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Maternity advice survey: sleeping position in Eastern Europe


AIM To identify hospitals in Eastern Europe promoting front infant sleeping position.

METHODS Questionnaires were distributed to maternity units in 22 countries during July to November 1999.

RESULTS A total of 489 hospitals in 20 countries responded. Preferred position in normal care units was back (26.6%), front (1.8%), side (65%), or combination/none (6.6%). Corresponding recommendations at discharge were 17.4%, 3.5%, 73%, and 6.1%.

  • sleeping position
  • questionnaire
  • maternity unit
  • sudden infant death syndrome

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Modification of front (prone) sleep position, a causal sudden infant death syndrome (SIDS) risk factor, represents a cost effective public health intervention. A number of child care practices (prone sleep position, soft underbedding, heavy dressing, bed sharing, and lack of breast feeding) have been associated with increased SIDS risk.1 ,2 The International Child Care Practices Study (ICCPS) collected information on child care practices associated with SIDS risk from 21 centres in 17 countries.3 One participating centre (Buenos Aires, Argentina) noted a relatively high rate of prone sleeping in the study population together with a significant incidence of SIDS in the community. With WHO regional office support, a successful “Link” programme between New Zealand and Argentina was launched to raise SIDS awareness and advise “boca arriba” (face up).4 The programme highlighted the potential for similar cost–effect interventions in other countries where SIDS may be an unrecognised but significant problem. In April 1998 representatives of SIDS International, the SIDS Global Strategy Task Force, and WHO proposed that a Maternity Advice Survey be initiated to determine what infant sleep position advice is given to mothers in maternity units. It was hypothesised that in countries where hospitals promote prone sleep position, there may be high rates of SIDS that are currently unrecognised.


The collaborative network of WHO in Eastern Europe (CCEE/NIS) identified 22 country coordinators, officially nominated by ministries of health. Details of all maternity units were collected and questionnaires were either posted to directors of obstetrics or paediatrics, administered by telephone, or collected personally during July to November 1999. Although it was recommended that maternity units with more than 1000 births be surveyed, responses were also received from smaller units. Units withmore than 200 annual births were included in the final analysis. Completed responses were received from 489 hospitals in 20 countries. The study instrument, in English and Russian, focused on advice given on infant sleep position and included pictures for clarity. Information was also sought on other advice given (breast feeding, smoking, immunisations, alcohol, drugs) and other child care practices (rooming in, bedding, clothing, pacifiers). Questionnaires were collated by WHO and data entry and statistical analysis was undertaken with Epiinfo software (Version 6.04c, Center for Disease Control, Atlanta, Georgia, USA).


Table 1 presents demographic details for the 20 participating countries. The 489 hospitals surveyed catered for more than a million births annually. Respondents were asked how babies were placed for sleep in both normal care and special care units. For each of the three possible sleep positions—back, front, and side—the acceptable codes were always, usually, sometimes, and never. A range of permutations were thus possible. Table 1 details some of this information. In normal care units the preferred sleep position was back (26.6%), front (1.8%), side (65%), and a combination (6.6%). Corresponding figures for special care units were 31.1%, 2.3%, 55.7%, and 10.9%. Table 2compares sleep position advice in normal care units to advice at discharge. A response that a particular position was “never” or “always” used may indicate a higher or lower level of SIDS risk awareness (table 3). Written information on sleep position was available to 23% of parents; 11% of hospitals had a written policy. Centres with either written information or policy were more like to place infants on the side (75% versus 68%) or front (4% versus 1%) than on the back (21% versus 31%) in normal care units (χ2 = 8, p = 0.018).

