Challenging Dogma - Fall 2011

Wednesday, December 28, 2011

Milwaukee Campaign Against Sleeping with Baby – Natasha Neal

Infant Mortality in Milwaukee, Wisconsin
Milwaukee, Wisconsin has higher rates of infant mortality in comparison to other areas of the United States and other parts of the world. Infant mortality is the number of infants that die during their first year of life (1). Milwaukee’s African-American infant mortality rate is ranked higher than at least 35 other countries, including some developing countries (2). The top four reasons for infant death in Milwaukee are complications of prematurity; congenital abnormalities and related complications; sudden infant death syndrome (SIDS), overlay, and accidental suffocation; and infections (2). In particular, Wisconsin is a state with one of the largest differences in infant mortality based on race. The gap between non-Hispanic white infants and African-American infants is quite large: for every five white infants that die prematurely, 14 African-American babies die (1). Based on the list of most common deaths in infants, the only cause that is preventable after birth is SIDS, overlay, and accidental suffocation.

In order to address the dismal situation, the City of Milwaukee’s Health Department created a Safe Sleep Awareness Campaign, in which they discourage the practice of co-sleeping, and more specifically, babies and adults sharing the same bed (3). They have used posters, as well as radio and television advertisements to get their point across to the public. To view the public health campaign advertisements, visit (3). The public has perceived these advertisements with mixed views as they depict a small baby sleeping in a bed next to a large knife. The poster states: “Your baby sleeping with you can be just as dangerous.” Some responses have been supportive towards catching parents’ attention on an important matter; however, others feel that the City of Milwaukee is demonizing parents. These posters were created with the intention of grabbing the attention of parents that may bed-share. It is very unlikely that parents that co-sleep are consciously putting their babies in harm’s way, explaining the negative reactions of some parents.

Problems with Milwaukee’s Campaign Against Co-Sleeping

Despite correctly identifying the large racial disparity in infant mortality, Milwaukee’s campaign is unlikely to be successful in closing this gap. The Health Department has chosen to focus on a much narrower health behavior in the hopes that it will significantly reduce the rates of infant mortality. The advertisements used in the campaign overlook four important social behavioral models: Labeling Theory, Optimism Bias, the Law of Small Numbers, and Psychological Reactance. Furthermore, The City of Milwaukee’s Health Department has done a poor job of approaching such a controversial, and poorly understood health behavior.

The Health Department has been quick to pinpoint bed-sharing as the form of unsafe sleeping practice that results in sudden infant death syndrome (SIDS) or sudden unexpected death in infancy (SUDI). However, based on a study released in 2011, the major risk factors for SIDS also include inadequate prenatal care, low birth weight, premature birth, short interval between births, and maternal substance abuse (4). It becomes clear that many of these factors are uncontrollable, and are often completely independent from whether an infant sleeps in the same bed as an adult or not, except for maternal substance abuse. Therefore, even infants that sleep in their own bassinet or crib are at risk of SIDS. In some unfortunate cases, despite parents following the safest child-rearing practices, an infant will still experience SIDS. In combination with the disparity in infant mortality between races, it encourages one to question whether an ethnic community in particular is engaging or has a history of increased risk factors, in addition to bed-sharing. It is important to examine the situation in relation to different races as one of the goals is to narrow the gap between infant mortality rates in Milwaukee.

Data included in the City of Milwaukee’s Fetal Infant Mortality Review (FIMR) also does not concretely support their view on targeting co-sleeping. The FIMR stated that Singapore had the lowest infant mortality rates, despite approximately 70% of the population engaging in bed-sharing, showing that bed-sharing can be practiced safely (5). Armed with this knowledge, one must ask what specifically, during bed-sharing, is the cause for increased infant mortality in the United States versus Singapore. Research has been conducted on this point, and it has been found that there are often other factors playing a role. For instance, the risk of infant death during bed-sharing often occurs if a parent also engages in smoking or alcohol abuse (6). In addition to this, in other countries where bed-sharing is the predominant form of sleep practice, it is important to be aware that in these countries, families often sleep on firm mats instead of softer mattresses (7). Therefore, it is a combination of the risks mentioned previously, including premature birth and maternal substance use, combined with bed-sharing, that can increase the risk of infant death.

