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Keywords:

  • health knowledge;
  • attitudes practice

Abstract

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim:  This study assessed levels of maternal knowledge of sudden infant death syndrome prevention strategies in a socio-economically disadvantaged, culturally diverse population.

Methods:  Pregnant women (n = 233) were asked to name three things they could do to reduce the risk of cot death. Answers were marked in accordance with the US National Institute of Child Health and Development guide-lines.

Results:  Of women 51.5% could correctly name two or more strategies that could reduce the risk of sudden infant death syndrome. There was significant difference by the woman’s country of birth: 68.2% of Australian-born women were able to correctly identify two or more strategies, compared with only 37.3% of those born overseas (P < 0.001). Most of the small number of Indigenous women included in the study were able to correctly identify two or more strategies. Year of arrival in Australia, number of previous children, age and level of education were not significantly related to women’s knowledge.

Conclusion:  Knowledge of sudden infant death syndrome prevention strategies was poorer in overseas-born women. Practitioners working with disadvantaged, overseas-born women should give consideration to women’s knowledge of sudden infant death syndrome prevention if current low rates of sudden infant death syndrome deaths are to be maintained.

In Australia the incidence of sudden infant death syndrome (SIDS) has reduced from 2.04 deaths per 1000 live births in the decade 1981–1990, to 0.84 deaths per 1000 live births in the decade 1991–2000. These reductions are attributed to the success of parent education campaigns promoting back-positioning conducted during the 1990s.1,2 It should not be assumed that these benefits will be maintained without continuing support and education of families to know about and engage in safe sleeping practices.3

International research has indicated that uptake of evidence-based strategies to reduce the risk of SIDS is related to socio-economic status with slow adoption among disadvantaged families.4–6 There is also evidence of racial disparities in SIDS risk reduction behaviours, with minority groups more likely to practise the prone-sleeping position.3,7–10 These socio-economic and racial differentials in SIDS risk reduction behaviour are reflected in higher child mortality, particularly from SIDS, among families living in neighbourhoods with greater socio-economic disadvantage.11 In Australia, the rate of SIDS has been reported to be higher in Indigenous children.2 The link between behaviour and risk is not always clear however. For example, in Australia the rate of SIDS is lower in the children of women born in Asia or Southern Europe,12 despite the fact that these children have been shown to be more likely to be kept inappropriately warm.13

Nevertheless, knowledge of SIDS risk reduction strategies, particularly in pregnant women, may be important for maintaining the low rates of SIDS in the population. There is evidence that once a child begins prone sleeping is it difficult to change that practice.8 Further, supine sleeping is associated with knowledge of the relationship between supine sleeping and reduced risk of SIDS.9,14,15

There is limited Australian evidence on the knowledge of SIDS prevention in pregnant women from lower socio-economic or culturally diverse families. Douglas et al. have reported poorer knowledge about SIDS in Indigenous mothers in North Queensland when compared with the knowledge of Caucasian mothers.16 Overall, 80.6% of women in Douglas’ sample of women with young children were able to list at least one recommendation to reduce the risk of SIDS, with 58.4% of Caucasian women able to list two or more recommendations. This work, however, did not note whether the Caucasian women were Australian- or overseas-born. A qualitative study has reported a lack of knowledge of SIDS in Thai-born women prior to their arrival in Australia.17

South-western Sydney is a region characterised by areas of disadvantage and a high proportion of overseas-born residents from non-English-speaking countries, and poor child and family outcomes, including poorer self-reported health.18 A randomised controlled trial of sustained early childhood nurse home visiting is currently being undertaken in a disadvantaged, culturally diverse community within the region. Within this programme there was an opportunity to ask: What factors are associated with SIDS knowledge among pregnant women from lower socio-economic and culturally diverse families?

Key Points

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Knowledge of SIDS prevention strategies is poor in overseas-born women.
  • 2
    Attention to women’s SIDS knowledge is needed to maintain the low incidence of SIDS deaths.
  • 3
    Practitioners should explore SIDS knowledge of their overseas-born and vulnerable clients.

Methods

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The study group consisted of vulnerable pregnant women resident in a disadvantaged community in south-western Sydney, who booked into the local hospital in the period February–October 2003 and March–December 2004 for future confinement. Vulnerability was determined during an interview conducted by midwives at the time the women booked in (average 18 weeks gestation). Women reporting the presence of any one of the following risk factors were eligible for inclusion in the study (n = 540 of a total population of 1058): under 19 years of age, did not attend the antenatal clinic until after 20 weeks gestation, lack of support, had experienced a major stressor in the past 12 months, were at risk of depression or low self-esteem, had a history of mental health problems, had experienced abuse in their own childhood, experienced domestic violence, or current substance misuse.

