Journal of Community Health

, Volume 43, Issue 5, pp 977–985 | Cite as

The Impact of Health Messages on Maternal Decisions About Infant Sleep Position: A Randomized Controlled Trial

  • Rebecca F. Carlin
  • Anna Abrams
  • Anita Mathews
  • Brandi L. Joyner
  • Rosalind Oden
  • Robert McCarter
  • Rachel Y. MoonEmail author
Original Paper


Sudden infant death syndrome (SIDS) rates in African-Americans are more than twice national rates, and historically, African-American parents are more likely than other groups to place infants prone, even when they are aware of supine sleep recommendations. Prior studies have shown African-Americans have low self-efficacy against SIDS but high self-efficacy against suffocation. This study aimed to determine the impact of a specific health message about suffocation prevention on African-American parental decisions regarding infant sleep position. We conducted a randomized controlled trial of 1194 African-American mothers, who were randomized to receive standard messages about safe sleep practices to reduce the risk of SIDS, or enhanced messages about safe sleep practices to prevent SIDS and suffocation. Mothers were interviewed about knowledge and attitude, self-efficacy and current infant care practices when infants were 2–3 weeks, 2–3 months and 5–6 months old. Analyses of covariance were conducted to estimate the change in knowledge, attitudes and practice in each group, and chi square tests were used to compare sleep position with each variable. Over the first 6 months, the proportion of African-American infants placed supine gradually decreased and was unchanged by enhanced education about SIDS, suffocation risk and sleep safety. While initially high self-efficacy against SIDS and suffocation correlated with supine positioning, by 5–6 months self-efficacy did not correspond to sleep position in either group.


Sudden infant death syndrome Infant sleep safety Sudden unexpected infant death Infant mortality Intervention Sleep position 



This project was supported by the Maternal and Child Health Bureau, Health Resources Service Administration 1R40MC21511 and the National Institute for Minority Health and Health Disparities P20MD000198.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest to disclose.