Another critical consideration of this intervention is the message that public health officials want to send. Research has shown that the risk of SIDS increases when babies sleep in a different room from parents (8). Despite this known fact, the advertisements do not include information indicating that although bed-sharing should not occur, room-sharing is important to the health of infants. The advertisements, while depicting the dangers of bed-sharing, contain little information on how to mitigate the risks. This information only appears on the website, and yet there is no guarantee that parents will spend the time going to the website. All information must easily reach parents in order for individuals to make educated decisions. The City of Milwaukee also ignores the positives that have been identified in literature regarding bed-sharing. These positive elements include making breastfeeding easier, allowing babies and parents to get more sleep, ensuring mothers are more responsive to the needs of the infant, and the practice encourages bonding and security between parent and infant (7). By purposely omitting this information, the public may feel as though the City of Milwaukee’s Health Department is trying to deceive or manipulate their behavior. This may be especially likely to occur in parents that are well-versed in the sleeping practices of other non-Western cultures.

Due to the vast majority and somewhat contradictory information available in regards to bed-sharing and co-sleeping, it becomes apparent that education must be the first step to behavior change. Parents are unaware of the pros and cons of different sleep practices. As well, many parents are misinformed about the definition of co-sleeping; some believe that co-sleeping is defined specifically as the practice of sharing the same bed with a baby; however, this is not true (3). Having a baby sleep in a bassinet or crib next to the parents’ bed is also a form of co-sleeping. Some experts have begun referring to room-sharing versus bed-sharing in order to clarify the difference in the two practices (3). One problem with the campaign is that the ads do not clarify this distinction. Therefore, the overall impression parents may be getting is that their babies need to sleep in a completely different room.

Labeling Theory and Racism's Effect on Health Disparities

Milwaukee’s Health Department has been quick to identify the difference in infant mortality rates between African Americans and non-Hispanic whites (2). However, one major flaw in their intervention was the obvious avoidance of addressing these differences in their campaign, other than including two versions of their ads, one featuring a white infant and the other featuring an African-American infant (3). It is important to consider the reasons behind why the rates of infant mortality differ so drastically between the two races, even when all other factors are similar. It has been reported that an African-American woman with a college degree has poorer infant mortality rates compared to a white woman with only a high school education (1). One contributing factor to this phenomenon may be due to labeling theory, and its relation to race. Institutionalized racism may play a huge role in the differences in infant morality rates between white and African-American infants. Differences in race are especially important as the City of Milwaukee is dramatically racially segregated (9).

One study has looked at biological differences between people of different races in order to determine reasons for such dramatic differences in health disparities in different populations of people. One study was conducted in order to identify why blood pressure can differ so drastically between black and white individuals (10). Researchers Krieger and Sydney concluded that when examining blood pressure, it was important to take into account how discrimination may affect health (10). Similarly, it is important to take into account the biological differences of African-American women in comparison to white women. African-American women typically have babies with lower birth weights and are more often born prematurely (9). Institutional racism, a form of racism that is not necessarily obvious, can result in African-American women having increased stress levels, perhaps due to the expectation that discrimination will occur in everyday life events (11). Increased stress levels may then lead to increased risk of premature births and low birth weight. It is important to help these women that must live with institutional racism overcome the hardships they may face, especially during pregnancy.

One other study looked at the differences in infant mortality between African-Americans and white mothers in relation to sleeping position. The study identified that the sleeping positions varied distinctly between the two races. African-American infants were more likely to sleep in the prone position, or on their stomachs, rather than the nonprone position (on the back or side) (12). The prone position is more highly associated with SIDS. This could be one reason why the disparity in infant mortality exists between the two races. The study also went on to find that African-American mothers more often recalled or were incorrectly told by health professionals that the prone position should be used (12). Here we see a form of institutionalized racism that impacts the mothers of different races, as it is unlikely physicians were purposely suggesting unsafe sleeping practices.

