Evaluation of mothers’ knowledge about infant sudden death syndrome and its risk factors

Abstract

BACKGROUND:

Sudden infant death syndrome is the third leading cause of infant death in the first year of life and is one of the most important health problems around the world. The exact etiology of this phenomenon is not clear yet, but some risk factors, especially prone sleep positions, have been described. Fortunately, by modifying some environmental factors, the SIDS incidence might be decreased. Mothers’ and caregivers’ knowledge about this neglected event could be an important factor in determining SIDS prevalence.

MATERIALS AND METHODS:

This cross-sectional study was conducted in the pediatric and neonatal specialty clinic of Bahar Shahroud Hospital in 2020. Five hundred and twenty-seven pregnant women of reproductive age (18 to 45 years) were included in the study. Assessment of mothers’ knowledge was done using a sudden infant death syndrome risk questionnaire. Statistical analysis of data was performed using independent t-test, Chi-square, and logistic regression.

RESULTS:

The number of 527 pregnant women of childbearing age participated in our study. 81.9% were under 35 years old. According to the study, factors such as maternal age, mother’s level of education, number of pregnancies, and history of previous infant death syndrome had a significant relationship with the mother’s level of knowledge about infant death syndrome. The findings showed that the mother’s age is over 35 years old during pregnancy (CI: 0.95-0.46-OR: 1.53) and the level of education under a diploma (CI: 3.13-1.6: 06, OR: 1.86), and increasing parity is associated with a lower level of knowledge about infant death syndrome.

CONCLUSION:

According to mothers’ lack of knowledge about SIDS and the availability of simple and cost-effective methods to prevent SIDS, improving mothers’ knowledge about this important event in pregnancy and postpartum, educational sessions are crucial.

Introduction

Sudden infant death syndrome (SIDS) refers to the sudden and unexpected death of a seemingly healthy infant less than one-year-old in which, after careful history taking and examination of the infant, evaluation of the death scene, and a complete autopsy, no cause can be found. SIDS is the third leading cause of death in infants; under one year of age, the male-to-female ratio is 3:2.[1] The peak incidence is between two and four months, and 95% of cases occur in the first six months of life.[2] There is a significant difference in the incidence of SIDS in different races and ethnicities, which is due to cultural differences. For example, in the United States, annually about 3,500 infants less than one-year-old die from SIDS during sleep. The exact mechanism of SIDS has not yet been determined, but the three-risk hypothesis explains that SIDS occurs when an infant with an inherent vulnerability is exposed to a stressful sleep environment during critical respiratory centers development. In addition, cardiac and respiratory control centers abnormalities in the brainstem, along with environmental risk factors, are thought to lead to the ultimate cascade of hypoxia, bradycardia, apnea, and death.[3] Risk factors of SIDS are male gender, preterm delivery, low birth weight, reduced prenatal medical care, low socioeconomic status of the family, young parents, low level of parental education, short periods between pregnancies, multiple pregnancies, medication taken by the pregnant mother, winter season, exposure to cigarettes during pregnancy and after birth, overheated environment, recent respiratory infection, maternal mental illness, and substance abuse.[4,5] The most important risk factors for SIDS are sleep conditions such as lying the infant in a prone and lateral position and sharing a bed with parents.[6,7] Except for the mentioned risk factors, there is no way to predict which infants will die from SIDS. To prevent SIDS, it is necessary to eliminate or change the mentioned modifiable risk factors.[3,8]

Increasing the awareness of mothers is essential to improve the quality of life and health of mothers and babies.[9] Based on in, awareness of the risk factors of sudden infant death and early identification of these risk factors as well as immediate intervention and treatment measures can prevent the sudden infant death. Based on this, the current study was conducted with the aim of investigating mothers’ awareness of the risk factors of sudden infant death, so that if mothers’ awareness in this field is low, by implementing educational programs, mothers’ awareness can be increased and the prevalence of sudden infant death reduced.

Materials and Methods

Study design and setting

A cross-sectional study was performed in the pediatric and neonatal subspecialty clinic of Bahar Hospital in Shahroud, Semnan, Iran. The study was conducted for a period of six months from April to October 2020.

Study participants and sampling

Pregnant women in the age range of 18 to 45 years who were referred to the neonatal intensive care unit were included in this study. Literate Iranian mothers of reproductive age (18 to 45 years) and pregnant women living in Shahroud were included in this study. Women who did not live in Shahroud were not willing to consent, did not want to participate in the study, and were excluded. The participants were selected using the available sampling method.

Data collection

Data were collected with a designed checklist, which included two main parts: demographic information with ten questions and level of knowledge about SIDS with 21 questions. Based on this, by referring to the pediatrics and newborns department of Bahar Hospital, after obtaining consent from the mothers, the required information was collected including demographic information, number of pregnancies, pregnancy rate, history of sudden infant death and also mothers’ knowledge about sudden infant death. It should be mentioned that based on the checklist, women’s awareness was divided into two categories: unaware and aware.

