The Status of Iowa Sleep-Related Infant Mortality: An Evaluation of Safe Sleep Education Delivery, Policy, and Practice in Birthing Hospitals

Problem: Sleep-related infant mortality, including sudden infant death syndrome, asphyxia, and undetermined or unknown causes, is the third leading cause of death nationally and in Iowa (Harris, 2014; Malloy & Ramirez, 2013). Evidence exists for increasing rates of bed sharing, a major risk factor for sleep-related mortality (Kemp et al., 2000). Preventive messaging is most widely and effectively delivered by health professionals at time of birth (Shaefer, Herman, Frank, Adkins, & Tehaar, 2010). The intent of this study was to provide a characterization of infant, maternal, and environmental factors contributing to sleep-related infant mortality and a comprehensive review of safe sleep education policy and practices in Iowa birthing hospitals. Procedures: An experimental, cross-sectional study design was used to analyze infant mortality data reported by the Iowa Office of the State Medical Examiner to the Child Death Reporting system from 2004-2012. Analyses included mortality trends for sleep-related mortality parsed by Sudden Infant Death (SIDS), asphyxia, and undetermined or unknown cause, descriptive statistics for maternal and infant demographic factors, and correlations for environmental factors potentially contributing to sleep-related death. An adjacent effort with Iowa birthing hospitals involved use of a web-based survey to assess policies, parent education programs, clinical practice, and training related to safe infant sleep or SIDS. The survey was directed toward obstetric unit coordinators with content drawn from previous efforts to ascertain clinical practice. Findings: Sleep-related mortality in Iowa has been steadily increasing since 2004. Subcategorical examination of this trend revealed rises in SIDS and undetermined or unknown cases, but a stable rate of deaths due to asphyxia. These infants (n=384) were more often males (58.6%), lived an average age of 102 days, were living with multiple children at time of death, and had a young mother. An alarming 42% of infants were bed sharing at time of death, with only 43% placed on their back to sleep prior to the event. Significant racial disparities were present. Non-white infants were more likely to have died while bed sharing compared to white infants, Pearson χ2(1, n=151)=6.7, p=0.01, and non-white infants were also more likely to usually sleep someplace other than a crib, Pearson χ2(2, n=151)=5.05, p=0.025. The hospital survey (N=42) revealed that three-quarters have policies addressing SIDS or safe sleep education. Of those with policies, topics covered included sleep positioning, surface, bed sharing, and the infant’s sleep environment. Respondents indicated nearly uniform demonstration of supine sleep, though some cited fear of aspiration, as a reason supine sleep might not be used. Less than half of hospitals require clinical staff to complete safe sleep education training. Unit coordinators rated their SIDS or safe infant sleep programs an average strength of 7.66 out of 10. Conclusions: Sleep-related mortality incidence in Iowa is increasing and state-specific risk factors exist. Racial disparities in sleep environment practice are of particular concern. Hospital policy addressing safe infant sleep is not universal. Consistent demonstration of supine sleep may be inhibited by concerns over aspiration. Training opportunities could be improved as access to programs external to the hospital setting and online are not fully utilized. Recommendations: Greater awareness of the risk factors associated with sleep-related infant mortality is needed among parents and caregivers of infants. Expansion or strengthening of existing hospital-based education programs may improve protective parental actions. The Health Belief Model may be an important tool in examining why parents are not be universally adhering to guidance against bed sharing.