Implications of Mothers' Social Networks for Risky Infant Sleep Practices

Community infant safe sleep and breastfeeding promotion and population level-outcomes: A mixed methods study

PROBLEM

In the U.S., sudden unexpected infant deaths due to accidental suffocation and strangulation in bed are increasing. Though breastfeeding is a protective factor against sudden unexpected infant death, motivations to breastfeed often couple with unsafe infant sleep practices. Racial/ethnic disparities are present in sudden unexpected infant death, accidental suffocation and strangulation in bed, and breastfeeding.

BACKGROUND

Promoting infant safe sleep and breastfeeding through community-level initiatives could address disparities in related outcomes.

AIM

Investigate the relationship between community-level strategies and associated state-level outcomes for infant safe sleep and breastfeeding.

METHODS

We employed an intervention mixed methods framework and exploratory sequential design. The qualitative component entailed a hermeneutical phenomenological framework to analyze key informant interview data from seven U.S. community-level providers participating in a practice improvement initiative. The quantitative component entailed descriptively analyzing infant safe sleep and breastfeeding indicators from the 2019 Pregnancy Risk Assessment Monitoring System and Ohio Pregnancy Assessment Survey. Qualitative and quantitative data were linked through embedded integration.

FINDINGS

We identified two mixed insights: gaps in promotion and outcomes, and persistent disparities between infant safe sleep and breastfeeding promotion and outcomes.

DISCUSSION

Our findings indicate conversational approaches could improve infant safe sleep and breastfeeding promotion, outcomes, and relative disparities. We find that community collaboration is needed to address organizational capacity limitations in promoting infant safe sleep and breastfeeding.

CONCLUSION

Community-level organizations and providers should consider tailoring program offerings and care delivery to include conversational approaches and community collaboration to promote infant safe sleep and breastfeeding and decrease relative disparities in outcomes.

The importance of community resources for breastfeeding

BACKGROUND

Breastfeeding has long-lasting effects on children's cognition, behavioral, mental and physical health. Previous research shows parental characteristics (e.g., education, race/ethnicity, income level) are associated with breastfeeding initiation and duration. Further, research shows significant variation in access to community resources by race/ethnicity. It is unclear how community resources may impact breastfeeding practices and how this might intersect with maternal race/ethnicity.

METHODS

This study combined nationally-representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed US mothers immediately after the infant's birth and at two to six months of infant age, with the Child Opportunity Index (COI) 2.0, a census tract measure of community resources associated with child development, to explore the association between community resources and breastfeeding initiation and whether this varies based on maternal race/ethnicity and country of birth. The SAFE Study used a stratified, two-stage, clustered design to obtain a nationally representative sample of mothers of infants, while oversampling Hispanic and non-Hispanic (NH) Black mothers. The SAFE study enrolled mothers who spoke English or Spanish across 32 US birth hospitals between January 2011 and March 2014.

RESULTS

After accounting for individual characteristics, mothers residing in the highest-resourced communities (compared to the lowest) had significantly greater likelihood of breastfeeding. Representation in higher-resourced communities differed by race/ethnicity. Race/ethnicity did not significantly moderate the association between community resources and breastfeeding. In examining within race/ethnic groups, however, community resources were not associated with non-US born Black and Hispanic mothers' rates of breastfeeding, while they were with US born Black and Hispanic mothers.

CONCLUSIONS

Findings suggest that even health behaviors like breastfeeding, which we often associate with individual choice, are connected to the community resources within which they are made. Study implications point to the importance of considering the impact of the contextual factors that shape health and as a potential contributor to understanding the observed race/ethnicity gap.

COVID-19 Impact on Group Prenatal Education: A Comparison of Virtual and In-Person Formats

This retrospective study compared knowledge, intention, and satisfaction outcomes between pregnant women who attended prenatal education in person (n = 202; 55%) prior to the COVID-19 pandemic or virtually (n = 166; 45%) during the pandemic. Results identified increases in knowledge and intention for a healthy pregnancy and safe infant care for both groups. Virtual participants were less likely to endorse developing a birth plan (p = 0.035), knowledge of breastfeeding resources (p = 0.006), confidence in the ability to breastfeed (p = 0.033), and plans to use only a safe infant sleep location (p = 0.045). Important education was provided by continuing Baby Talk during the pandemic. However, topics with activities/demonstrations during in-person learning that were discontinued for virtual learning had significantly lower increases for virtual participants. Virtual education should incorporate more demonstrations/activities.