Data analysis

Independent t-test and Chi-square analysis were used for statistical analysis. Univariate logistic regression analysis was also used first. In this analysis, each of the variables was examined separately, and if there was a significant relationship with the mother’s knowledge of infant death syndrome, though the relationships may be affected by confounding factors, multivariate logistic regression analysis was used. To estimate the adjusted odds ratio, the variables were examined in the Backward Logistic Regression model. All analyses were calculated using SPSS software version 19. The significance level of statistical relationships was considered less than 0.05.

Ethical consideration

An informed consent form was prepared and provided to the participants. Individuals’ personal information was kept confidential and was not reported. The participants had full freedom and could refuse to participate in the study if they did not want to. Ethics approval was obtained from the ethics committee of Shahroud University of Medical Sciences (ethical code: IR.SHMU.REC.1398.145).

Results

In the present study, 527 pregnant and women in childbearing were studied. Most of the surveyed women lived in urban (70.3%). 81.9% were under 35 years old, 41.8% had high school education, more than 36% of women had one or two pregnancies, 47% had more than 3 years between pregnancies, and 98.5% of women had no history of sudden infant death syndrome [Table 1].

Table 1.

Characteristics of pregnant women based on knowledge and lack of knowledge about SIDS

Variable	Aware (n=192)	Unaware (n=335)	P
Residence
Rural	135 (70.7)	235 (70.1)	0.8
Urban	56 (29.3)	100 (29.9)
Maternal age
<35	148 (77.1)	278 (84)	0.1
35≤	148 (78.3)	53 (16)
Mother’s education level
High school	38 (20.4)	83 (25.7)	0.02
Diploma	70 (37.6)	143 (44.3)
University	78 (41.9)	97 (30)
Gravid
1	65 (34.4)	126 (37.8)	0.6
2	70 (37)	122 (36.6)
3	34 (18)	61 (18.3)
4≤	20 (10.6)	24 (7.2)
Pregnancy interval
1˂	48 (30.4)	91 (32.7)	0.7
3–1	37 (23.4)	37 (23.4)
>3	73 (46.2)	132 (46.2)
History of infant death syndrome
Yes	5 (2.6)	3 (9.0)	0.1
No	187 (97.4)	332 (99.1)

The results of univariate logistic regression analysis [Table 2] showed that location, and the time interval between pregnancies, had no significant relationship with knowledge about SIDS. On the other hand, factors such as maternal age, mother’s level of education, number of pregnancies, and history of SIDS have a significant relationship with the mother’s level of knowledge about SIDS. The results showed that women over 35 years of age have a higher level of knowledge about infant death syndrome (OR: 1.45). But with an increasing level of education, the mother’s knowledge about infant death syndrome increases. At the same, the level of knowledge in women under a diploma is lower (OR: 1.75) and in women with a diploma and high school education (OR: 1.06) is higher. Also, as the number of pregnancies increases, the possibility of a lack of knowledge about infant death syndrome increases. Knowledge level, respectively, in women with two pregnancies (OR: 1.11), in women with three pregnancies (OR: 1.80), and in women with more than four pregnancies (OR: 2.61) had a descending manner. Findings of multivariate analysis showed that increasing maternal age over 35 years reduces mothers’ knowledge about sudden infant death syndrome. (OR: 1.53) Also, the level of education below the diploma, in older mothers, decreases their knowledge about sudden infant death syndrome (OR: 1.86).

Table 2.

Relationship between demographic variables and level of awareness of SIDS

Variable	Odds ratio	Significance	Matching odds ratio	Significance
Residence
Rural	1	1	-	-
Urban	1.02 (0.69–1.51)	0.9	-	-
Maternal age (year)
<35	1	1	1	1
35≤	1.45 (0.92-2.28)	0.1	1.53 (0.95-2.46)	0.009
Mother’s education level
High school	1.75 (1.08–2.85)	0.02	1.86 (1.013-3.06)	0.01
Diploma	1.72 (0.66-1.06)	0.8	1.13 (0.69-1.84)	0.6
University	1	1	1	1
Gravid
1	1	1	-	-
2	1.11 (0.73-1.69)	0.6	-	-
3	1.08 (0.64-1.8)	0.8	-	-
4≤	2.61 (0.83-3.14)	0.2	-	-
Pregnancy interval
1˂	1.21 (0.7-2.01)	0.5	-	-
3–1	0.95 (0.06-1.49)	0.8	-	-
>3	1	1	-	-
History of infant death syndrome
Yes	1	1	1	1
No	2.95 (0.69-12.52)	0.1	3.46 (0.08-14.89)	0.09

