Ethnicity, Breastfeeding & Sleep
The Bradford Infant Care Study
Janette Westman,
Midwife / Infant Feeding Specialist - Bradford Royal Infirmary
Helen Ball,
Professor of Anthropology / Director, Parent-Infant Sleep Lab,
Durham University
Acknowledgements
Research Team:
Dr Eduardo Moya - Consultant Paediatrician, Bradford Royal Infirmary
Prof. John Wright - Director of Research, Bradford Institute for Health
Research
Ms Lesley Fairley - Statistician, Bradford Institute for Health Research
Dr. Sam Oddie - Consultant Neonatologist, Bradford Royal Infirmary
BiB Research Team – telephone survey
FSID -- funding
Parents – answering questions!!
SIDS and infant care guidance
ICD-8 code 795 = SIDS
Unexpected infant death with
no explainable cause
How do you prevent it?
Case-control studies
Odds ratios and relative risks
Modifiable risk factors
Infant care
NZ 1990
Prone sleep, not breastfeeding, maternal smoking =
79% SIDS deaths
NZ 1991
1st Back to Sleep Campaign
NZ 1992
Bed-sharing added as risk factor
National case-control trials: UK, Ireland, Norway
Prone risk confirmed
Back-to-Sleep widely adopted throughout nineties
Dramatic reductions in SIDS rates
Ethnic variation in SIDS in UK
National SIDS data 1993-1998
immigrant mothers to the UK from ‘New Commonwealth’
countries (India, Pakistan, Bangladesh and Caribbean) SIDS rate
(0.37/1000 births) was 42% lower than that of mothers born in the
UK (0.64/1000 live births) (ONS 2000).
Bradford data also reflect a low rate of SIDS for South
Asian-origin infants in comparison to White British-origin
infants.
1996-2003 28 SIDS deaths reported for Bradford district
Rate = 0.5/1000 live births (national rate for England and Wales
over same period = 0.4/1000).
Rate for S. Asian-origin infants = 0.2/1000 live births,
Rate for White British-origin infants = 0.8/1000.
Born in Bradford (BiB)
Bradford district
Population 500,000; Birth rate around
5000/year
In inner city Bradford 40% of the
population is of Pakistani origin
Significant socio-economic deprivation
‘Born in Bradford’
Longitudinal cohort study of 13,000+
families
Recruitment commenced in Spring
2007
BiB lays the foundation for the most
thorough cohort study of health
outcomes in a multi-ethnic population
conducted in the UK
www.borninbradford.nhs.uk (from
where we have shamelessly
‘borrowed’ photos!)
BradICS Survey
Bradford Infant Care Study (BradICS) conducted at 2-4
months age Target cohort of 5000 infants from Born in
Bradford Project
Telephone questionnaire to families of infants reaching
8 weeks of age from September 2008 to January 2010.
Conducted by BiB researchers using appropriate
languages
Aimed to obtain data from 2500 families
Objectives
To describe and explore the
current variability in infant
care in the dominant ethnic
groups in Bradford.
Examine exposure to SIDS
risks in the South Asian and
White British families.
Use the above data to
identify areas for targeted
SIDS prevention.
SIDS-risk reduction guidance
Since 1990s infant sleep environment has
played a prominent role in SIDS reduction
advice
Infant sleep location (parental room);
Infant sleep position (supine);
Infant sleep surface (cot or crib
‘designed’ for infant use);
Infant position within cot (feet to foot);
Infant sleep environment (avoidance of
toys, pillows, duvets);
Moderate room temperature;
Breastfeeding;
Pacifier use for sleep;
Smoke free environment.
BradICS Survey
Questionnaire domains all
related to known SIDS risk
factors
Sleep position
Sleep surface
Sleep location
Pacifier use
Overheating
Cot/crib safety
Breastfeeding
Bed-sharing
Sofa-sharing
Smoking
Alcohol consumption
Example questions…
What surface does your baby normally sleep on?
