Media and midwives: More on bed sharing

The NZ College of Midwives recently wrote to Coroner Wallace Bain about his comments regarding bedsharing… read on…

Coroner Wallace Bain,
Dear Mr Bain,

We are writing to you with our concerns regarding a recent media article in which you have been quoted as saying that “parents sleeping with their babies is a form of child abuse”. We understand that as the coroner, you see some disturbing cases in which young babies have died, however, we are concerned that such remarks may be unhelpful in the education of parents.
The New Zealand College of Midwives (NZCOM) is the professional organisation for midwifery. Our members are employed and self employed and collectively represent 90% of the practising midwives in this country.

There are around 3000 midwives who hold an Annual Practising Certificate (APC). These midwives provide maternity care to on average 64,000 women and babies each year. The New Zealand model of maternity care provides the opportunity for women to receive continuity of care throughout their maternity experience. For the majority of women in New Zealand this means having the same midwife Lead Maternity Carer (LMC), or her back up, providing the majority of their care – from early pregnancy, through the labour and birth and for the first few weeks following birth. This care may be home based or provided within a variety of community settings. Midwives who work as LMC’s practice in an integrated way, working in close collaboration with other specialised services and practitioners, across primary, secondary and tertiary service environments.

The death of a baby is devastating for all involved and it is always important that any death is investigated so that contributory factors can be identified and future deaths avoided. However, it is also important that parents receive consistent evidence based information that supports safe sleeping messages. We are concerned that the focus on bed sharing as a problem causes increased confusion and guilt for parents without ensuring that parents are provided with
the important key messages that are known to support safe sleeping practices.

The cosleeping debate

There has been an ongoing unresolved debate regarding the safety/risks of bed sharing (also known as co-sleeping) for many years. To summarise:

Co-sleeping is a culturally embedded and highly prevalent practice in many societies globally, with high levels of cosleeping found in Sweden, Norway, Japan, China, Hong Kong, Bangladeshi infants in the United Kingdom and Pacific Island communities (Gantley, Davies et al. 1993; Nelson, Taylor et al. 2001; Blair, Sidebotham et al. 2009; Sobralske and Gruber 2009). The incidence of Sudden Infant Death Syndrome (SIDS) also known as Sudden Unexpected Death of an Infant (SUDI) is low in many of these countries.

Cultural beliefs and values strongly influence sleep habits and the reaction of society to co-sleeping (also known as bedsharing) (Mindell, Sadeh et al. 2010).

Research suggests that the benefits of bedsharing include; longer term breastfeeding and enhanced maternal monitoring of the baby, more frequent infant arousals and improved sleeping patterns for babies (McKenna and Mosko 1994; McKenna and Mosko 1994; Baddock, Galland et al. 2007; Blair, Heron et al. 2010) .

There is also evidence that bedsharing in particular situations increases the risk of SIDS and in response to this evidence some countries have chosen to advise against cosleeping in the first months of life.

However, a recent longitudinal case control study undertaken in the United Kingdom (UK) explored the factors associated with sudden infant death and the specific circumstances in which SIDS occurred while co-sleeping (Blair, Sidebotham et al. 2009). The authors found that it was not the bedsharing itself that was the main factor in SIDS but bedsharing along with other high risk behaviours such as smoking, alcohol and/or drug consumption (Blair, Sidebotham et al. 2009).

There was a significant correlation between SIDS, co-sleeping and the recent use of alcohol or drugs by the parents. Of particular concern the authors found that the proportion of SIDS infants found on a sofa has increased significantly since 1993-96. They expressed concern that parents are often discouraged from bedsharing but are not necessarily informed of the hazards of falling asleep with their baby on the sofa – and that this is a far more hazardous sleep location.

By focusing warnings on bedsharing rather than the specific risks, the misconceptions are perpetuated.

What are the factors that increase risk when bedsharing?

There is consistent evidence from epidemiological studies investigating the risk of SIDS/SUDI during bedsharing that the following factors increase risk (Scragg, Mitchell et al. 1993; Blair, Fleming et al. 1999; Blair, Platt et al. 2006):

  •  Co-sleeping on a sofa
  •  Maternal smoking in pregnancy
  •  Maternal alcohol and drug consumption
  •  Over tiredness
  •  Excess bedding
  •  Infants sleeping with people other than parents
  • Prematurity

While approximately half of the 50-60 SUDI deaths per year in New Zealand occur in an adult bed there is little data available on maternal smoking or alcohol/drug consumption for these cases (Child and Youth Mortality Review Committee 2009) – two factors which are identified in the literature as contributing to most of the risk associated with bedsharing.