Vulnerable pregnant women were recruited to this study during the second or third trimester of pregnancy (average 25 weeks gestation). To be eligible, the women required English language skills sufficient to be able to complete a simple English-language questionnaire without the aid of an interpreter (135 of the 540 women had insufficient English language skills). More than half (233 of the 405 eligible pregnant women, 57.5%) consented to participate.

Prior to commencing participation in the larger randomised controlled trial, women were interviewed by the research assistant in their own homes. All interviews were conducted in English. Country of birth, year of arrival in Australia (for overseas-born women), educational level, maternal age and parity data were collected. SIDS knowledge was assessed by asking women the open-ended question: ‘Can you tell me three things you can do to reduce the risk of cot death?’ The women’s statements were noted. No prompting or guidance was provided by the research assistant. This method has the advantage of garnering knowledge without providing any false information to the women. Open-ended questioning to assessing maternal knowledge of SIDS prevention strategies has been used in two previous Australian studies,16,19 with this particular question being used by Armstrong et al.19 Subsequently, the number of answers that were in accordance with the National Institute of Child Health and Human Development were recorded.20 Correct answers included:

  • • 
    Place baby on back to sleep, for example, ‘sleep on back’. ‘Sleep on side’ was not marked as a correct answer, as was ‘don’t put baby on tummy’, unless the mother also indicated that that meant placing the child on their back rather than their side
  • • 
    Place your baby on a firm mattress, such as in a safety-approved cot, for example, ‘have Australian standards cot’
  • • 
    Remove soft, fluffy and loose bedding and stuffed toys from your baby’s sleep area, for example, ‘no toys in the cot’
  • • 
    Make sure your baby’s face and head stay uncovered during sleep, for example, ‘tuck baby in at the bottom of the cot’
  • • 
    Do not allow smoking around your baby, for example, ‘always smoke outside’
  • • 
    Don’t let your baby get too warm during sleep, for example, ‘not too many blankets’

Scores ranged from 0 (could not name any correct strategies) to 3 (could name three correct strategies). For the purpose of analysis, the results were dichotomised into those who could name two or more correct strategies, and those who could name less than two correct (one or none). This dichotomy was chosen to represent those women who had a more comprehensive knowledge (i.e. knowledge of more than one strategy) versus those with more limited knowledge (i.e. knowledge of one or fewer strategies). Univariate analyses (χ2 and t-test) were used to explore factors related to differences in SIDS knowledge.

Results

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The average age of participants was 27.5 years (standard deviation 6.15). More than one-third (37.3%) were expecting their first child, 33.7% were expecting their second child and 29.0% were expecting their third or subsequent child. More than half of the interviewed women (n = 126, 54.1%) were born overseas, with 116 being from non-English-speaking countries. Consenting women did not differ from non-consenting women in their age, parity, or whether they were overseas- or Australian-born.

Of the 233 pregnant women interviewed, 75.5% could name at least one strategy that could reduce the risk of SIDS and 51.5% could correctly name two or more. One quarter (n = 57, 24.5%) of all women could not correctly name any risk minimising strategy. Overall, there were no significant differences in the number of strategies named by women of differing age, parity or educational level. There were, however, significant differences by the woman’s country of birth, with 68.2% of women born in Australia able to correctly name two or more strategies, compared with 37.3% of those born overseas (P < 0.001; Table 1). Three quarters (73.7%) of women who could not correctly name any strategies were born overseas. Pregnant women from 11 of the 14 households in which a member was of Aboriginal or Torres Strait Islander descent were able to correctly name two or more strategies.

Table 1.  Number of correctly named sudden infant death syndrome risk prevention strategies by characteristics of overseas-born and Australian-born women
 Overseas-born women n (%)Australian-born women n (%)P-value (χ2)
Less than two strategiesTwo or more strategiesLess than two strategiesTwo or more strategies
  • Overseas-born women;

  • ‡Australian-born women.