Cot (large)
Crib, carry-cot, Moses basket, Pram (in which baby lies
flat)
Baby-seat, car seat, pushchair (in which baby cannot lie
flat)
Adult bed
Adult mattress on floor
Sofa/arm-chair
Floor
Mother’s body
Other
Participants
Characteristic
Maternal age <20 years
White British ethnicity
Single (never married)
Not living with partner
Annual Income after tax less than £9300
Parity 3+
Male baby
Low birthweight (<2500g)
Preterm (<37 weeks gestation)
Mother smoked during pregnancy or 3 months before
Mother drank alcohol in pregnancy or 3 months before
Mother used drugs in pregnancy or 3 months before
Completed
(N=2560)
n
%
134
5.2
968
37.8
655
25.6
345
13.5
420
16.4
350
13.7
1336
52.2
190
7.4
121
4.7
462
18.0
Not completed
(N=774)
n
%
82
10.6
333
43.0
293
37.9
171
22.1
183
23.6
90
11.6
369
47.7
52
6.7
43
5.6
194
25.1
p-value
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.16
0.03
0.51
0.35
<0.0001
801
31.3
261
33.7
0.34
20
0.8
18
2.3
<0.0001
Participants
White British
(N=922)
All
Characteristic
n
%
n
%
Pakistani
(N=1143)
n
%
Indian
(N=100)
n
%
Bangladeshi
(N=59)
n
%
Mother’s education
None
School
Further and higher
Other
Mother’s age
<20 years
20-24 years
25-29 years
30-34 years
35+ years
Parity
0
1
2
3+
<0.0001
314
715
925
270
14.1
32.2
41.6
12.1
91
323
354
154
9.9
35.0
38.4
16.7
213
358
481
91
18.6
31.3
42.1
8.0
5
18
61
16
5.0
18.0
61.0
16.0
5
16
29
9
8.5
27.1
49.2
15.3
<0.0001
116
572
769
486
281
5.2
25.7
34.6
21.9
12.6
89
241
287
173
132
9.7
26.1
31.1
18.8
14.3
26
301
425
263
128
2.3
26.3
37.2
23.0
11.2
0
15
37
33
15
15.0
37.0
33.0
15.0
1
15
20
17
6
1.7
25.4
33.9
28.8
10.2
<0.0001
877
656
375
316
39.4
29.5
16.9
14.2
451
289
107
75
48.9
31.3
11.6
8.1
361
315
241
226
31.6
27.6
21.1
19.8
47
36
10
7
47.0
36.0
10.0
7.0
18
16
17
8
30.5
27.1
28.8
13.6
Language at baseline
English
Non- English
p-value*
<0.0001
1820
404
81.8
18.2
922
0
100.0
753
390
65.9
34.1
86
14
86.0
14.0
59
0
10.00
Results
Pakistani
Unadjusted
OR
95%CI
Adjusted*
OR
95%CI
Sleeping environment
Baby sleeps in room on own
Baby sleeps in adult bed
Baby sleep under duvet
Baby sleeps in infant sleeping bag
0.06
12.71
3.82
0.17
(0.04, 0.09)
(4.60, 35.11)
(2.92, 4.98)
(0.13, 0.21)
0.05
8.48
3.24
0.20
(0.03, 0.09)
(2.92, 24.63)
(2.39, 4.40)
(0.16, 0.26)
Co-sleeping
Baby ever bed shared with mother
Baby regularly bed shares with mother
Baby ever sofa shared
Baby swaddled in bed
2.07
3.85
0.24
3.76
(1.60, 2.68)
(2.51, 5.90)
(0.17, 0.33)
(1.10, 12.79)
2.13
3.57
0.22
5.65
(1.59, 2.86)
(2.23, 5.72)
(0.15, 0.34)
(1.54, 20.81)
Breastfeeding and pacifier use
Baby ever breastfed
Baby breastfed for 8 weeks or more
Pacifier used at all at night
1.77
1.94
0.40
(1.46, 2.14)
(1.60, 2.34)
(0.33, 0.48)
2.00
1.65
0.40
(1.58, 2.53)
(1.31, 2.07)
(0.33, 0.50)
Lifestyle
Mother currently smokes
0.07
(0.05, 0.12)
0.07
(0.04, 0.12)
*Model adjusted for maternal age, maternal education, parity, language proficiency and baby age at interview
Sleep-sharing by ethnicity
Sleep-sharing by breastfeeding
status
Breastfeeding duration, ethnicity &
ever bed sharing
Ever bed-share vs ever sofa-share
