Maternal adherence to safe infant sleep recommendations in the USA: trends and disparities from PRAMS 2016-2022

Sleep-related infant deaths in the USA have plateaued despite long-standing evidence-based recommendations for safe sleep. Understanding maternal patterns of adherence and associated disparities is critical to improving infant safety. Using nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 8 surveillance data (2016-2022), we estimated adherence to four safe sleep recommendations, examined temporal trends and assessed sociodemographic and behavioural correlates of non-adherence.

We analysed 125 931 weighted maternal responses (weighted count: 6 372 445) on infant sleep position, location, surface and bedding. Temporal trends were assessed using log-linear regression and expressed as the average annual percentage change (APC). Disparities were examined using multiple logistic regression, reporting adjusted ORs (AORs) and 95% CIs.

Adherence was highest for supine sleep position (79.8%; 95% CI 79.4 to 80.2) and lowest for safe bedding (32.8%; 95% CI 32.4 to 33.2). Significant improvements were observed in adherence to safe bedding (APC=11.5%) and safe sleep surfaces (APC=2.8%). Compared with non-Hispanic white mothers, non-Hispanic black mothers had substantially higher odds of unsafe practices, including non-supine position (AOR 3.4; 95% CI 3.2 to 3.7), infant bed-sharing (AOR 2.4; 95% CI 2.3 to 2.6), unsafe sleep surfaces (AOR 1.5; 95% CI 1.4 to 1.6) and loose bedding (AOR 3.6; 95% CI 3.3 to 3.9). Elevated risks were also seen among Hispanic mothers, Medicaid or uninsured, unmarried, smokers and those not receiving healthcare worker advice.

Maternal adherence to safe sleep recommendations remains low, with persistent sociodemographic disparities. These findings highlight the need for stronger integration of safe sleep counselling within antenatal and postpartum care.