Ethnicity, Breastfeeding & Sleep The Bradford Infant Care Study

1. Ethnicity, Breastfeeding & SleepThe 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

2. 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!!

3. 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

4. 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

5. 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.

6. 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!)

8. 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

9. 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.

10. 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.

11. 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

12. 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

13. Participants

14. Participants

15. Results *Model adjusted for maternal age, maternal education, parity, language proficiency and baby age at interview

16. Sleep-sharing by ethnicity

17. Sleep-sharing by breastfeeding status

18. Breastfeeding duration, ethnicity & ever bed sharing

19. Ever bed-share vs ever sofa-share

20. South Asian parents conformto 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

21. South Asian parents do notconform to SIDS reduction advice regarding: • Sleeping infants under duvets • Feet to foot position • Use of pillows • Swaddling • Bed-sharing • Pacifier at night .

22. 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

23. 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

24. 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?

25. 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

26. 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

27. Infant care practices, parental behaviours and cultural beliefs

28. 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?

29. the Wahakura program

30. 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 - Bed-sharers in UK differ from US, • Safe sleep messages should be based on local practices, not imported • Avoid blanket recommendations