Results from multivariable logistic regression analyses for ever bed sharing
Adjusted
Variable
Category
OR
95% CI
Ethnic group
White British
1
Pakistani
2.09 (1.47, 2.97)
Breast feeding
Never & <1 week
1
1-8 weeks
1.40 (0.97, 2.03)
8 weeks or more
3.17 (2.34, 4.30)
Results from multivariable logistic regression analyses for ever sofa sharing
Adjusted
Variable
Category
OR
95% CI
Ethnic group
White British
1
Pakistani
0.21 (0.14, 0.31)
Marital and cohabitation status
Married and living with
1
partner
Not married and living
0.82 (0.54, 1.23)
with partner
Not living with partner
0.50 (0.29, 0.87)
Mother currently smokes
No
1
Yes
1.79 (1.14, 2.80)
Breast feeding
Never & <1 week
1
1-8 weeks
1.56 (1.04, 2.35)
8 weeks or more
1.76 (1.19, 2.58)
South Asian parents conform
to SIDS reduction advice regarding:
Avoidance of prone
sleep
Keeping infants in the
same room
Avoidance of alcohol
Maternal smoking
Sofa sharing
Implementation and
continuation of
breastfeeding
South Asian parents do not
conform to SIDS reduction advice
regarding:
Sleeping infants under
duvets
Feet to foot position
Use of pillows
Swaddling
Bed-sharing
Pacifier at night
In contrast White British
parents conform with SIDS
reduction advice regarding:
Avoidance of prone
sleep
Sleeping infants under
duvets
The use of pillows
Pacifier at night
White British parents do not
conform with SIDS reduction
advice regarding:
Maternal smoking
Keeping infants in the
same room
Initiating or continuing
breastfeeding
Avoiding sleeping with
infants on a sofa
Avoiding parental alcohol
consumption
And yet …
In Bradford Infants of South Asian
origin have a SIDS rate which is FOUR
times lower than babies of White
British origin
Why is that?
Conform with guidance
South Asian families
Keeping infants in the
same room
Avoidance of alcohol
Maternal smoking
Sofa sharing
Implementation and
continuation of
breastfeeding
White British families
Sleeping infants under
duvets
The use of pillows
Pacifier at night
not conforming to guidance
South Asian families
Sleeping infants
under duvets
Feet to foot position
Use of pillows
Swaddling
Bed-sharing
Pacifier at night
White British families
Keeping infants in the
same room
Maternal smoking
Initiating or continuing
breastfeeding
Avoiding sleeping with
infants on a sofa
Avoiding parental
alcohol consumption
Infant care practices, parental
behaviours and cultural
beliefs
How modifiable are
‘Modifiable SIDS Risk Factors’?
Infant care practices:
Sleep position
Sleep surface
Sleep location
Pacifier use
Overheating
Cot/crib safety
Parental behaviours
Breastfeeding
Bed-sharing
Sofa-sharing
Smoking
Alcohol consumption
Cultural Beliefs
How do we address different levels of engagement with risk
reduction and different types of behaviour?
the Wahakura program
A final thought ….
When writing policies we need to allow for
cultural beliefs and behavioural variations
Culturally targeted campaigns are important
Be creative with interventions
Cautious transfer of recommendations - Bedsharers in UK differ from US,
Safe sleep messages should be based on local
practices, not imported
Avoid blanket recommendations