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Yale University
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Yale Medicine Thesis Digital Library
School of Medicine
January 2019
Assessing Risk Factors For Sudden Infant Death Syndrome And
Assessing Risk Factors For Sudden Infant Death Syndrome And
Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep
Caregivers’ Perceptions Of The Cardboard Box For Infant Sleep
Nisha Dalvie
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Recommended Citation
Recommended Citation
Dalvie, Nisha, “Assessing Risk Factors For Sudden Infant Death Syndrome And Caregivers’ Perceptions Of
The Cardboard Box For Infant Sleep” (2019). Yale Medicine Thesis Digital Library. 3893.
https://elischolar.library.yale.edu/ymtdl/3893
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Assessing Risk Factors for Sudden Infant Death Syndrome and Caregivers’ Perceptions of
the Cardboard Box for Infant Sleep
A Thesis Submitted to the
Yale University School of Medicine
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Medicine
by
Nisha Dalvie
2020
ASSESSING RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME AND
CAREGIVERS’ PERCEPTIONS OF THE CARDBOARD BOX FOR INFANT SLEEP.
Nisha S. Dalvie, Victoria Nguyen, Eve Colson, and Jaspreet Loyal. Department of Pediatrics,
Yale University, School of Medicine, New Haven, CT.
Some US hospitals are giving out cardboard boxes as a way to address behaviors
associated with Sudden Infant Death Syndrome (SIDS). Our goal was to evaluate the
cardboard box for this purpose by quantifying current practices and qualitatively assessing
caregivers’ perceptions of the cardboard box. Study participants were English or Spanish-
speaking caregivers of 2-16 week old infants presenting to primary care clinics in New
Haven, CT. Caregivers completed a survey asking about demographic data and SIDS risk
factors, such as non-supine positioning and bed-sharing. Some caregivers also participated in
a semi-structured interview about the cardboard box, created used a grounded theory
approach. Of 120 survey respondents, 38% of all participants and 63% of Spanish-speaking
participants reported bed-sharing at least some of the time. Factors associated with bed-
sharing included Spanish as the primary language (OR: 4.3 [95% CI: 1.9-9.9]). Factors
associated with non-supine positioning included Hispanic ethnicity (OR: 2.6 [95% CI 1.2-
5.8]), caregiver born outside the US (OR: 4.2 [95% CI: 1.8-9.6]), Spanish as the primary
language (OR: 6.3 [95% CI: 2.7-14.7]), and less than high school education (OR: 3.4 [95%
CI: 1.3-8.9]). Of 50 interview participants, 52% said they would use the cardboard box for
their infant to sleep in compared with 48% who said they would not. The following 3 themes
emerged from the data: (1) safety of the cardboard box; (2) appearance and (3) variation in
planned use. In conclusion, bed-sharing rates were higher in our study population compared
to the national average, highlighting the need for better resources; however, participants were
divided about whether they would actually use the cardboard box, indicating it may not be a
successful intervention in our community.
Acknowledgements
Thank you to Dr. Eve Colson for her introduction to this field and her crucial
expertise. Thank you to Dr. Maryellen Flaherty-Hewitt and Camisha Taylor for their
flexibility in the primary care clinic workflow so that this project could succeed. Most
importantly, thank you to Dr. Jaspreet Loyal for her incredible mentorship, unwavering
support, and life-long lessons in pediatric clinical care that all clinician-educators should
aspire to.
This work was supported by the National Institutes of Health
[Grant 2 T35 HL 7649-31].
Table of Contents
Introduction…………………………………………………………………………………………………
Sudden Infant Death Syndrome: Background and Risk Factors……………….
Barriers to Safe Sleep and Studied Interventions……………………………………
The Cardboard Box for Infant Sleep……………………………………………………..
Our Project……………………………………………………………………………………….
Statement of Purpose and Specific Aims…………………………………………………………
Methods………………………………………………………………………………………………………
Setting and Sample…………………………………………………………………………….
Data Collection………………………………………………………………………………….
Data Analysis…………………………………………………………………………………….
Results…………………………………………………………………………………………………………
Overall……………………………………………………………………………………………..
Sleep Positioning……………………………………………………………………………….
