Mothers living in the same neighbourhoods of a northern UK city, who had received and were aware of national SIDS-reduction guidance, implemented different infant sleeping practices for personal and cultural reasons. Many SIDS-reduction practices were part of normal Pakistani infant care (supine sleep; room-sharing; avoiding alcohol, smoking and sofa-sharing); as much of the guidance was irrelevant to Pakistani mothers they felt that Safe Sleep guidance was not directed to them. Consequently, where the guidance conflicted with traditional Pakistani beliefs about infant sleep (bed-sharing, pillow use, overheating) mothers prioritised their traditional practices and dismissed the official guidance. White British mothers consciously adapted or dismissed several aspects of the guidance (room-sharing; avoiding sofa-sharing) that they felt to be not applicable or unnecessary, while questioning others (lateral sleep position; any smoking or alcohol consumption). Their responses also suggested that the implementation of some SIDS-reduction practices compensated for the lack of others, highlighting parental perceptions that risk-reduction strategies can be traded against each other.
Growing evidence indicates that SIDS is less prevalent among infants who sleep near their parents [11–13]. However, keeping babies in the parental bedroom for 6 months was dismissed by many white British mothers who also placed their infants in separate rooms for daytime sleep: solitary sleep both at night and during the day was a common white British infant care practice. These participants were unaware that adult presence during daytime sleep is equally important as for night-time sleep [14, 15].
In previous research we found that Pakistani infants were significantly less likely than white British infants to sofa-share [7, 8]. In the present study Pakistani mothers explained that lying on a sofa was socially and culturally unacceptable, signifying laziness; Pakistani women remained in their bedrooms at night to feed their babies. White British mothers attempted to avoid bed-sharing by sofa-sharing, propping themselves up in bed, or using armchairs to feed their infants at night, even though SIDS-reduction guidelines includes avoidance of sofas and armchairs for night-time feeding. There is no specific advice to parents on how to feed babies safely during the night; this is an important omission that leaves mothers trying to choose between several apparently dangerous locations.
All white British mothers were aware of dangers in their baby’s sleeping environment; the majority did not use pillows or blankets preferring baby sleeping bags for night-time sleep. Pakistani mothers preferred sheets and blankets and infant ‘pillows’ (head positioners) even though they were aware of disapproval from health professionals regarding the latter. White British mothers were sceptical of the advice to avoid the side sleep position for infants, however, studies from England and New Zealand have shown that this position is unstable and infants risk rolling into the prone position [16–19]. Participants were unaware of this instability or that side sleeping infants could fall into the prone position before they were physically capable of rolling, suggesting some explanation is needed here.
Multiple studies have confirmed an association between maternal smoking, alcohol consumption and SIDS [20–23]. White British mothers’ attitudes to alcohol consumption warrants further research as some participants were unaware that alcohol could influence their infant care judgements and decisions (such as unintentionally falling asleep with a baby on a sofa). Furthermore, and importantly, many white British mothers believed smoking and alcohol consumption to be factors associated with SIDS only in conjunction with breastfeeding or bed-sharing, suggesting that these relationships may have been over emphasised.
Pakistani mothers repeatedly asserted that UK SIDS-reduction guidelines were not applicable to them noting that pictures and diagrams within the literature did not depict their own social and cultural environments, and the messages did not acknowledge or reflect their cultural beliefs and practices; this supports the view that SIDS-reduction messaging should acknowledge the culturally valued parenting behaviours and beliefs of the target communities in order to make messages more effective [24–26].
In summary, this study found that UK SIDS intervention strategies were limited in their effect on both Pakistani and white British families in Bradford as mothers were aware of, but did not implement, the risk-reduction guidance offered. Similar ineffectiveness has recently been reported in SIDS-reduction campaigns in north-west England [27] and Australia [28]. To date, safe sleep promotion and SIDS reduction has been founded on a ‘health persuasion’ model of risk elimination, described by Beattie as an authoritative top-down expert-led approach [29]. Given the well-known disparities in SIDS rates across ethnic, socio-economic and other sub-cultural groups, new approaches are clearly needed. One promising approach is to refocus SIDS reduction around Beattie’s ‘health negotiation’ model of risk minimisation involving tailored information delivered at community and individual levels [29]. We have discussed the need for risk-minimisation in infant safe sleep recommendations in more detail elsewhere [2–4], and the UK National Institute for Health and Care Excellence has recently recommended an individually tailored approach [30].
Additionally, we suggest that SIDS advice, literature and leaflets should depict the multi-cultural social and ecological contexts in which infant care is performed. Mothers may consider SIDS advice more readily if they see that the guidance acknowledges their cultural preferences. Health professionals could be trained to be more aware and understanding of how infant care decisions are mediated and performed amid differing social and cultural environments, and to provide tailored information to allow parents to work within their personal constraints to make informed choices regarding SIDS-risk reduction.
