Results

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).

Discussion

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.