标题：Socioeconomic Position and Factors Associated With Use of a Nonsupine Infant Sleep Position: Findings From the Canadian Maternity Experiences Survey
摘要：Objectives. With a focus on socioeconomic position, we examined the association between maternal education and nonsupine infant sleep position, and examined patterns of effect modification with additional sociodemographic, maternal, infant, and health services predictors. Methods. Data were from the Maternity Experiences Survey, a national population-based sample of 76 178 new Canadian mothers (unweighted n = 6421) aged 15 years or older interviewed in 2006–2007. Using logistic regression, we developed multivariate models for 3 maternal education strata. Results. Level of maternal education was significantly and inversely related to nonsupine infant sleep position. Stratified analyses revealed different predictive factors for nonsupine infant sleep position across strata of maternal education. Postpartum home visits were not associated with use of this sleep position among new mothers with less than high school completion. Adequacy of postpartum information regarding sudden infant death syndrome was not associated with nonsupine infant sleep position in any of the educational strata. Conclusions. These findings suggest a need to revisit Back to Sleep health promotion strategies and to ensure that these interventions are tailored to match the information needs of all families, including mothers with lower levels of formal education. Optimizing infant sleep position in an effort to reduce the incidence of sudden infant death syndrome (SIDS) has been an important maternal child health promotion strategy since nonsupine sleep position was identified as an important modifiable risk factor for SIDS in the early 1990s. 1 Dramatic decreases in SIDS rates in many countries over the subsequent decade 2–5 were largely credited to the success of public health campaigns that initially advised that infants be placed in nonprone positions for sleep and later restricted the recommendation to the supine sleep position only. 5–10 In Canada and the United States, SIDS rates dropped by 70% and 60%, respectively, between 1985 and 2004. 2,5,6,11 These reductions in SIDS rates were accompanied by reductions in postneonatal mortality rates, suggesting that they were real reductions rather than artifacts of changes in diagnostic criteria or coding practices. 5 More recently, SIDS rates have stabilized in most countries. In some countries, such as the United States and New Zealand, 5 and among socioeconomically disadvantaged, indigenous, and African American subpopulations, 12,13 SIDS rates remain unacceptably high. These rates have been linked to the need for ongoing promotion of risk-reduction activities, such as supine sleep position, particularly in communities still experiencing a high SIDS burden. 5 For example, despite efforts to promote parents’ and caregivers’ use of a supine position for infant sleep, longitudinal data from the National Infant Sleep Position Study in the United States have demonstrated that a sizable proportion of infants continue to be placed in nonsupine positions for usual sleep (27.9% in 2008). 14 Moreover, following consistent increases in the proportion of infants being placed to sleep in supine positions throughout the 1990s, the rates have shown little change since approximately 2001. 14 Analysis of data from the US Pregnancy Risk Assessment Monitoring System survey has shown that socioeconomic position (SEP), measured by both education level and income, has been consistently, significantly, and positively associated with supine sleep position across states. 15 Accordingly, nonsupine sleep position has been associated with socioeconomic deprivation in several other studies. 16,17 For example, in a prospective cohort study of sleep position among inner-city mothers of infants aged 3 to 7 months in the United States, Brenner et al. 16 found that mothers living below the poverty level were 1.81 times more likely to put their infant to sleep in a prone position than mothers living above the poverty level (95% confidence interval [CI] = 1.10, 2.99). Low SEP was not found to be significantly associated with nonsupine sleep position in an analysis of the National Infant Sleep Position Study; however, this data set underrepresented women with fewer than 12 years of education by more than 50% compared with other national surveys. 18,19 The size and scope of the population surveyed by the Canadian Maternity Experiences Survey (MES) provided a unique opportunity to pursue our study objectives, which were to (1) clarify the significance of the association between SEP and nonsupine sleep position, and (2) examine patterns of effect modification by SEP on the associations between nonsupine infant sleep position and additional sociodemographic, maternal, infant, and health services predictors.
