1. Janette Westman, Midwife / Infant Feeding Specialist - Bradford Royal Infirmary Helen Ball, Professor of Anthropology / Director, Parent-Infant Sleep Lab, Durham University Ethnicity, Breastfeeding & Sleep The Bradford Infant Care Study

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 1 st 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.ukwww.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. Completed (N=2560) Not completed (N=774) Characteristic n%n% p-value Maternal age <20 years 1345.28210.6 <0.0001 White British ethnicity 96837.833343.0 <0.0001 Single (never married) 65525.629337.9 <0.0001 Not living with partner 34513.517122.1 <0.0001 Annual Income after tax less than £9300 42016.418323.6 <0.0001 Parity 3+ 35013.79011.6 0.16 Male baby 133652.236947.7 0.03 Low birthweight (<2500g) 1907.4526.7 0.51 Preterm (<37 weeks gestation) 1214.7435.6 0.35 Mother smoked during pregnancy or 3 months before 46218.019425.1 <0.0001 Mother drank alcohol in pregnancy or 3 months before 80131.326133.7 0.34 Mother used drugs in pregnancy or 3 months before 200.8182.3 <0.0001 Participants

14. All White British (N=922) Pakistani (N=1143) Indian (N=100) Bangladeshi (N=59) p-value* Characteristicn%n%n%n%n% Mother’s education <0.0001 None31414.1919.921318.655.058.5 School71532.232335.035831.31818.01627.1 Further and higher92541.635438.448142.16161.02949.2 Other27012.115416.7918.01616.0915.3 Mother’s age<0.0001 <20 years1165.2899.7262.3011.7 20-24 years57225.724126.130126.31515.01525.4 25-29 years76934.628731.142537.23737.02033.9 30-34 years48621.917318.826323.03333.01728.8 35+ years28112.613214.312811.21515.0610.2 Parity<0.0001 087739.445148.936131.64747.01830.5 165629.528931.331527.63636.01627.1 237516.910711.624121.11010.01728.8 3+31614.2758.122619.877.0813.6 Language at baseline <0.0001 English182081.8922100.075365.98686.05910.00 Non- English40418.2039034.11414.00 Participants

15. Pakistani UnadjustedAdjusted* OR95%CIOR95%CI Sleeping environment Baby sleeps in room on own0.06(0.04, 0.09)0.05(0.03, 0.09) Baby sleeps in adult bed12.71(4.60, 35.11)8.48(2.92, 24.63) Baby sleep under duvet3.82(2.92, 4.98)3.24(2.39, 4.40) Baby sleeps in infant sleeping bag0.17(0.13, 0.21)0.20(0.16, 0.26) Co-sleeping Baby ever bed shared with mother2.07(1.60, 2.68)2.13(1.59, 2.86) Baby regularly bed shares with mother3.85(2.51, 5.90)3.57(2.23, 5.72) Baby ever sofa shared0.24(0.17, 0.33)0.22(0.15, 0.34) Baby swaddled in bed3.76(1.10, 12.79)5.65(1.54, 20.81) Breastfeeding and pacifier use Baby ever breastfed1.77(1.46, 2.14)2.00(1.58, 2.53) Baby breastfed for 8 weeks or more1.94(1.60, 2.34)1.65(1.31, 2.07) Pacifier used at all at night0.40(0.33, 0.48)0.40(0.33, 0.50) Lifestyle Mother currently smokes0.07(0.05, 0.12)0.07(0.04, 0.12) *Model adjusted for maternal age, maternal education, parity, language proficiency and baby age at interview Results

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 conform to 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 not conform 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. 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 A final thought ….