a view shared by bedsharing advocates. But given the increase in rates of bedsharing, all parents need to know how to make bedsharing safe, in the event bedsharing is a strategy mothers choose in order to make it through the night.

Despite awareness of the “Back to Sleep” recommendation, many mothers in the study agreed with the outdated belief that the prone (face down) position reduces the risk of choking and was therefore safer than the supine (face up) position. Those mothers who were not overly worried about their babies choking in their sleep did initially put their babies on their backs. However, most later switched their babies to sleeping face down because they felt their babies slept better in that position.

Few mothers in the study knew that the prone position increases their babies’ risk for SIDS. In fact, most thought a link between SIDS and tummy sleeping was unlikely.

Recommendations
The connection between SIDS risk and prone sleeping is clear, but the message isn’t being heard by all parents.

Repeated exposure, early and often, to positive messages is key to ensuring healthy behavior. Sleep position and location deserve the same attention as use of car seats, seat belts, and bicycle helmets.

Doctors, midwives, nurses, and others who are on the frontline caring for pregnant women and infants should be sure to address sleep position, bedsharing, and breastfeeding with their patients.