Community-based approaches to infant safe sleep and breastfeeding promotion: a qualitative study

BACKGROUND

In the U.S., sudden unexpected infant deaths (SUID) due to accidental suffocation and strangulation in bed (ASSB) are increasing, with disparities by race/ethnicity. While breastfeeding is a protective factor against infant mortality, racial/ethnic disparities are present in its uptake, and motivations to breastfeed are also often coupled with non-recommended infant sleep practices that are associated with infant sleep deaths. Combining infant safe sleep (ISS) and breastfeeding promotion on the community level presents opportunities to address racial/ethnic disparities and associated socioeconomic, cultural, and psychosocial influences.

METHODS

We completed a descriptive qualitative hermeneutical phenomenology using thematic analysis of focus group data. We examined the phenomenon of community-level providers promoting ISS and breastfeeding in communities vulnerable to ISS and breastfeeding disparities. We asked eighteen informants participating in a national quality improvement collaborative about i.) areas requiring additional support to meet community needs around ISS and breastfeeding, and ii.) recommendations on tools to improve their work promoting ISS and breastfeeding.

RESULTS

We identified four themes: i.) education and dissemination, ii.) relationship building and social support, iii.) working with clients' personal circumstances and considerations, and iv.) tools and systems.

CONCLUSIONS

Our findings support embedding risk-mitigation approaches in ISS education; relationship building between providers, clients, and peers; and the provision of ISS and breastfeeding supportive material resources with educational opportunities. These findings may be used to inform community-level provider approaches to ISS and breastfeeding promotion.

Racial differences in the impact of maternal smoking on sudden unexpected infant death

BACKGROUND

Prenatal smoking increases the risk of Sudden Unexpected Infant Death (SUID). Whether exposure patterns and associations differ by race requires further study.

OBJECTIVES

Determine if patterns of exposure and associations between SUID and maternal smoking before and during pregnancy differ by race.

METHODS

Using U.S. National Center for Health Statistics linked birth/infant death files 2012-2013, we documented SUID by smoking duration and race. Maternal smoking history: never, pre-pregnancy only, and pre-pregnancy plus first, first, second, or all trimesters.

RESULTS

Smoking was more common in non-Hispanic White (NHW) than non-Hispanic Black (NHB) mothers and more evident for both in SUID cases. The most common exposure duration is from before and throughout pregnancy (SUID: 78.3% NHW, 66.9% NHB; Survivors: 60.22% and 53.96%, respectively). NHB vs. NHW SUID rates per 1000 live births were 1.07 vs. 0.34 for non-smokers and 3.06 and 1.79 for smokers, ORs trended upward for both with increasing smoking duration.

CONCLUSION

Fewer NHB mothers smoked, but both NHB and NHW groups exhibited a dose-response relationship between smoking duration and SUID. The most common duration was from before to the end of pregnancy, suggesting difficulty in quitting and a need for effective interventions.

The Impact of Maternal Worry on Infant Care Practices

OBJECTIVES

Examine the 1) prevalence of worries among US mothers of infants; 2) association between worries and American Academy of Pediatrics recommended infant care practices (breastfeeding, supine sleep, roomsharing without bedsharing); 3) association of maternal and household characteristics with worries.

METHODS

We analyzed a nationally representative sample of 3165 mothers who were surveyed regarding safe sleep and breastfeeding when infants were 2 to 6 months of age in 2011-2014. We examined the prevalence of 8 maternal worries (housing, job, income, neighborhood, family relationships, health, baby's health, family member health). We used multivariable logistic regression to examine associations of A) both overall number of worries and individual worries with each infant care practice; and B) maternal and household characteristics with worries.

RESULTS

Twenty-six percent of mothers reported 0 worries, 26% reported 1-2 worries, 23% reported 3-4 worries, and 25% reported 5-8 worries. Compared to those with 0 worries, mothers with 5-8 worries had increased odds of bedsharing (adjusted odds ratio = 1.60 [1.19-2.14]) and non-supine sleep (aOR = 1.37 [1.07-1.74]). Specific worries associated with increased odds of bedsharing included: housing (aOR = 1.39 [1.09-1.78]), income (aOR = 1.35 [1.09-1.67]), neighborhood (aOR = 1.37 [1.05-1.78]), family relationships (aOR = 1.43 [1.10-1.86]), and health of a family member (aOR = 1.24 [1.06-1.46]). Maternal worries were not associated with infant feeding practices.