A separate study found that interpersonal racial discrimination experienced by African-American women a year prior to birth as well as over a lifetime was a risk factor for premature birth (13). Nancy Krieger defines interpersonal racism as “directly perceived discriminatory interactions” (14). The City of Milwaukee should consider examining whether members of the African-American community experience higher levels of interpersonal racism, in order to prevent this from occurring. In the study conducted by Rankin, David, and Collins, they found that using active coping behaviors to deal with interpersonal racism could weaken the association between the risk factor and premature birth (13).

Understanding the differences between African-American women and white women is one way to focus Milwaukee’s intervention and an important factor in determining how to reduce the infant mortality rate. Milwaukee’s campaign does not inform women that babies born prematurely or with low birth weights are at higher risks for SIDS, and the necessity to take more precautions. The racial segregation in Milwaukee can further impact the situation as areas with high populations of African-Americans may have fewer resources for pregnant and new mothers, such as clinics, primary care offices, and prenatal classes.

Optimistic Bias and the Law of Small Numbers

The Health Department has overlooked the roles that the theory of optimistic bias in combination with the law of small numbers may play in this campaign. The Law of Small Numbers is the theory that people will often associate their risk with one positive case despite substantial information contradicting this (15). For example, a smoker will doubt that smoking increases the risk of cancer despite the vast evidence supporting this simply because they have a family member who smoked their entire life and never developed cancer. Optimism bias refers to the fact that an individual will know the risks of a particular behavior, but will underestimate their own risk (16). The campaign against bed-sharing emphasizes the dangers through the use of the knife and tombstones in the ads (3). While this may communicate the risk of bed-sharing with the public, individuals may believe that they will be the exception to the statistics. In the television ad depicting a mother that tosses and turns while sleeping, the overall impression is that bed-sharing may lead to a parent or adult suffocating their child. However, based on optimistic bias, people viewing the ad may think that while suffocation of a child may happen to others, it will not happen to them – they will be the exception to the rule (16). This becomes especially important for parents who already have had a child, and who practiced bed-sharing without any incidence of SIDS or SUDI. Based on their previous experience, they are likely to experience the law of small numbers, and be confident they can bed-share with smaller risks than the general public, although this may not necessarily true (17). Another factor to consider is the social networks of people, and the different sleeping practices friends and families engage in. One study found that at 2 weeks of age, 42% of parents shared a bed, at 3 months 34% shared a bed, and 28% at a year of age (18). These statistics show that bed-sharing is not rare and many people likely know of other parents that sleep in the same bed as their infants. The knowledge of others that have bed-shared successfully can lead people to believe in the Law of Small Numbers - that those people that have successfully practiced bed-sharing are in fact the norm. These individuals will question the veracity of the ads in conjunction with having an increased risk of infant death, especially if these parents believe that bed-sharing is a better parenting technique. Combined with optimistic bias, knowing others that successfully bed-share make it unlikely that these ads will be effective in changing the behavior of parents that co-sleep in the same bed, especially those that have never known someone whose child suffered from SIDS or SUDI.

Psychological Reactance and Pushback Against the Ads

It is very important to gauge how the public perceives the advertisements. Psychological reactance occurs when people feel their control is being taken away (19). It becomes particularly important in the issue of co-sleeping because parents have differing opinions on the pros and cons of bed-sharing based on the literature available and the cultural norms of different populations. Therefore, when advertisements tell people that their method of child-rearing is incorrect or unsafe and should not be practiced anymore, it is in effect taking away the freedom for people to decide how they want to raise their children, and what they believe is best for their child’s development. In a study conducted, investigators found that countercultural parents in the US were more likely to also be “pronatural.” This group of parents was interested in following “natural parenting” and often follows practices more common in non-Western countries, such as breast-feeding rather than formula use, bed-sharing, and using only organic foods (20). However, they may be unaware that in non-Western countries, firmer mats instead of softer mattresses are used. These parents believe that they are practicing the best form of parenting, and will therefore not heed the warning, and they will perceive a loss of control over their style of parenting. When people experience psychological reactance, they will often engage in the prohibited behavior much more strongly (19).

Solutions for Co-Sleeping and High Infant Mortality Rates

It is important to consider the root causes of high infant mortality. Despite perhaps not being the largest cause of SIDS and SUDI, proper co-sleeping may lower the rates of infant mortality in Milwaukee. However, identifying the differences in racial groups will also be impactful if addressed in the intervention. A new intervention is being proposed that will effectively remove the barriers in the already existing intervention.