  1. 1.
    United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS). (2018). Linked Birth/Infant Death Records on CDC WONDER Online Database. Accessed March 9, 2018.
  2. 2.
    NISP. (2018). National Infant Sleep Position study website. Accessed March 12, 2018.
  3. 3.
    Moon, R. Y. (2016). Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics, 138(5), e20162938.CrossRefGoogle Scholar
  4. 4.
    Kattwinkel, J., Brooks, J., Keenan, M. E., & Malloy, M. H. (2000). Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. American Academy of Pediatrics. Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. Pediatrics, 105(3 Pt 1), 650–656.Google Scholar
  5. 5.
    Hauck, F. R., Herman, S. M., Donovan, M., et al. (2003). Sleep environment and the risk of sudden infant death syndrome in an urban population: The Chicago Infant Mortality Study. Pediatrics, 111(5 Part 2), 1207–1214.PubMedGoogle Scholar
  6. 6.
    Li, D. K., Petitti, D. B., Willinger, M., et al. (2003). Infant sleeping position and the risk of sudden infant death syndrome in California, 1997–2000. American Journal of Epidemiology, 157(5), 446–455.CrossRefPubMedGoogle Scholar
  7. 7.
    Blair, P. S., Fleming, P. J., Smith, I. J., et al. (1999). Babies sleeping with parents: Case-control study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ, 319(7223), 1457–1462.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Fleming, P. J., Blair, P. S., Bacon, C., et al. (1996). Environment of infants during sleep and risk of the sudden infant death syndrome: Results of 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Confidential enquiry into stillbirths and deaths regional coordinators and researchers. BMJ, 313(7051), 191–195.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Carpenter, R. G., Irgens, L. M., Blair, P. S., et al. (2004). Sudden unexplained infant death in 20 regions in Europe: Case control study. Lancet, 363, 185–191.CrossRefPubMedGoogle Scholar
  10. 10.
    Rasinski, K. A., Kuby, A., Bzdusek, S. A., Silvestri, J. M., & Weese-Mayer, D. E. (2003). Effect of a sudden infant death syndrome risk reduction education program on risk factor compliance and information sources in primarily black urban communities. Pediatrics, 111(4 Pt 1), e347–e354.CrossRefPubMedGoogle Scholar
  11. 11.
    Moon, R. Y., Oden, R. P., Joyner, B. L., & Ajao, T. I. (2010). Qualitative analysis of beliefs and perceptions about sudden infant death syndrome (SIDS) among African-American mothers: Implications for safe sleep recommendations. The Journal of Pediatrics, 157(1), 92–97. Scholar
  12. 12.
    Centers for Disease Control and Prevention.(2017) PRAMStat. Atlanta, GA. Accessed July 18, 2017.
  13. 13.
    Corwin, M. J., Lesko, S. M., Heeren, T., et al. (2003). Secular changes in sleep position during infancy: 1995–1998. Pediatrics, 111(1), 52–60.CrossRefPubMedGoogle Scholar
  14. 14.
    Colson, E. R., McCabe, L. K., Fox, K., et al. (2005). Barriers to following the back-to-sleep recommendations: Insights from focus groups with inner-city caregivers. Ambulatory Pediatrics, 5(6), 349–354.CrossRefPubMedGoogle Scholar
  15. 15.
    Mosley, J. M., Stokes, S. D., & Ulmer, A. (2007). Infant sleep position: Discerning knowledge from practice. American Journal of Health Behavior, 31(6), 573–582.CrossRefPubMedGoogle Scholar
  16. 16.
    Moon, R. Y., & Omron, R. (2002). Determinants of infant sleep position in an urban population. Clinical Pediatrics, 41(8), 569–573.CrossRefPubMedGoogle Scholar
  17. 17.
    Ottolini, M. C., Davis, B. E., Patel, K., Sachs, H. C., Gershon, N. B., & Moon, R. Y. (1999). Prone infant sleeping despite the “Back to Sleep” campaign. Archives of Pediatrics and Adolescent Medicine, 153, 512–517.CrossRefPubMedGoogle Scholar
  18. 18.
    Willinger, M., Ko, C.-W., Hoffman, H. J., Kessler, R. C., & Corwin, M. J. (2000). Factors associated with caregivers’ choice of infant sleep position, 1994–1998: The National Infant Sleep Position Study. JAMA, 283(16), 2135–2142.CrossRefPubMedGoogle Scholar
  19. 19.
    Moon, R. Y., & Biliter, W. M. (2000). Infant sleep position policies in licensed child care centers after back to sleep campaign. Pediatrics, 106(3), 576–580.CrossRefPubMedGoogle Scholar
  20. 20.
    Moon, R. Y., Weese-Mayer, D. E., & Silvestri, J. M. (2003). Nighttime child care: Inadequate sudden infant death syndrome risk factor knowledge, practice, and policies. Pediatrics, 111(4 Pt 1), 795–799.CrossRefPubMedGoogle Scholar
  21. 21.
    Oden, R., Joyner, B. L., Ajao, T. I., & Moon, R. (2010). Factors influencing African-American mothers’ decisions about sleep position: A qualitative study. Journal of the National Medical Association, 102(10), 870–880.CrossRefPubMedGoogle Scholar
  22. 22.
    Mathews, A., Joyner, B. L., Oden, R. P., He, J., McCarter, R. Jr., & Moon, R. Y. (2016). Messaging affects the behavior of African American parents with regards to soft bedding in the infant sleep environment: A randomized controlled trial. The Journal of Pediatrics, 175, 79–85. Scholar
  23. 23.
    Willinger, M., Hoffman, H. J., Wu, K.-T., et al. (1998). Factors associated with the transition to nonprone sleep positions of infants in the United States: The National Infant Sleep Position Study. JAMA, 280, 329–335.CrossRefPubMedGoogle Scholar
  24. 24.
    Muhuri, P. K., MacDorman, M. F., & Ezzati-Rice, T. M. (2004). Racial differences in leading causes of infant death in the United States. Paediatric and Perinatal Epidemiology, 18(1), 51–60.CrossRefPubMedGoogle Scholar
  25. 25.
    Brenner, R., Simons-Morton, B. G., Bhaskar, B., et al. (1998). Prevalence and predictors of the prone sleep position among inner-city infants. JAMA, 280, 341–346.CrossRefPubMedGoogle Scholar
  26. 26.
    Brenner, R. A., Simons-Morton, B. G., Bhaskar, B., Revenis, M., Das, A., & Clemens, J. D. (2003). Infant-parent bed sharing in an inner-city population. Archives of Pediatrics and Adolescent Medicine, 157(1), 33–39.CrossRefPubMedGoogle Scholar
  27. 27.
    Willinger, M., Ko, C. W., Hoffman, H. J., Kessler, R. C., & Corwin, M. J. (2003). Trends in infant bed sharing in the United States, 1993–2000: The National Infant Sleep Position study. Archives of Pediatrics and Adolescent Medicine, 157(1), 43–49.CrossRefPubMedGoogle Scholar
  28. 28.
    Colson, E. R., Rybin, D., Smith, L. A., Colton, T., Lister, G., & Corwin, M. J. (2009). Trends and factors associated with infant sleeping position: The national infant sleep position study, 1993–2007. Archives of Pediatrics and Adolescent Medicine, 163(12), 1122–1128. Scholar
  29. 29.
    Brown, H., & Prescott, R. (2006). Applied mixed models in medicine (2nd ed.). Chichester: Wiley.CrossRefGoogle Scholar
  30. 30.
    Liu, H., & Wu, T. (2005). Sample size calculation and power analysis of time-averaged difference. Journal of Modern Applied Statistical Methods, 4(2), 434–445.CrossRefGoogle Scholar
  31. 31.
    Diggle, P. J., Liang, K. Y., & Zeger, S. L. (1994). Analysis of longitudinal data. New York: Oxford University Press.Google Scholar
  32. 32.
    Moon, R. Y. (2016). Task Force on Sudden Infant Death Syndrome, SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics, 138(5), e20162940.CrossRefPubMedGoogle Scholar
  33. 33.
    Mitchell, E. A., Thach, B. T., Thompson, J. M. D., & Williams, S. (1999). Changing infants’ sleep position increases risk of sudden infant death syndrome. Archives of Pediatrics and Adolescent Medicine, 153, 1136–1141.CrossRefPubMedGoogle Scholar
  34. 34.
    Colson, E., Geller, N. L., Heeren, T., & Corwin, M. J. (2017). Factors associated with choice of infant sleep position. Pediatrics, 140(3), e20170596. Scholar
  35. 35.
    U.S. Census Bureau. (2012). 2006–2010 American Community Survey. Accessed July 19, 2016.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Rebecca F. Carlin
    • 1
    • 2
  • Anna Abrams
    • 1
  • Anita Mathews
    • 1
  • Brandi L. Joyner
    • 1
  • Rosalind Oden
    • 1
  • Robert McCarter
    • 3
    • 4
  • Rachel Y. Moon
    • 5
    Email author
  1. 1.Division of General Pediatrics and Community HealthChildren’s National Medical CenterWashingtonUSA
  2. 2.Department of PediatricsGeorge Washington University School of Medicine and Health SciencesWashingtonUSA
  3. 3.Center for Translational ScienceChildren’s National Medical CenterWashingtonUSA
  4. 4.Department of Epidemiology and BiostatisticsGeorge Washington UniversityWashingtonUSA
  5. 5.Department of PediatricsUniversity of VirginiaCharlottesvilleUSA

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