Sleep Location……………………………………………………………………………………
Qualitative Themes…………………………………………………………………………….
Perceptions of the Cardboard Box, Demographics, and Sleep Practices…..
Discussion……………………………………………………………………………………………………
Our Caregiver Population…………………………………………………………………..
Comparing National Prevalence of Sleep Practices with Our Data………….
Evaluation of the Cardboard Box for Infant Sleep………………………………….
Study Limitations and Opportunities for Future Work…………………………….
References……………………………………………………………………………………………………
Appendices…………………………………………………………………………………………………..
Appendix A: PDF of Yale Qualtrics Survey……………………………………………
1-10
1
3
6
9
11
12-16
12
12
15
17-30
17
20
22
26
29
30-45
29
31
37
41
46-51
52-62
52
1
Introduction
Sudden Infant Death Syndrome (SIDS): Background and Risk Factors
Sudden infant death syndrome (SIDS), a type of sudden unexpected infant death
(SUID) often associated with sleep, is defined as the sudden unexpected death of a child
less than 1 year of age and outside of the perinatal period that remains unexplained after
thorough work-up, including a complete autopsy.1 It is the leading cause of post-neonatal
mortality in the United States and the third leading cause of infant death overall,
responsible for 3,600 deaths in 2017.2 Although SIDS remains a diagnosis of exclusion,
risk factors related to intrinsic biological factors as well as the external sleep environment
have been identified.3 The most well-established risk factors are non-supine sleep
positioning, soft and loose bedding, presence of items such as pillows and blankets,
sleeping on surfaces other than cribs (i.e. adult beds, sofas), and bed-sharing, where bed-
sharing is defined as an infant sleeping on the same surface as another person.4 Other
factors correlated with higher SIDS incidence include male sex, black race, families who
identify as lower socio-economic status, mothers younger than 20, low birth weight / pre-
term infants, and cigarette smoking during pregnancy.5 It is important to note that none of
these risk factors are sufficiently strong enough to identify a pathophysiologic cause, but
have assisted in creating a descriptive profile that associates maternal, neonatal, and
environmental factors with SIDS risk, as illustrated in Figure 1.
Based on this emerging profile, the American Academy of Pediatrics has published
recommendations for pediatricians to counsel families on modifiable factors to prevent
SIDS. The first guideline, published in 1992, recommended that infants be placed in a non-
prone position for sleep; in 1994, this guideline became the basis for the “Back-to-Sleep”
2
Figure 1: Maternal, Neonatal, and Environmental Risk Factors for SIDS (Triple Risk
Model adapted from Filiano and Kinney6)
campaign (later becoming the “Safe-to-Sleep” campaign), a collaboration between the
AAP and the National Institute of Child Health and Development (NICHD).7 Over the next
8 years, the percent of infants placed on their backs to sleep increased from 17% to 70%,
and the incidence of SIDS decreased by over 40%.8-9 Some papers note that part of the
reason for the drop in SIDS incidence may simply be because of diagnostic shift, with
more cases of SUID being ruled as accidental suffocation rather than SIDS as more
thorough death scene investigations were performed later in the decade, but it is unlikely
for changing classifications to account for all the decrease throughout the decade.10-12 The
safe sleep recommendations have been updated several times since the 1990s, with the
most recent 2016 recommendations expanding to specify placing infants in the supine
position for sleep, avoiding cigarette smoke during and after pregnancy, using a firm sleep
3
surface with tight fitting bedding and no other loose articles such as pillows, and to avoid
bed-sharing.5
Despite the improved strength of these recommendations and their uptake by
pediatricians and parents alike, SIDS incidence has not significantly decreased in the past
two decades in the United States as a whole, although there are wide variations between
states.13 Several large-scale studies have identified non-adherence to the AAP
recommendations and associated factors as a potential explanation for this plateau. An
analysis of results from the Web-based National Child Death Review Case Reporting
System (NCDR-CDS) showed that, out of over 3000 cases of SIDS across 9 states, 70% of
cases identified the infant on a surface not intended for infant sleep and 64% of infants
were sharing a sleep surface with an adult or older child.14 The nationally representative
Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed over 3000
caregivers about infant sleep practices between 2011-2014, found that although 77.3% of
mothers usually place their child supine, only 43.7% intentionally place their child
exclusively supine.15 In addition, this study found that black mothers and mothers with less
than a high school education were more likely to place their child in a non-supine position