Overall79 (62.7)47 (37.3)34 (31.8)73 (68.2)<0.001 (inline image = 22.2)
Year of arrival in Australia    0.12 (inline image = 2.6)
 Prior to 199123 (53.5)20 (46.5)   
 Since 199148 (68.6)22 (31.4)   
Parity    0.46 (inline image = 0.6)†; 0.82 (inline image = 0.1)
 First child34 (66.7)17 (33.3) 9 (27.3)24 (72.7) 
 Subsequent child43 (59.7)29 (40.3)21 (30.4)48 (69.6) 
Level of education    0.12 (inline image = 4.3)†; 0.10 (inline image = 4.7)
 School only36 (67.9)17 (32.1)18 (32.1)38 (67.9) 
 Vocational 9 (42.9)12 (57.1) 9 (34.6)17 (65.4) 
 Professional25 (65.8)13 (34.2) 0 (0.0)10 (100.0) 

For women born overseas, knowledge of SIDS prevention strategies was equally lacking regardless of how long the women had been in Australia. Of those who had moved to Australia prior to 1991, 53.5% were unable to correctly identify two strategies with 68.6% of those who migrated since 1991 also unable to identify two correct strategies (P = 0.12; Table 1).

It may be reasonable to suppose that pregnant women who had had previous children would have had greater exposure to SIDS prevention messages. The proportion of overseas-born women or Australian-born women who could, or could not, correctly name two or more strategies, however, did not differ significantly by whether they had had previous children (overseas-born women P = 0.46; Australian-born P = 0.82; Table 1).

Overseas-born women with vocational level of education had a level of knowledge similar to vocationally trained Australian-born women (overseas-born 57.1% women two or more correct, Australian-born 65.4%; P = 0.76). However, knowledge of SIDS prevention strategies was not significantly related overall to level of education for either the Australian- or overseas-born group (overseas-born women P = 0.12; Australian-born P = 0.10; Table 1). Knowledge of SIDS prevention strategies was also not significantly related to maternal age for either the Australian-born or overseas-born groups.

Both Australian- and overseas-born women who could not correctly name three strategies included a diverse range of suggested behaviours that were not in accordance with the National Institute of Child Health and Human Development guide-lines. Commonly mentioned was heightened monitoring of the child, including frequent checking (e.g. ‘check every half hour’), using baby monitors and keeping child within sight at all times. Other suggestions related to infant feeding such as burping the baby or not putting baby to bed immediately following feeding. Other women suggested behaviours directly contrary to the recommendations including ensuring child is kept warm (e.g. ‘put baby in sleeping bag and cover with blankets’) and putting baby to sleep on their stomach or their side.

Discussion

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Although there is no national benchmark for SIDS knowledge, overall the women in this study had levels of knowledge of SIDS risk reduction strategies that were comparable to the women in Douglas et al.’s study in Northern Queensland.16 In contrast with previous international and Australian evidence, knowledge of SIDS prevention strategies was highest among the small number of households where a member was of Aboriginal or Torres Strait Islander descent. Nevertheless, the inability of a large proportion of overseas-born mothers in this disadvantaged community to correctly name two or more SIDS prevention strategies is concerning.

This study is not able to tell us whether there is an increased or decreased rate of SIDS for children of Australian-born or overseas-born women or whether the SIDS rate in these population groups is related to maternal level of knowledge of SIDS risk reduction strategies. This study does, however, provide some information on levels of SIDS knowledge among Australian-born and immigrant women in a disadvantaged community, and raises questions about SIDS prevention strategies that need to be explored further in other studies.

Although knowledge of SIDS prevention strategies was higher for Australian-born women in this study, the proportional, although non-significant, difference in knowledge between those with a tertiary education and those with school or vocational education suggests the need for further exploration of the adoption of SIDS messages by women with lower educational levels.

National community education campaigns were conducted in 1991 and again in 1997 and 2002; however, knowledge of SIDS prevention strategies was not significantly better for overseas-born women who were in Australia during these campaigns. Similarly, overseas-born women who had had previous children (most of whom were born since mother arrived in Australia) were no more likely to have knowledge of SIDS prevention strategies than those pregnant with their first child, nor was SIDS knowledge related to level of education or maternal age. These results indicate that the adequacy of the current methods of presenting SIDS risk reduction messages to overseas-born women requires exploration, particularly as this sample of overseas-born women had sufficient English language skills to not require an interpreter.

It is recognised that there can be a disjunction between knowledge and behaviours: lack of ability to name SIDS prevention strategies does not necessarily mean that these mothers will be putting their babies to sleep unsafely. In fact, as suggested by Rice and Naksook,17 there may be many protective behaviours within migrant communities that require further investigation. Nevertheless, practitioners working with vulnerable pregnant women and young families should give particular consideration to their overseas-born clients’ knowledge of SIDS prevention strategies in order to ensure that our current low rate of SIDS deaths is maintained.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The home visiting trial is funded by the Australian Research Council, NSW Health, NSW Department of Community Services and Sydney South West Area Health Service. The authors thank research assistants Astrid Toscan and Henna Aslam (both from the University of New South Wales) and the staff and families who have made this study possible.