CONCLUSIONS

We found a high prevalence of worries regarding basic needs, family relationships, and health among US mothers. Greater total worries and several individual worries were associated with higher odds of bedsharing. The "cognitive load" of maternal worries may impact adherence to safe sleep practices and requires further investigation.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

What kinds of social networks protect older adults' health during a pandemic? The tradeoff between preventing infection and promoting mental health

When the coronavirus emerged in early 2020, older adults were at heightened risk of contracting the virus, and of suffering mental health consequences from the pandemic and from the precautions designed to mitigate it. In this paper, we examine how social networks prior to the pandemic helped to shape health beliefs, behaviors, and outcomes among older adults during its onset, focusing on (1) perceived risk of COVID-19, (2) preventative health behaviors, and (3) mental health, including loneliness, perceived stress, depression, and anxiety. Drawing on the longitudinal Social Networks in Alzheimer Disease study, we find that networks high in bridging social capital predict greater perceived risk and more precautions taken, but worse mental health. In contrast, networks high in bonding social capital predict less perceived risk and fewer precautions taken, but better mental health. We discuss this apparent tradeoff between physical and mental health.

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths has remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.

Infant Care Practices, Caregiver Awareness of Safe Sleep Advice and Barriers to Implementation: A Scoping Review

Modifiable infant sleep and care practices are recognised as the most important factors parents and health practitioners can influence to reduce the risk of sleep-related infant mortality. Understanding caregiver awareness of, and perceptions relating to, public health messages and identifying trends in contemporary infant care practices are essential to appropriately inform and refine future infant safe sleep advice. This scoping review sought to examine the extent and nature of empirical literature concerning infant caregiver engagement with, and implementation of, safe sleep risk-reduction advice relating to Sudden Unexpected Deaths in Infancy (SUDI). Databases including PubMed, CINAHL, Scopus, Medline, EMBASE and Ovid were searched for relevant peer reviewed publications with publication dates set between January 2000–May 2021. A total of 137 articles met eligibility criteria. Review results map current infant sleeping and care practices that families adopt, primary infant caregivers’ awareness of safe infant sleep advice and the challenges that families encounter implementing safe sleep recommendations when caring for their infant. Findings demonstrate a need for ongoing monitoring of infant sleep practices and family engagement with safe sleep advice so that potential disparities and population groups at greater risk can be identified, with focused support strategies applied.

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough

OBJECTIVES

Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC.

METHODS

Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed.

RESULTS

Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present.

CONCLUSIONS FOR PRACTICE

Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Norwegian parents avoid placing infants in prone sleeping positions but frequently share beds in hazardous ways

AIM

Campaigns to prevent prone sleeping and other modifiable risk factors have greatly reduced the incidence of sudden infant death syndrome in Norway. Sleep-related infant deaths still occur sporadically and may be preventable. We studied infants' sleeping environments and whether parents followed safe sleep recommendations.

METHODS

Parents with infants up to 12 months of age were invited to complete an online questionnaire from May to December 2018. It was publicised by health centres and on websites and social media.

RESULTS

We received 4886 responses and 4150 met the age criteria and were included. Just under two-thirds (62.7%) reported routine bed-sharing, and this practice was associated with increased nocturnal breastfeeding, single parents and having more than one child. A small number of infants under six months were occasionally placed prone when they were laid down to sleep (2.1%) and 29.7% were placed on their side. Nearly three-quarters (72.6%) of the 2330 parents with infants under six months of age reported previous high-risk behaviour, such as sleeping together on a sofa or bed-sharing after smoking or drinking.

CONCLUSION

Norwegian parents rarely used prone sleeping positions for infants. However, bed-sharing was common, including high-risk scenarios such as smoking, alcohol use and sofas.

Can respondent driven sampling be used to recruit new mothers? A mixed methods study in metropolitan Washington DC

Background

Respondent driven sampling (RDS) is employed to recruit populations that are hard-to-reach, “hidden,” or without a sampling frame. For new mothers (those with infants <6 months) in countries without national health care systems or registries, there is no sampling frame, and random samples may only be attained through costly strategies, e.g., random-dial calling.

Objective

To assess the feasibility of RDS to recruit new mothers.

Methods

In the initial study, we recruited 30 new mothers (“seeds”) from a single birth hospital; each was given 3 referral coupons to give to other mothers (“referrals”). When our sample did not self-perpetuate with referrals, additional seeds were recruited. Demographics of seeds and referrals were compared. A subset of mothers participated in focus groups and were asked about their experience with RDS. We also conducted a second survey of new mothers to further assess feasibility of RDS in this population.

Results

Of the 402 mothers recruited in the initial study, 305 were seeds and only 97 were referrals. Referrals were more likely to be White, highly educated, older, and privately insured (all p≤0.001). Focus group participants indicated that the time required to meet other mothers was an important barrier. In the second survey we recruited 201 mothers; only 53.7% knew ≥1 mother whom they could invite to the study.