The new intervention will consist of various different platforms: it will use television advertisements as well as offering educational programs in the community. This new intervention is based largely on three models useful for changing behavior: the Theory of Planned Behavior, Social Expectations Theory, and Advertising Theory. In combination, these will overcome the problems seen in Milwaukee’s current campaign, and will hopefully reduce the number of deaths that can be attributable to unsafe sleeping practice, as well as reducing the number of SIDS and SIDU deaths in general in Milwaukee.

New television advertisements will be created for the intervention. The advertisements will depict images of the important milestones in a child’s life: first birthday, first steps, first day of school, graduation, marriage, and then the birth of a grandchild. Following the images, a parent who experienced the death of an infant due to SIDS or SIDU will speak out. More specifically, the parent will emphasize the point that they were unaware of the importance of safe-sleep practices, that they missed out on so many of the milestones they expected to experience, and they will encourage parents to seek out new information regarding safe sleep practices. They will also suggest ensuring children sleep in an environment without blankets or pillows, to avoid the risk of suffocation, and that parents always place their babies on their back or supine position to sleep (8). If parents are concerned about moving in their sleep, the ad will go on to explain that the safest place for a child is in a crib or bassinet. However, it will emphasize the importance of infants sleeping in the same room as a parent.

In addition, the new intervention will have nurses available at churches, clinics, or community centers for expecting and new mothers. These nurses will be concentrated in African-Americans communities, where clinics and services may be harder to come by and where infant mortality rates are much higher – in particular, the zip codes of 53206, 53210, and 53233, which have the highest rates of infant mortality in Milwaukee (2). The nurses will act as educators, talking about the increased risk of SIDS for premature or low birth weight babies. They will ensure that African-Americans have strategies in place to deal with any type of discrimination they may face. They will describe common safe sleep practices outlined in the report by the American Academy of Pediatrics, such as always placing an infant in a supine position, using a firm mattress, avoiding pillows and blankets near the infant, encouraging breast-feeding, encouraging room-sharing over bed-sharing, and encouraging the avoidance of exposure to tobacco smoke, alcohol, and illegal drugs (8).

Finally, the City of Milwaukee should start a program where parents can donate cribs or bassinets once they are no longer needed. These will be provided to parents of newborns that are interested in room-sharing rather than bed-sharing, but that may not have the means to purchase these items.

Social Expectations Theory for Community-Based Interventions

The Social Expectations Theory suggests the importance of examining individuals based on the community they live in and the values they hold (21). As Milwaukee is racially segregated, this theory would be very helpful in addressing the differences in community norms and values. This theory, and its examination based on a community level, will help overcome weaknesses due to the Labeling Theory and racism. Do mothers in the African-American communities place more importance on bed-sharing or sleeping in the prone position? Does this belief stem from the norms and values of their culture? Is there a way to educate these mothers on safer methods of co-sleeping that may reduce risk of smothering and suffocation?

It is also important to focus on the issue of infant mortality among African-Americans in general, as this population has the highest rates of infant mortality in the city. The first step would be to identify the resources available to new and expecting mothers. Placing more resources in these lacking communities may have a profound effect on infant mortality. Finally, it will be important to examine the communities, and in particular, the African-American communities, for indicators of excess stress levels mothers may encounter due to discrimination and racism. If these two issues can be combatted, perhaps the number of premature or low birth weight cases will decrease. Following this identification, if the City of Milwaukee can take a more active role in the resources available to pregnant women combatting discrimination, perhaps Labeling Theory and racism can be overcome, in turn decreasing the number of cases of premature and low birth weight babies, and in turn decreasing the number of cases of SIDS or SIDU.

The Theory of Planned Behavior

The first step to effecting behavior change, especially in regards to a topic that individuals may not be familiar with, is education. Using the Theory of Planned Behavior, one can begin to develop a new intervention that may be more effective in reaching people that currently do not practice safe sleep techniques. The Theory of Planned Behavior is based on the fact that individuals weigh their attitudes and social norms against expected outcomes when engaging in a particular action (22). An important factor is their perceived behavioral control, also known as self-efficacy, in carrying out a particular behavior (22). This theory, with a focus on education, can be used to overcome optimism bias and the law of small numbers. In order for this to occur, it is imperative that individuals are educated on the safest sleeping practices for children from birth to the age of one.