compared to white mothers and mothers with at least a high school education, aligning
with results from a prior national survey from 1993-2007 and older studies on SIDS risk
factors.5,16
Barriers to Safe Sleep and Successful Interventions
These findings lead to the all-important question: why are caregivers still practicing
sleep positions that are non-adherent to current safety recommendations? It seems unlikely
to be primarily caused by lack of adequate education, as caregivers who practice non-
4
supine positioning indicate they are aware of their doctors’ recommendations, although
studies have found caregivers that use prone positioning are less likely to be aware of the
associated SIDS risk.16 Studies on the “ABC” messaging of safe sleep (Alone, on the Back,
and in a Crib) have found no statistically significant changes in sleep positioning before
and after caregivers receive this information via crib card, as more than 80% of them were
already aware supine positioning is the safest. This study found significant changes in sleep
environment before and after patients communicated with nursing about safe sleep
practice, including a 40% reduction in loose articles within the crib, but could not attribute
this to “ABC” messaging due to low compliance of using the crib card.17 These findings
indicate that such communication methods may not be the most effective target to reducing
SIDS risk factors, possibly because lack of knowledge is no longer the biggest barrier to
safe sleep practices as it was in the 1990s and early 2000s: in 2015, 99% of caregivers at
one hospital were aware of supine positioning and crib recommendations both at time of
discharge and at 6 month follow-up, a significant increase compared to the National Infant
Sleep Position (NISP) study results from 1993-2010.16,18
Interventions based in health messaging have been more successful if they gave
caregivers specific rationales rather than re-iterating the best practices. This has been
demonstrated by randomized controlled trials in Washington, DC and Porto Alegre, Brazil
that showed reduced bed-sharing rates and increased supine positioning after educational
sessions designed to elicit reasons for choosing sleep positions.19-20 Other examples of
successful education-based interventions include a nursing quality improvement (NQI)
pilot to provide postpartum teaching about safe sleep practices prior to discharge, and a
mobile health texting service to deliver tailored messages to caregivers about safe sleep for
5
2 months post-discharge. These were both evaluated through the Social Media and Risk-
Reduction Training (SMART) clinical trial, which demonstrated that caregivers who
received both the NQI and the mobile health interventions for safe sleep reported the
highest percentages of adherence to safe sleep practices.21 The success of all these
initiatives emphasizes the importance of understanding families’ attitudes about safe sleep
practices in order to actually counteract barriers adherence: the one-on-one discussions,
mobile health messages, and nursing education time were to address each caregiver’s
unique concerns about safety recommendations, specifically about the comfort of supine
positioning and reminders that their children are not immune to SIDS.
This was not the first study to identify caregivers’ attitudes around the AAP
recommendations as a potential barrier to safe sleep practices. In 2005, qualitative findings
from focus groups of mainly black mothers in urban areas, a population which has been
identified as high-risk for non-adherent practices since the 1990s, demonstrated concerns
about choking in supine position, lack of trust in health providers compared to mothers in
their families, and the perception that infants would be more comfortable on their
stomachs.22 The previously mentioned Study of Attitudes and Factors Effecting Infant
Care (SAFE) from 2011-2014 also examined caregivers’ attitudes about sleep practices,
and identified that mothers who believed they did not have control over their infants’
choice of sleeping position were much more likely to include prone sleep in their intended
practices.15 These findings make it clear that simply stating AAP recommendations to
caregivers is not enough to ensure their uptake- successful interventions must address the
root causes of parents’ concerns, whether that means anticipatory explanations about
choking risk in the supine position or being culturally respectful of mothers’ traditions
6
while explaining the dangers of bed-sharing. This framework is particularly important for
populations that are already at a higher risk for SIDS, particularly pre-term infants, black
families, and younger or less formally educated mothers.
Cardboard Box for Infant Sleep
With the context of SIDS risk factors, AAP recommendations, and the best
interventions to improve adherence, we can now focus on a proposed intervention that has
captured the attention of pediatricians around the globe: a cardboard box for infant sleep.