Table 1

Participating countries from WHO in Eastern Europe (CCEE/NIS) region showing demographic information (1999 World Health Report) and usual sleep position in normal care units, and recommended advice given on sleep position on discharge

Table 2

Relation between preferred sleep position in normal care units with the sleep position recommendations made at discharge from 489 hospitals in 20 countries in Eastern Europe

Table 3

Sleep position that was “always” and “never” recommended in normal and special care units as an indicator of SIDS awareness in 489 hospitals in 20 countries in Eastern Europe


Public health campaigns advising parents not to place their infants in the prone sleep position have resulted in dramatic reductions in SIDS mortality rates of 50% or greater. A parent's decision on how to place the infant to sleep will depend on a number of factors including peer norms and advice received from health professionals. Initial advice given to mothers by nursing staff in the maternity hospitals is anticipated to influence actual infant sleep practices.

The results of this survey were partly reassuring in that few hospitals were preferentially placing infants in the prone position (1.8%), and relatively few (3.5%) were recommending prone sleeping at discharge from hospital. However, the majority of hospitals placed infants on the side (65%) and also recommended this position at discharge (73%). Hospitals that “never place infants on the back” may represent a marker for low awareness of SIDS risk. Earlier education campaigns to “reduce the risks of SIDS” advised back or side sleep position. Subsequent studies have shown that the side sleep position is also a risk factor for SIDS. The American Academy of Pediatrics Task Force on Infant Positioning and SIDS published a consensus statement advising against side sleep position, and a subsequent meta-analysis reached a similar conclusion.5 Despite these recommendations hospital staff are still reluctant to advise that a newborn infant be placed on the back to sleep for fear that the infant may vomit and aspirate. Comments on questionnaires indicated that this was also a concern for hospitals in Eastern Europe. Although the United Kingdom's “back to sleep” campaign has not resulted in increased complications such as aspiration,6 more information is needed to convince hospital staff that it is completely safe to place infants supine immediately after birth.

Although relatively few hospitals in the survey promoted the prone sleep position, most favoured the side position. This is also a SIDS risk factor albeit with smaller relative risk. No information was obtained on SIDS rates in the participating countries. It should also be noted that recommendation may not imply actual practice. Participating countries should consider collecting information of actual sleep position used by infants after discharge from hospital, together with data on unexpected infant deaths within the communities. The development and evaluation of an appropriate health promotion programme encouraging back sleeping in hospitals, on discharge and at home to reduce infant mortality, should be investigated.


MAS Study Group Members for WHO EURO region: Dr Nedime Ceka,Tirana, Albania; Dr Pavlik Mazmanian, Yerevan, Armenia; Dr Zinaida Sevkovskaya, Minsk, Belarus; Dr Naila Beganovic, Sarajevo, Bosnia and Herzegovina; Dr Pavao Dzeba, Banja Luka Republic Srpska, Bosnia, and Herzegovina; Dr Ervin Saik, Tallinn, Estonia; Dr Maya Kherkheulidze, Tbilisi, Georgia; Dr Antal Czinner, Hungary; Dr Anara Turginbaeva, Almaty, Kazakhstan; Dr Ilze Kreicberga, Riga, Latvia; Dr Jurgis Bojarskas, Kaunas, Lithuania; Dr Elizabeta Zisovska, Skopje, Macedonia, Former Yugoslavia Republic; Dr Ekaterina Stasii, Chisinau, Republic of Moldova; Dr Dragos Pradescu, Bucharest, Romania; Dr Tatiana Dinekina, Murmansk, Russian Federation; Dr Milan Kuchta, Kosice, Slovak Republic; Dr Lev Bregant, Ljubljana, Slovenia; Dr Olga Ataeva, Ashgabat, Turkmenistan; Dr Zinaida Shatova, Kiev, Ukraine; Dr Uktam Djalilov, Tashkent, Uzbekistan. Dorothy Ford provided details and questionnaires used for a “Midwifery and antenatal practice survey: reducing the risks of SIDS” conducted in Melbourne, Australia (Ford D, Quayle C, Middleton C. The next phase: establishing the reducing the risk of SIDS child care practices into routine parent education. 5th SIDS International Conference, Rouen, 1998). The Norwegian SIDS Society provided some financial support. Kaarene Fitzgerald, Chairman, SIDS Global Strategy Task Force gave helpful comments and advice.


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