If prenatal classes are available in the community and are well attended, the City of Milwaukee should ensure that expectant mothers are educated about safe sleeping practices during these classes. This allows mothers to be exposed to the information, and they can include it during their decision process. If prenatal classes are not offered, programs will be created in churches, community centers, and clinics in the community, which will be free of charge. By basing these educational events in a group setting, new social norms are being created around safe sleeping practices. These safe-sleeping practices can be geared towards room-sharing over bed-sharing.

The information presented in the sessions will include information about the pros of co-sleeping, the definitions of co-sleeping, room-sharing, and bed-sharing and the pros and cons of each. Classes will encourage parents to use bassinets or cribs that can be close to the bed, which are completely empty except for the mattress. For parents that are determined to bed-share, it is important to portray a safe way to do so – by placing blankets and pillows away from infants, by placing infants on their backs to sleep, and by ensuring that the parents are not restless sleepers that tend to move in their sleep. It is important, on the part of the educators, not to give the impression that parents are being told how to raise their children. By using education rather than commanding or ordering parents to engage in a particular behavior, we are allowing parents to make their own decisions on child-rearing practices. This will help mitigate psychological reactance because we are not taking away individuals’ sense of control (19). Instead, we are giving control to parents – they are now in control of making safe and smart decisions when choosing a particular sleep practice based on all of the information available.

One important addition to the Theory of Planned Behavior is the component of self-efficacy (22). Parents must be made to feel as though they can actually change their behavior and be successful. One barrier to self-efficacy in the context of room-sharing may be that the parent does not have access to a bassinet or a crib, due to financial circumstances. Therefore, this needs to be addressed in the intervention. It is unreasonable to institute a campaign encouraging mothers to practice safe-sleeping techniques if they are unable to afford the necessary requirements. The program involving crib and bassinet donations from the public will allow parents to obtain these needed items when financial limitations exist. By using donations, Milwaukee’s Health Department will not need to worry about financial constraints.

Advertising Theory and Connecting to the Community

Advertising theory should be considered when reaching out to the target population. Advertising theory is composed of three main components: the promise, core values, and support. These work together to reach the public on an emotional level (23). Therefore, advertisements need to be created which touch individuals on all three components. The promise the new set of advertisements will offer to viewers is the possibility of being a part of all important milestones in a child’s lifetime: first steps, first birthday, graduation, wedding, and the birth of their first child. These are all experiences that parents will treasure over the course of their child’s life, and will reach a wider target. These images will support the promise of experiencing life’s many milestones, and will play on the values of love, family, and aspirations. In order to overcome the law of small numbers, following the images, a parent will speak about how they missed out on all of these important life events because they were unaware of safe sleep practices, and therefore, they suffered the death of a child. They will show a picture of their baby that passed away due to SIDS. This overcomes the law of small numbers because people can now relate to someone who has experienced SIDS rather than knowing someone that has successfully bed-shared. Advertising Theory has proven successful in an intervention known as the Truth Campaign in Florida (24). This campaign was able to build a brand based on values, and resulted in decreased rates of high school and middle school students smoking (24). Similarly to this campaign, Milwaukee’s safe-sleeping campaign will place most attention on life’s important milestones for a parent, and the values of love and family, in order to connect with parents and change behavior.


Milwaukee is a city that is unique in its mortality rate differences based on ethnicity. It is critical to narrow the gap, and decrease the infant mortality rate. Milwaukee has correctly identified one potential area that may reduce the rates of infant mortality – the incidence of bed-sharing, but by basing their intervention on fear alone, they are unable to make an emotional connection with viewers that will encourage parents to change their behavior. Using the Social Expectations Theory, The Theory of Planned Behavior, and Advertising Theory for the basis of a new intervention, Milwaukee will be more successful in reaching their target population, and lowering the rates of infant mortality due to SIDS and SIDU.

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