Disclosure of Infant Unsafe Sleep Practices by African American Mothers in Primary Care Settings

Abstract

This study assesses the disclosure rates of African American new mothers regarding their infants’ unsafe sleep practices by analyzing the mothers’ responses during separate encounters with a research assistant, health educator, and pediatrician.

African American infants from low-income families remain at high risk for sleep-related deaths despite the reduction in infant sleep deaths in the general population.¹ As part of a larger research study,² 46 African American mothers were asked about their infants’ sleep practices during 3 separate encounters on the same day: a survey administered by a research assistant (RA), a well-baby visit with the pediatrician, and a safe sleep discussion with a health educator (HE). Based on the mothers’ responses during each encounter, this study assesses the disclosure rates for unsafe sleep practices.

Methods

The setting for this survey study was an urban pediatric clinic serving children from low-income, predominantly African American families. On the day of or prior to the infant’s 2-week well-baby visit, the mother was asked for consent to participate in the study. To minimize disruption to patient care, interactions were conducted in the examination room. This study was approved by the institutional review board of Johns Hopkins University, Baltimore, Maryland. For this report, we included mothers who identified as African American and provided written consent to participate in the intervention arm of the study.

The pediatric encounter included a comprehensive medical history and infant examination that follow professional guidelines covering age-appropriate anticipatory guidance topics, which include safe sleep.² This visit was audiotaped, after which all sleep-related conversations were transcribed and coded for assessment of the disclosure rates of unsafe sleep practices.

As part of the study, the mother also completed a structured 15-minute survey with an RA, who recorded answers electronically. Questions about sleep practices included if the infant ever co-slept, slept with objects (eg, blanket, wedge, or pillow), was put to sleep on the side or stomach, or slept on an adult bed. These questions correspond to the safe-sleep messages known as the ABCs—sleeping alone (no people or objects), on the back, and in a crib or other safe space.³

After the pediatric encounter and RA interview, the mothers participated in a 15- to 30-minute standardized intervention on safe sleep that was facilitated by an HE. The mother was asked to describe “how and where baby is sleeping.” The HE used a checklist to record the disclosure of unsafe sleep practices, added relevant comments, and later coded the observations to identify the unsafe sleep practices.

Results

Among the 46 mothers included in this study, the mean (SD) age was 26 (5.6) years. Forty-two mothers (91%) either received or had applied for medical assistance, and 21 mothers (46%) had some schooling experience beyond high school. The mothers disclosed unsafe sleep practices more often to the RA than to the pediatrician or the HE (Figure 1). For example, 14 mothers (30%) disclosed co-sleeping to the RA whereas only 6 mothers (13%) disclosed this behavior to the HE and none disclosed it to the pediatrician. Even when the mothers were asked directly by a pediatrician about each safe sleep behavior, most mothers who had disclosed unsafe behaviors to the RA did not disclose to the pediatrician (Figure 2).

Figure 1. Mothers’ Disclosure Rates for Infants’ Unsafe Sleep Practices Based on 3 Encounters.

Figure 2. Pediatrician Questions and Mothers’ Responses Among Mothers Who Disclosed Unsafe Sleep Practices to a Research Assistant (RA).

Discussion

The differences in the disclosure rates among these 3 encounters are most likely attributable to the number and specificity of the questions asked. The RA asked 18 standardized questions, the HE asked 2, and the pediatricians did not have a standardized approach. The pediatricians’ approach to sleep assessment ranged from asking many questions to not asking any. We believe that the higher reporting to the RA was a result of asking separate questions for each sleep practice, and asking if any unsafe behavior was “ever” practiced. In contrast, most pediatricians do not ask if the behavior was practiced “ever,” but rather ask questions about the current and/or typical behavior, for example, “Where does baby sleep?” The small sample size did not allow us to examine disclosure rates based on the race of the RA, HE, or pediatrician.

Given the persistent disparity of infant sleep-related deaths among African American individuals, it is imperative that clinicians learn about parents’ risky infant sleep practices in order to emphasize sleep safety. However, time constraints in clinical settings coupled with many other compelling pediatric topics to be covered during well-baby visits do not allow for devoting sufficient attention to discussing safe sleep. Given the other clinical decision support tools⁴ in the electronic medical records, we propose the use of technology to assess infant sleep practices by using a standardized tool. Such an approach could maximize the disclosure of information from parents; consequently, the clinical time could be dedicated to having a meaningful dialogue with the goal of reducing unsafe practices.