Vital Signs

Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015

Jennifer M. Bombard, MSPH; Katherine Kortsmit, PhD; Lee Warner, PhD; Carrie K. Shapiro-Mendoza, PhD; Shanna Cox, MSPH; Charlan D. Kroelinger, PhD; Sharyn E. Parks, PhD; Deborah L. Dee, PhD; Denise V. D'Angelo, MPH; Ruben A. Smith, PhD; Kim Burley; Brian Morrow, MA; Christine K. Olson, MD; Holly B. Shulman, MA; Leslie Harrison, MPH; Carri Cottengim, MA; Wanda D. Barfield, MD


Morbidity and Mortality Weekly Report. 2018;67(1):39-46. 

In This Article

Conclusions and Comment

Among all mothers responding, 21.6% reported placing their infant to sleep in a nonsupine position, 61.4% shared their bed with their infant, and 38.5% reported using soft bedding. The noted variation observed in nonsupine sleep positioning by maternal characteristics is similar to several disparities observed in sleep-related death rates.[2,3] Sleep-related infant deaths have been consistently highest among American Indian or Alaska Native followed by non-Hispanic black mothers[2] and those who are aged <20 years and have less education.[3] Unsafe sleep practices were most commonly reported by younger, less educated, and racial/ethnic minority mothers, suggesting priority groups that might need to be reached with clear, culturally appropriate messages.

While most states and subpopulations observed a significant decline over time in nonsupine sleep positioning, these findings highlight the need to implement and evaluate interventions to continue improving safe sleep practices. Evidence-based approaches to increase use of safe sleep practices include developing health messages and educational tools for caregivers and educating health and child care professionals on safe sleep practices.[11,12] For example, a recent randomized controlled trial among postpartum mothers found a 60-day mobile health program significantly improved uptake of safe sleep practices. The mobile health program included sending frequent emails or text messages with short videos related to infant safe sleep practices.[13] Other strategies include removing known barriers to safe sleep practices (e.g., providing free or reduced cost cribs for families), identifying and addressing cultural and social practices that are unsafe (e.g., by holding safe-sleep baby showers), and implementing legislative and regulatory supports (e.g., requiring SIDS risk reduction training for licensed child care providers).[11]

States and health care providers can play an important role in promoting implementation of AAP safe sleep recommendations in a variety of settings. In the Study of Attitudes and Factors Effecting Infant Care, 55% of caregivers reported receiving appropriate advice, 25% received incorrect advice and 20% received no advice on safe sleep practices from health care providers. Caregivers who received appropriate advice were significantly less likely to place their infants to sleep in a nonsupine position than were those who received inappropriate or no advice on safe sleep practices.[7] In recent years, state public health agencies have worked with partners to implement a variety of efforts to promote safe sleep, including communication campaigns, messaging delivered during WIC program visits and home-visiting programs, policies in facilities and clinics, and hospital-based quality improvement initiatives and collaboratives.¶¶ States aiming to improve safe sleep practices can examine successful interventions that have been implemented in other states. For example, the Massachusetts Perinatal-Neonatal Quality Improvement Network implemented a safe sleep initiative in neonatal intensive care units that improved safe sleep practices by modeling safe practices for parents of medically stable premature infants in advance of infant discharge.[14]*** The Tennessee Department of Health demonstrated that having a hospital policy to correctly model safe sleep practices reduced the percentage of infants placed to sleep in an unsafe environment (e.g., not on their back) while in the hospital by nearly half.[15] Finally, state participation in national initiatives, such as the National Action Partnership to Promote Safe Sleep Improvement and Innovation Network††† and Collaborative Improvement and Innovation Network to reduce infant mortality,§§§ can help facilitate and monitor the use of evidence-based strategies related to safe sleep according to standardized metrics of success.

Continued surveillance of infant sleep practices in the United States is necessary to monitor whether the prevalence of safe sleep practices is improving, especially among populations where sleep-related infant mortality is disproportionately high. The state-specific estimates derived from PRAMS can complement other data sources used to assess initiatives to reduce sleep-related infant deaths. Of note, CDC also supports 16 states and two jurisdictions through its Sudden Unexpected Infant Death (SUID)¶¶¶ Case Registry to monitor sleep-related deaths and related circumstances, including the sleep environment. This surveillance effort, which captures 30% of all SUID cases in the United States, focuses on improving data quality and completeness of SUID investigations to inform strategies to reduce sleep-related deaths.[16]****

The findings in this report are subject to at least three limitations. First, results are limited to states that implemented PRAMS, met the required response rate threshold for inclusion in data analysis, and included questions regarding safe sleep practices on their state-specific PRAMS survey. Second, AAP recommends placing the infant to sleep in the supine position every time; however, the PRAMS survey only asked respondents the sleep position their infant was placed most often. Also, prior to 2016, PRAMS collected data on the unsafe practice of bed sharing, but not on the AAP-recommended practice of room sharing. Finally, PRAMS data are self-reported and might be subject to both recall and social desirability biases.

Despite recommendations from AAP regarding safe sleep practices for infants, this report demonstrates that placement of infants in a nonsupine sleep position, bed sharing with infants, and use of soft bedding are commonly reported by mothers. Evidence-based interventions that encourage infant safe sleep practices by caregivers, particularly within populations where unsafe infant sleep practices are higher, could help reduce sleep-related infant mortality.