The government of Finland has utilized this resource since the 1930s, during which time
infant mortality rate was recorded as high as 9%.23-24 Initially, only low-income mothers
who had attended all their prenatal care appointments were eligible, making the box both
an incentive for mothers to attend all their appointments and a public health intervention
for mothers who could potentially not afford another sleeping space; the box itself came
with gauze diapers, muslin to stitch baby clothes, and a baby mattress.25 Although it is
impossible to determine the effect of these kits on maternal health or infant outcomes such
as SIDS, especially with other important interventions such as vaccinations and midwife
delivery beginning during this time period, the infant mortality rate in Finland decreased to
3% by 1950 and is now 0.17%, one of the lowest in the world.26 The cardboard box kit is
now offered to all new caregivers, including those who adopt, and includes indoor and
outdoor baby clothes, diapers, toys, bibs, bathing products, and a picture book in addition
to the fitted mattress.27 Over 95% of caregivers choose the kit over an alternative cash
voucher, indicating its popularity and long-standing place in Finnish culture.23
Its popularity is expanding to other countries, both in the form of public health
interventions and commercial products. In 2017, Scotland approved the distribution of
7
baby boxes with a mattress, fitted sheet, clothes, a thermometer, bath towels, and a
changing mat to any mother who fills out a request form at her 24-week perinatal
appointment, at a £6 million annual cost.28 The Finnish baby box has also been cited as an
inspiration for products such as the Barakat Bundle, a kit which includes a foldable cradle
and sterile delivery supplies for rural Indian mothers, and the Thula Baba Box, a plastic bin
for South African mothers to use as an infant bath tub complete with bathing supplies.29-30
In the United States and Canada, the baby box has become a phenomenon largely due to
The Baby Box Company, a company that sells baby boxes directly to parents as well as to
hospitals for large-scale distribution.31 All boxes come with a mattress and fitted sheet, but
can also include various clothes, toys, and diapers for a higher cost; all boxes also come
with an online educational course created by The Baby Box Company on SIDS risk factors
and safe sleep practices.32
Part of the cardboard boxes’ popularity can be attributed to Dr. Meghan Heere’s
work at Temple University Hospital. In 2016, as director of the well-baby nursery, she set-
up a large pilot study including over 2,500 women who delivered at Temple University
Hospital. Mothers were surveyed over the phone about bed-sharing and breastfeeding
practices within the first week of their hospital discharge. 1,264 of these women received
no education safe sleep practices or other resources after delivery; 423 of them received
face-to-face education on safe sleep practices prior to discharge; and 391 received a
cardboard box for their infants to sleep in as well as face-to-face education on safe sleep
practices. Analysis demonstrated that women who received both the cardboard box and the
inpatient education reported 27% less bed-sharing with their infant in the first week of life
compared to women in the control group, and exclusively breastfeeding mothers reported
8
nearly 50% less bed-sharing compared to women in the control group. Half of the mothers
reported using the cardboard box for infant sleeping, with 12% using it as the primary
sleeping space; many mothers also reported satisfaction with the box, especially as
proximity to the infant facilitated breast-feeding.33
The cardboard box was deemed a successful intervention based on these results,
prompting the creation of the Sleep Awareness Family Education at Temple (SAFE-T)
Program at Temple University Hospital. This program was created to continue funding the
distribution of cardboard boxes and face-to-face safe sleep education from specially trained
inpatient nursing staff. The boxes are purchased from The Baby Box Company, with
funding from donations by Temple University Hospital and the Lewis Katz School of
Medicine at Temple University; the SAFE-T program has given out over 10,000 boxes
with safe sleep education since 2016.34 Dr. Heere’s research efforts are now focused on
quality improvement cycles for the SAFE-T program as well as long-term effects on