References

  1. Top of page
  2. Abstract
  3. Key Points
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Dwyer T, Ponsonby AL, Blizzard L, Newman NM, Cochrane JA. The contribution of changes in the prevalence of prone sleeping position to the decline in sudden infant death syndrome in Tasmania [See comment]. JAMA 1995; 273: 7839.
  • 2
    Sids and kids. SIDS information paper August 2003. National SIDS Council of Australia, 2003.
  • 3
    Willinger M, Ko C-W, Hoffman HJ, Kessler RC, Corwin MJ. Factors associated with caregivers’ choice of infant sleep position, 1994–1998. The National Infant Sleep Position study. JAMA 2000; 293: 213542.
  • 4
    Paterson J, Tukuitonga C, Butler S, Williams M. Awareness of sudden infant death syndrome risk factors among mothers of Pacific infants in New Zealand. N. Z. Med. J. 2002; 115: 335.
  • 5
    Chung EK, Hung YY, Marchi K, Chavez GF, Braveman P. Infant sleep position: associated maternal and infant factors. Ambul. Pediatr. 2003; 3: 2349.
  • 6
    Corwin MJ, Lesko SM, Heeren T et al. Secular changes in sleep position during infancy: 1995–1998. Pediatrics 2003; 111: 5260.
  • 7
    Schlaud M, Eberhard C, Trumann B et al. Prevalence and determinants of prone sleeping position in infants: results from two cross-sectional studies on risk factors for SIDS in Germany. Am. J. Epidemiol. 1999; 150: 517.
  • 8
    Ottolini MC, Davis BE, Patel K, Sachs HC, Gershon NB, Moon RY. Prone infant sleeping despite the ‘Back to Sleep’ campaign. Arch. Pediatr. Adolesc. Med. 1999; 153: 51217.
  • 9
    Brenner RA, Simons-Morton BG, Bhaskar B et al. Prevalence and predictors of the prone sleep position among inner-city infants. JAMA 1998; 280: 3416.
  • 10
    Rasinski KA, Kuby A, Bzdusek SA, Silvestri JM, Weese-Mayer DE. Effect of a sudden infant death syndrome risk reduction education program on risk factor compliance and information sources in primarily black urban communities. Pediatrics 2003; 111: 34754.
  • 11
    Blakely T, Atkinson J, Kiro C, Blaiklock A, D’Souza A. Child mortality, socioeconomic position, and one-parent families: independent associations and variation by age and cause of death. Int. J. Epidemiol. 2003; 32: 41018.
  • 12
    Potter A, Lumley J, Watson L. The ‘new’ risk factors for SIDS: is there an association with the ethnic and place of birth differences in incidence in Victoria, Australia? Early Hum. Dev. 1996; 45: 11931.
  • 13
    Watson L, Potter A, Gallucci R, Lumley J. Is baby too warm? The use of infant clothing, bedding and home heating in Victoria, Australia. Early Hum. Dev. 1998; 51: 93107.
  • 14
    Moon RY, Omron R. Determinants of infant sleep position in an urban population. Clin. Pediatr. 2002; 41: 56973.
  • 15
    Moon RY, Oden RP, Grady KC. Back to Sleep: an educational intervention with women, infants, and children program clients. Pediatrics 2004; 113: 5427.
  • 16
    Douglas TA, Buettner PG, Whitehall J. Maternal awareness of sudden infant death syndrome in North Queensland, Australia: an analysis of infant care practices. J. Paediatr. Child Health 2001; 37: 4415.
  • 17
    Rice PL, Naksook C. Child rearing and cultural beliefs and practices amongst Thai mothers in Victoria, Australia: implications for the sudden infant death syndrome. J. Paediatr. Child Health 1998; 34: 3204.
  • 18
    Chavez R, Kemp L, Harris E. The social capital: health relationship in two disadvantaged neighbourhoods. J. Health Serv. Res. Policy 2004; 9 (Suppl. 2): 2934.
  • 19
    Armstrong KL, Fraser JA, Dadds MR, Morris J. A randomized, controlled trial of nurse home visiting to vulnerable families with newborns. J. Paediatr. Child Health 1999; 35: 23744.
  • 20
    National Institute of Child Health and Human Development (NICHD). Safe Sleep for Your Baby: Reduce the Risk of Sudden Infant Death Syndrome. Bethesda, MD: National Institutes of Health, 2003.