Conclusions

New mothers are not easily recruited using RDS because they have a limited number of contacts who are also new mothers. Those recruited through RDS are more likely to be older, Caucasian and of high socioeconomic status, indicating it is not an effective way to recruit a representative sample of new mothers.

Social network influences on new mothers' infant sleep adjustments

Despite public awareness campaigns, some parents continue to engage in infant sleep practices that are considered risky by health experts, such as bedsharing or placing their infants on their stomachs. This study examines the role their social networks play in shaping parents' responsiveness to new information and/or suggestions about how they should place their infants for sleep, paying attention to the respective effects of health professionals and their close interpersonal ties. We collected data from a sample of 323 new mothers in Washington, D.C., who described their infant sleep practices and perceived personal social networks. We find evidence that mothers' social networks play a significant role in the likelihood that they adjust their infant sleep practices within the first few months of their infants' lives. Mothers are more likely to change sleep practices when health professionals and/or (lay) family members advise them to do so. The influence of network members is not always positive. For mothers who initially follow safe practices, their probability of change increases if their network members substantially espouse unsafe practices. Among mothers with initially unsafe practices, network members' level of support for safe sleep practices is not predictive of the likelihood of sleep practice change. Implications for potential interventions are discussed.

Investigating Mechanisms for Maternal Education Disparities in Enacting Health-Promoting Infant Care Practices

BACKGROUND

Although higher education and healthier practices are positively associated, the explanatory mechanisms for this association remain unclear. The purpose of this study was to better understand mechanisms underlying this association by examining maternal adherence to 2 health-promoting infant care practices: supine placement and breastfeeding.

METHODS

We analyzed nationally representative data from the Study of Attitudes and Factors Effecting Infant Care, which surveyed US mothers after infant birth and 2 months thereafter. Using the Theory of Planned Behavior as a framework, we used structural equation models to elucidate mediational pathways from maternal education to supine infant placement or any breastfeeding.

RESULTS

Data from 3297 mothers demonstrated 77.0% of infants usually were placed supine, and 57.8% received any breastfeeding. The overall direct effect of maternal educational level on supine placement and any breastfeeding was odds ratio (OR) 1.31 (95% confidence interval [CI] 1.11-1.54) and OR 2.82 (95% CI 2.35-3.37), respectively. In pathway analyses, the strongest associations with both supine position and breastfeeding were seen with positive attitudes (supine: aOR 18.96, 95% CI 9.00-39.92; breastfeeding: aOR 3.86, 95% CI 2.19-6.82) and positive social norms (supine: aOR 6.69, 95% CI 4.52-9.89; breastfeeding: aOR 5.17, 95% CI 4.28-6.23). Mothers with more education had higher odds of both positive attitudes and positive norms for the 2 practices.

CONCLUSIONS

The associations linking educational attainment with health practices are intricate, with multiple mediating pathways. Attitudes and social norms are powerful forces that mediate the association between maternal educational attainment and both infant supine positioning and breastfeeding, and may be important mediators for other health behaviors.

The Influence of Social Networks and Norms on Breastfeeding in African American and Caucasian Mothers: A Qualitative Study

Background: Social networks and subjective norms (individuals' perceptions of what other people think) can be influential in decision-making. Although there are data about the importance of support in initiation and duration of breastfeeding, no studies have explored the influence of women's social networks and the norms within those networks on breastfeeding. Research Aim: To investigate, through qualitative methods, the influence of mothers' social networks and subjective norms, both within and outside of her network, with regard to breastfeeding practices. Materials and Methods: Twenty-eight mothers participated in focus groups or individual interviews. Probing questions concerning breastfeeding intent, initiation, continuation, and support with regard to social networks and subjective norms were asked. Themes were developed in an iterative manner from coded data. Matrix coding queries assessed patterns in the data and compared quotes based on the respondents' race and social network type. Results: General themes that emerged were the importance of breastfeeding experience within one's social network, the influence of the infant's father, handling disagreement within one's network, and the effects of social norms that exist outside of one's network. Mothers described support for breastfeeding from network members as especially important when breastfeeding was not the norm within the network. There were no differences in themes by race or social network type. Conclusion: Breastfeeding behavior is influenced by a mother's social network, regardless of her race or social network type. Even when breastfeeding is not normative within one's social network, by relying on one network member to support them, mothers may be able to resist the opposing norms of their social network. Since breastfeeding is known to be beneficial to infants and mothers, education or interventions to improve breastfeeding rates may be more effective if they include individual network members who can provide strong support to new mothers.