sleeping practices during the first year of life and Philadelphia’s SUID mortality rate.35
The results of this program, combined with the reputation of baby boxes from
Finland, prompted other hospitals in the US and Canada to partner with The Baby Box
Company to give out cardboard boxes and a membership for their online safe sleep
education program.36 After year-long pilots, New Jersey and Texas now have universal
state-wide programs for every mother who wants to receive a box, which totaled to about
400,000 boxes given away from each state in 2017.37-38 Alabama’s public health
department sponsored 60,000 boxes between 2017 and 2018 with the plan to examine their
effect on bed-sharing rates before increasing distribution plans.39 Ohio state government
launched a partnership with several Cincinnati hospitals to give out 160,000 boxes in 2017,
9
and similar pilot programs have launched in Alberta and Toronto, Canada to a few
thousand expecting mothers in 2018.40-42
Despite the growing popularity of baby boxes in the US, many pediatricians,
government officials, and parents have reservations about the use of the cardboard box for
infant sleep. The AAP has declined to state that cardboard boxes are safe, citing both the
lack of evidence in preventing infant deaths as well as the lack of regulation around them.43
Since the boxes do not meet the federal definition of a crib, bassinet, play yard, or
handheld carrier, they are not required to meet the same regulations set by the Consumer
Product Safety Commission.44 Experts, including members of the AAP’s Task Force on
SIDS, have expressed concern about how popular the cardboard boxes are, especially
given their somewhat vague intended use: per the company’s instructions, the box is meant
to be “placed on the floor or a sturdy wide surface, such as a coffee table” and not placed
in the adult bed or used as a carrier, yet the way they are designed easy for parents to do
both.45-46 Pediatricians have also raised specific concerns about the durability of cardboard,
the lack of visibility in a cardboard box compared to a crib or bassinet, and the risk of
injury if the box is placed on the floor or a high surface47; these exact concerns were
echoed by a focus group of mothers when asked interviewed about the cardboard boxes.48
Our Project
Amidst the abundance of controversy, the fact remains that there is limited
evidence on cardboard boxes as an intervention to improve safe sleep practices and SIDS
outcomes. Their safety and efficacy, especially in populations at higher risk for SIDS, are
of particular research interest as their usage expands into larger academic hospital centers.
Therefore, we sought to evaluate cardboard boxes as a resource for caregivers at Yale New
10
Haven Hospital’s Pediatric Primary Care Centers (PCC), a population that has been
previously identified as at high risk for unsafe sleep practices.49 By collecting baseline data
about current sleep practices and SIDS risk factors among these caregivers, our objective
was to better understand our own community as well as analyze whether the cardboard box
would address the same barriers that Dr. Heere identified at Temple University Hospital.
Secondarily, we would collect data on attitudes towards safe sleep practices and
perceptions of the cardboard box itself to understand what caregivers’ response would be if
the boxes were to be distributed by the hospital, especially in the context of The Baby Box
Company considering a partnership with Yale New Haven Hospital. To this end, we
designed a mixed-methods study combining a quantitative survey with a qualitative
interview in order to capture both of these key steps in designing a successful intervention
against unsafe sleep and SIDS.
11
Statement of Purpose
To evaluate the cardboard box for infant sleep as an intervention to improve safe sleep
outcomes among urban caregivers, by identifying their current barriers to safe sleep
practices and understanding their perceptions of the cardboard box as a resource.
Specific Aims
1. Quantify baseline prevalence of SIDS risk factors among caregivers in our community,
including formula feeding, smoking, bed-sharing, and infant sleep positioning.
2. Elicit caregivers’ attitudes towards safe sleep in the context of the cardboard box and
determine what factors influence positive or negative qualitative perceptions.