In many Western societies parents strive to ensure separate sleeping environments for their babies, however, studies indicate that between 50 to 70% of parents bed share with their baby at some point in time (Blair and Ball 2004). Parents identify many reasons for bedsharing and these include: being an intrinsic part of their culture, part of a baby-focused parenting style, a way of facilitating breastfeeding, a response to an unsettled baby or sometimes to facilitate better maternal or infant sleep. (Ball 2002; Baddock, Galland et al. 2007; Lahr, Rosenberg et al. 2007; Ball 2009; Sobralske and Gruber 2009). Parents also identify that bedsharing may be accidental.

Therefore the argument that co-sleeping is a form of child abuse would suggest that the majority of parents in this country could be accused of child abuse at some time. As well as distracting from the actual causes of SUDI, this may trivialise the very serious nature of child abuse rather than contributing towards an improved understanding for parents of the importance of ensuring a safe sleep for every child at every sleep.

As the main health professionals involved in maternity, midwives have a key role in providing information to support parents in their early parenting practices. We are working collaboratively with other professional groups to ensure that we provide clear, concise and consistent information to parents to ensure that they are aware of what contributes to safe sleeping practices for all babies. When parents have a full understanding of what contributes to hazardous sleeping practices, they are better prepared and able to ensure that they follow safe sleeping practices in whatever environment they are in.

Assisting parents to understand the principles of safe sleeping practices means parents themselves are better placed to ensure that every sleep for their baby is a safe one.

The unequivocal evidence based messages for all those involved in reducing SIDS/SUDI are that when infants are sleeping they should be:

  •  face up
  •  face clear
  •  smokefree

We would be grateful if you and your colleagues could repeat and promote these messages as their priority.

I have enclosed a copy of the New Zealand College of Midwives consensus statement which guides midwives in these conversations and highlights the issues that need to be considered when advising parents on safe sleeping practices.

Yours sincerely
Karen Guilliland
CEO, New Zealand College of Midwives

References

Baddock, S., B. Galland, et al. (2007). Sleep Arrangements and Behaviour of Bed-Sharing Families in the Home Setting. Pediatrics. 119: e200.
Ball, H. (2009). “Airway covering during bed-sharing.” Child: Care, Health & Development 35(5): 728-737.
Ball, H. L. (2002). “Reasons to bed-share: why parents sleep with their infants.” Journal of Reproductive and Infant Psychology 20(4).
Blair, P., P. Fleming, et al. (1999). “Babies sleeping with parents: case-control study of factors influencing the risk of the suddent infant death syndrome.” BMJ 319: 1457-1462.
Blair, P., M. Platt, et al. (2006). “Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention.” Arch Dis Child 91(2): 101-6.
Blair, P., P. Sidebotham, et al. (2009) “Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England.” BMJ, 339;b3666 DOI: 10.1136/bmj.b3666.
Blair, P. S. and H. L. Ball (2004). “The prevalence and characteristics associated with parent-infant bed-sharing in England.” Arch Dis Child 89: 1106-1110.
Blair, P. S., J. Heron, et al. (2010). “Relationship between bed sharing and breastfeeding: longitudinal, population-based analysis.” Pediatrics 126(5): e1119-26.
Blair, P. S., M. W. Platt, et al. (2006). “Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention.”
Archives of Disease in Childhood 91(2): 101-6.
Child and Youth Mortality Review Committee (2009). Fifth Report to the Minister of Health: Reporting mortality 2002 – 2008. Wellington, Child and Youth Mortality Review Committee.
Gantley, M., D. P. Davies, et al. (1993). “Sudden infant death syndrome: Links with infant care practices.” British Medical Journal 306(6869): 16-20.
Lahr, M. B., K. D. Rosenberg, et al. (2007). “Maternal-infant bedsharing: risk factors for bedsharing in a population-based survey of new mothers and implications for SIDS risk
reduction.” Maternal & Child Health Journal 11(3): 277-286.
McKenna, J. and S. Mosko (1994). “Sleep and arousal, synchrony and independance, among mothers and infants sleeping apart and together (same bed): an experiment in
evolutionary medicine.” Acta Paediatrica Supplement 397: 94-102.
McKenna, J. J. and S. S. Mosko (1994). “Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine.” Acta Paediatrica Supplement. 397: 94-102.
Mindell, J. A., A. Sadeh, et al. (2010). “Cross-cultural differences in infant and toddler sleep.” Sleep medicine 11: 274-280.
Nelson, E. A., B. J. Taylor, et al. (2001). ” International Child Care Practices Study: infant sleeping environment.” Early Hum Dev 62(1): 43-55.
Scragg, R., E. A. Mitchell, et al. (1993). “Bedsharing,smoking and alcohol in the sudden infant death syndrome. New Zealand Cot Death Study Group.” BMJ . 307(6915): 1312

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Posted on August 6, 2011, in Current issues, Safety, Sleep and Crying. Bookmark the permalink. Leave a comment.

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