Opportunities to Address Safe Infant Sleep and Breastfeeding

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a cooperative surveillance system between the US Centers for Disease Control and Prevention (CDC) and state, territorial, and local health departments established in 1987 to monitor factors responsible for infant morbidity and mortality.¹ PRAMS utilizes a combination of telephone and mail surveys to collect information from mothers between 2 and 6 months after giving birth. States, territories, and local health departments have increased participation over the years, and some have worked with the CDC to add optional survey questions for targeted issues such as breastfeeding and safe sleep. The response rate is on average around 60%, and the CDC’s threshold for participation is 55%, accounting for 1000 to 3000 participants per year. PRAMS offers strengths and opportunities to inform policymakers, public health officials, researchers, and clinicians about ways to improve infant outcomes by decreasing maternal morbidity and mortality, conditions that continue to rise in the US and are affected by social drivers of health. PRAMS also provides essential data to potentially improve maternal behaviors associated with poor infant outcomes.² Improvements in methods of survey delivery and timeliness of data capture and analysis have been suggested as opportunities to improve this surveillance system in order to be more responsive to emerging public health concerns or public health interventions that benefit from more immediate analysis, such as inability to access prenatal and postpartum care during the COVID-19 outbreak. Furthermore, potential participants from underserved communities may be unaware of PRAMS and/or refuse completion of the survey due to mistrust and/or concerns related to confidentiality.³ A study by Decker et al, published in this issue of Pediatrics,⁴ utilized PRAMS data to inform the Pennsylvania Department of Health (PADOH) about the effectiveness of a statewide safe sleep intervention.

The PADOH implemented a hospital-based safe sleep initiative that bundled an updated policy; nursing staff education; parental education with posters, videos, and brochures; and modeling of safe infant sleep throughout the hospital stay and determined whether this initiative improved individual maternal behaviors postdischarge by utilizing the PRAMS survey. Given that PRAMS uses the birth certificate to identify potential participants, researchers were able to identify whether the mothers had delivered at one of the 27 intervention hospitals or, as a comparator, were delivered elsewhere. The exposure to the intervention was presumed if the hospital was one of the 27 hospitals in the program, although actual modeling or exposures to the education materials and curriculum were not tested. Four safe sleep practice questions were analyzed: placing the infant on their back to sleep vs side, stomach, or combination; always placing the infant on a separate approved sleep surface (such as a crib) vs often, sometimes, rarely, or never; placing their infant to sleep without soft bedding or objects such as toys or pillows; and usually placing infant alone in their crib in the same room as mother. The Core Question for 9th Phase of PRAMS (2022 to present) for the last item is, “In the past 2 weeks, was your baby’s crib or bed in the same room where you or another adult slept?” There is an additional question, “In the past 2 weeks, where have you placed your new baby to sleep at night or during naps?” with option of crib, bassinet, mattress or bed, couch or sofa, etc., but it does not appear that this question was used in the data analysis by Decker et al. Furthermore, the 8th Phase (used in years 2016-2022, and for this study) had different questions: “In the past 2 weeks, how often has your new baby slept alone in his or her own crib or bed?” (response options: Always, Often, Sometimes, Rarely, Never); if never, the following was to be answered: “When your new baby sleeps alone, is his or her crib or bed in the same room where you sleep?” (response options: Yes, No). It appears authors have combined responses to both of these questions to determine the composite room sharing without bedsharing.⁵ Although the American Academy of Pediatrics (AAP) recommends “room sharing without bed sharing,”⁶ there is no specific question in the PRAMS survey that asks about bedsharing; therefore, it is difficult to ascertain how mothers who either sometimes or routinely bedshared interpreted and responded to this set of questions.