12
Methods
Setting and Sample
The study was conducted at two pediatric primary care clinics in New Haven,
Connecticut. Our sample included English and Spanish-speaking mothers of infants ages 2
to 16 weeks who presented for well-child visits at our pediatric primary care clinics from
June to August 2017. We attempted to approach every family with an infant aged 2 to 16
weeks on any given day in clinic. Our inclusion criteria were designed to identify
participants who have experienced a key concept being explored in the study and/or have
membership in a subgroup with distinct characteristics; in this case, the subgroup in this
study were mothers of young infants, thus the use of the cardboard box would be relevant
to them and would allow them to make salient comments about its usage for the qualitative
portion. Patients were screened for inclusion / exclusion criteria by Jaspreet Loyal, the
primary investigator (JL) on a weekly basis, with the list being passed down to the student
Nisha Dalvie (ND) once reviewed and approved by Maryellen Flaherty-Hewitt, the clinic
director (MFH). We chose the pediatric primary care clinics to access families at higher
risk of not following AAP recommendations for safe sleep, as identified in the background,
and were also likely to use our hospital maternity services.49
Data collection
Our mixed-methods approach included in-person surveys and audio-recorded
interviews, both of which were performed by the student (ND) with caregivers at their
child’s well visits between 2-16 weeks after birth. The quantitative survey was adapted
from the Infant Care Practices survey, a validated tool administered nationally by the Slone
Epidemiology Center.51 Survey data included questions about where the infants sleeps,
13
infant sleep positioning practices and intentions, bed-sharing practices and intentions, and
other risk factors such as cigarette smoking and breast feeding; demographic data collected
included age, race/ethnicity, years of education, and health insurance (see Appendix A for
full survey). The semi-structured interviews were conducted using a grounded theory
approach, where each new interview was discussed by the research team in order to inform
the structure of the next interview.50, 52 An initial interview guide was created based on
current literature and expert opinion. The interview guide (Table 1) was revised in an
iterative process as new information emerged from the data.
Table 1: Semi-structured Interview Guide
Interview question
1. Have you heard of the cardboard box for babies to sleep in?
If no, research associate shows picture or actual box.
2. What do you think of the cardboard box?
3. What are some things you like about the cardboard box? What are some things
you dislike about the cardboard box?
4. What do you think you would use it for? (Probing question: Would you use it for
your baby to sleep in?)
5. (If participant stated he/she would not use it for their infant to sleep in). The
hospital is planning to give the cardboard box to parents at no cost, what do you
think about that? How would this affect your decision to use the cardboard box?
6. Where would you put the cardboard box in your home?
7. Do you have anything else to share?
14
Verbal was obtained from each participant in English or Spanish by the student
(ND) at the time of their appointment. The survey was conducted via secure Yale Qualtrics
link on an encrypted electronic tablet held by the student (ND), while verbally asking each
question to the caregiver in either English or Spanish. Surveys were conducted during
caregivers’ waiting time in the exam room and took approximately 10 minutes each. Semi-
structured interviews were conducted by the student (ND) in a private room in the clinic
space after the conclusion of the medical visit, each lasting for 15 to 20 minutes. During the
interview, participants were shown a picture of the cardboard box (Figure 2) or the
physical box itself – at the time of this study, the cardboard boxes were being distributed
with a lid. Interviews were audiotaped and transcribed verbatim by the student (ND).
Interviews conducted in Spanish were translated into English during the transcription
process by the student (ND), who is a certified Spanish language translator in the Yale New
Haven Hospital system. Approval from the Yale University Human Investigation Committee
as well as the primary care clinic directors was obtained prior to beginning the project.
Figure 2: Image of the cardboard box shown to qualitative interview participants
15
Data Analysis
Quantitative survey data was exported from Qualtrics to Microsoft Excel 2016 by
the student (ND) and organized by anonymous, randomized response ID. Variable names
were calibrated for further analysis and relationships of interest were identified by the
student (ND) before being sent to the primary investigator (JL) who had access to the
necessary software. Data analysis, including calculated chi-square values, odds ratios, and
associated 95% confidence intervals, was completed in SPSS (Armonk, NY). Reported
behaviors were compared demographic data to quantify outcomes such safe infant
positioning, bed-sharing frequency, and other practices of interest. Unadjusted odds ratios
for which the confidence interval did not include 1.0 were considered statistically
significant.
Data from the qualitative transcripts were analyzed using coding techniques
common to qualitative research using grounded theory methodology.53-54 Data analysis was
conducted in an iterative process, with data collection and analysis continuing concurrently
until no new themes emerged (‘thematic saturation’). In the first part of the analysis, an
initial code list was created based on the first read-through of transcripts. Codes, defined as
participant’s words, phrases, or authors’ concept words, served as labels for important
participant data. Transcripts were coded by 4 independent investigators: the student (ND),
the primary investigator (JL), an expert in the field of safe sleep practices (EC), and a
nursing trainee (VN). Transcripts were then compared and discussed as a group to share
reflections and abstract commonalities in the codes each author had assigned. From these
codes, the initial code list was created. This list was iteratively revised using the constant
comparative method as new interviews were conducted and coded. In the second part of the
16
analysis, codes were clustered into cohesive categories. To reduce redundancy among the
categories and to ensure the category linkages were firmly established, all researchers came
to agreement in the coding schema, which was then reviewed for data that expressed the
main ideas or themes. In the third part of the analysis, data were reviewed for evidence of
relationships among themes.