Discussion

As explained, sudden infant death syndrome is considered when there is no specific medical cause for the death of an infant during sleeping. This type of death is a tragic experience for the family and affects the parents’ morale. The infant’s unexpected death will cause a sudden cessation or discontinuation of the parent’s ability to provide physical and emotional security. Many parents even felt abandoned by God or the world.[10,11]

Globally, SIDS resulted in 22,000 deaths in 2010, and it makes up about 80% of sudden and unexpected infant deaths (SUIDs).[12,13] After recognizing SIDS as an official cause of death in 2011, the World Health Organization created a category for it.[14] The Centers for Disease Control and Prevention (CDC) reports in 2017 showed that the incidence of SIDS in the United States was 35.4 per 100,000 live births, and in 2018, about 1300 deaths due to SIDS, 1300 deaths due to unknown causes, and 800 deaths due to accidental suffocation and strangulation in bed were recorded.[2,15,16] The death rate has a significant variation from 0.05 per 1000 in Hong Kong to 6.7 per 1000 in Native Americans.[17] Indeed, as the name implies, there is no well-established cause for SIDS, but some studies have identified risk factors for them and usually, a combination of these factors is thought to cause the syndrome, such as premature birth, male gender, low socioeconomic status, sleeping in a prone position, overheating, mother’s smoking during and after pregnancy, infection, and stress.[18,19,20] Many of these factors can be corrected by increasing mothers’ knowledge and beliefs about SIDS. Thus, it is so important to recognize mothers’ beliefs and awareness. Despite the global recognition of this syndrome, the knowledge of Iranian mothers is low. Few studies are available about this problem in Iran, but its prevalence is thought to be high, which further increases the government’s responsibility for careful planning to increase public awareness.

In the current study, it was observed that 81% of mothers were aged >35 years. And based on our results, it was found that with higher age, the mother’s knowledge about this syndrome decreases. It was the same as El-deen et al.[21] study which reported nearly three-quarters of mothers were aged >20–30 years old. And Bezerra et al.[22] also found that the majority of unaware mothers were aged >20 years old. On the contrary, Botia was against these studies and reported that most unaware mothers were aged <34 years old.[23]

Regarding mothers’ level of education, in our study 23/8% of them had elementary, 41/8% of them had secondary education, and 34/4% of them had an academic university education. According to the results, increasing the level of education of mothers increases awareness of SIDS. Our results were to the Caraballo and Mims findings, as they found that the majority of their participants had secondary education.[23,24] Elsokey study showed that more than half of mothers had secondary education.[25] In the Eman Wardany et al.[26] study, more than half of mothers had secondary education.

Regarding the number of parity of the studied mothers, 36/6% of mothers were primiparous and nearly three-quarters of mothers were multiparous. And in multiparous, the risk of unawareness of SIDS was unexpectedly higher. In Elsobkey’s study, 80% of the unaware mothers were primiparous, as the same Mims reported that the majority of mothers had one child.[24,25] Nofal et al.[27] showed that mothers with at least one child had better knowledge than those without any children.

As the mothers did not receive any health education about SIDS during pregnancy and after delivery, almost all of them had poor knowledge about it. Isezuo and Elsobkey’s studies were consistent with our study and revealed that mothers had poor knowledge.[25,28] de Lima Bezerra reported that only 15% of the studied mothers heard about SIDS.[22] The majority of mothers in the Mohamed study also did not have information about SIDS before the education programs.[26] From our point of view, the mother’s educational level played an important role in the improvement of their knowledge, as the level of education increased, mothers’ awareness improved.

In our study, mothers’ site of residence (urban or rural) had no significant relationship with their level of SIDS awareness. Alzahrani et al.[29] report shows more knowledge in participants from rural regions than those from urban regions. But previous studies reported those from urban areas had better knowledge.[30] In Mathews’ study in the US, they found that the majority of the studied mothers had no exposure to cigarettes in their house.[31] Wardany’s study showed that about half of mothers stated that somebody smokes at their house, and it was due to the lack of the mother’s knowledge about cigarette exposure dangers.[26]

Limitations and offers

The limitations of the present study include 1—the reluctance of some mothers to participate in the study and 2—the presence of a history of encountering the sudden death of children had led to an increase in awareness among some mothers, which was less in cases where they had not encountered it, and this caused a difference in their level of awareness. It is suggested to carry out studies with educational intervention in the field of increasing the awareness of mothers in the field of sudden infant death and investigate its effectiveness.

Conclusion

Regarding mothers’ lack of knowledge about SIDS and the existence of simple and cost-effective methods to prevent this event, scheduled education programs should be planned during pregnancy and postpartum visits to enhance mothers’ awareness about SIDS.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.