Trustworthiness in the data was established through 1) ongoing debriefing sessions
by the authors to discuss reflections, insights and incoming data; 2) coding development over
3 months, enabling prolonged engagement with the data to recognize biases or distortions
and 3) member checking during interviews to ensure correct interpretation of what was being
shared, and by discussing tentative themes and interpretations with a subset of research
participants. Data was organized in Microsoft Excel 2016.
17
Results
Overall
Of 129 caregivers approached, 120 caregivers (93%) consented to fill out the
survey. Out of the participants who consented to the survey, 50 caregivers (42%) also
consented to participate in the semi-structured interview. Most of the mothers who did not
consent to either the survey or the interview portion cited time as their principal reason for
not participating. Characteristics of survey and interview participants are shown in Table 2.
Sex of infants was almost equally split between male and female in both the total
surveyed group and subset who also participated in the interview. There was representation
of several infant ages, with 42.5% presenting at their 2 week or 4 week well-child visits,
25.8% presenting at their 4 month well-child visit, and 31.7% presenting in between those
visits; distribution was comparable in the interview-participant subset. 59.2% of
respondents identified as mothers and the primary caregiver of their infant, compared to
35% of respondents identifying equal caregiving between mother and father and a small
group (5.8%) identifying as non-parent caregivers, consisting of grandparents, an aunt, and
a non-relative. In the interview-participating group, 90% of participants were mothers who
identified as the primary caregiver; only 2 mother-father pairs were interviewed, as well as
one grandmother. Caregiver age was nearly equally distributed between younger than 30
years and older than 30 years, with no caregivers younger than 20 years. For 26.7% of
caregivers, the infant at the appointment was their first child compared to 73.3% with at
least one other child at home. In the interview-participating subset, this distribution was
similar with 36% respondents having only one child and 67% having more than one.
18
Table 2: Demographics of Participants (Total N = 120, Interview N = 50)
Characteristic
Total Number
(Percent)
Interview Number
(Percent)
Infant Sex
Female
Male
59 (49.2%)
61 (50.8%)
26 (52%)
24 (48%)
Infant’s age (weeks)
Less than 1 month
1-3 months
4 months
51 (42.5%)
38 (31.7%)
31 (25.8%)
24 (48%)
15 (30%)
11 (22%)
Primary Caregiver
Mother
Mother and Father
OtherA
71 (59.2%)
42 (35.0%)
7 (5.8%)
45 (90%)
2 (2%)
3 (6%)
Age of Primary Caregiver (years)
Less than 30
30+
57 (47.5%)
63 (52.5%)
27 (54%)
23 (44%)
Number of Children in household
One
Two or more
32 (26.7%)
88 (73.3%)
18 (36%)
32 (64%)
Caregiver’s country of birth
United States incl. Puerto Rico
OtherB
86 (71.7%)
34 (28.3%)
37 (74%)
13 (26%)
Race/Ethnicity of Caregiver
Black
Hispanic
White
Asian
OtherC
60 (50%)
50 (41.7%)
5 (4.2%)
3 (2.5%)
2 (1.7%)
24 (48%)
14 (28%)
8 (16%)
2 (4%)
2 (4%)
Preferred Language of Caregiver
English
Spanish
85 (70.8%)
35 (29.2%)
38 (76%)
12 (24%)
Highest Education Level of Caregiver
Less than high school
High school/GED
Some college or college graduate
20 (16.7%)
55 (45.8%)
45 (37.5%)
4 (8%)
25 (50%)
21 (42%)
Smoking Status of Caregiver
Current Smoker
Before Pregnancy
Never smoked
5 (4.2%)
15 (12.5%)
100 (83.3%)
1 (2%)
3 (6%)
46 (92%)
Breastfeeding Status of Caregiver
Mostly or only breastmilk
Equal breastmilk and formula
Mostly or only formula
51 (42.5%)
28 (23.3%)
41 (34.2%)
25 (50%)
15 (30%)
10 (20%)
AOther includes grandparents (5), an aunt (1), and a non-relative such as babysitter or friend (1)
BIncludes Ecuador (9), Mexico (9), the Dominican Republic (1), El Salvador (1), Guatemala (2), Honduras (2), Trinidad
(1), Spain (2), Albania (1), Greece (1), Barbados (1), Jamaica (1), Grenada (1), China (1), and Togo (1)
CIncludes Pacific Islander (1) and Native American (1)
19
Of 120 total participants, 50% identified as black and 41.7% identified as Hispanic,
compared to 4% of participants who identified as white. In the interview-participating
subset, 47% of respondents identified as black and 28% identified as Hispanic and
compared to 16% of participants who identified as white. The majority of participants
(71.7%) were either from the continental United States or Puerto Rico compared to 28.3%
from various other countries in Central America, South America, Europe, and Asia;
distribution was similar in the interview-participating subset. The majority of participants
identified English as their primary language (70.8%) compared to 29.2% of primarily
Spanish speakers. For the interview portion, 76% of interviews were conducted in English
and 24% were conducted in Spanish.
Of 120 participants, 45.8% reported their highest level of education was high
school or equivalent compared to 16.7% with less than high school education and 37.5%
with at least some college education; distribution was similar in the interview subset. Most
participants reported they had never smoked (83.3%) compared to 12.5% who quit before
pregnancy and 4.2% who smoked during pregnancy or currently; distribution was similar
in the interview subset. Of 120 participants, 42.5% reported mostly or exclusively
breastfeeding compared to 34.2% who used mostly or exclusively formula and 23.3% who
did an equal mix of breastfeeding and formula feeding. In the interview subset, 50% of
participants reported mostly or exclusively breastfeeding compared to 20% who mostly or
exclusively formula fed and 30% who reported and equal mix of formula and
breastfeeding.
20
Sleep practices
Survey participants were asked about how they position their infant to sleep (on the
back, on the side, or on the stomach), where their infant sleeps (free text response that was
grouped into categories), and the environment their infant sleeps in (i.e. with a firm
mattress, with a swaddle blanket, or with other items such as thick blankets, pillows, or
toys.) In the context of each of these behaviors, they were also asked to identify their initial
plans for sleep practices before bringing their infant home, the most commonly occurring
practice since bringing their infant home, and any other practices that sometimes occur;
these are signified by “Intended Practice”, “Most Common Practice” and “Practice occurs
Sometimes” respectively in Table 3.
Table 3: Intended and Most Commonly Practiced Sleep Behaviors (Total N = 120)
Intended
PracticeA
(% of Total)
Most Common
Practice
(% of Total)
Practice occurs
SometimesA
(% of Total)
Positioning
Supine
Side
Prone
103 (85.8%)
25 (20.8%)
18 (15%)
105 (87.5%)
10 (8.7%)
5 (4.3%)
120 (100%)
24 (20%)
13 (10.8%)
Location
Crib / Bassinet
Pack and Play
Car seat
Moses basketB
Bed-sharingC
120 (100%)
0
0
2 (1.7%)
25 (20.7%)
115 (95.8%)
1 (.8%)
0
2 (1.7%)
2 (1.7%)
117 (97.5%)
35 (29.2%)
6 (5%)
2 (1.7%)
46 (38.3%)
EnvironmentD
Firm mattress
Swaddle blanket
Thick blankets, pillows,
or toys
–
–
–
113 (94.1%)
17 (14.2%)
2 (1.7%)
120 (100%)
29 (24.2%)
6 (5%)
ARespondents were able to select more than one option for Intended Practice and Practices occurring Sometimes, so the sum of
all responses is greater than total N of 120
BIncludes any product designed to be placed on adult mattress
CIncludes any surface where an infant sleeps on the same surface as another person, such as adult mattresses and sofas
DCaregivers were not asked about intended sleeping environment and these are not mutually exclusive choices, so the sum of all
responses is greater than total N of 120
