Exploring infant safe sleep practices and sleep arrangement motivations in a South African sample

Sudden unexpected infant death remains a significant public health concern, with South Africa reporting among the highest incidence globally. However, little is known about infant sleep practices, motivations for sleep arrangements, or adherence to safe sleep recommendations within this context. This study explored caregiver and child characteristics associated with potential sleep-related risk, and caregiver motivations underlying infant sleep arrangements, among South African caregivers. A cross-sectional online survey was completed by 201 caregivers of infants. Prevalence of adherence to American Academy of Pediatrics guidelines was determined. A safe sleep composite score, derived from items of the Brief Infant Sleep Questionnaire-Revised, classified caregivers into low-, moderate-, and high-adherence groups. Bivariate associations between demographic characteristics and low-adherence group membership were examined using chi-square tests, with hierarchical multiple regression to identify predictors of adherence to guidelines. Prevalence of motivations for sleep arrangements were determined and compared across demographic characteristics. Bed-sharing and non-supine sleeping was common. Unemployed caregivers were more than twice as likely to fall into the low-adherence group (45.9% vs. 20.5%), and caregiver characteristics explained significant variance beyond child characteristics (ΔR² = 0.20, p = .022), with unemployment the only significant independent predictor. No child characteristics were associated with adherence. Feeding, bonding, and safety were the primary motivations for bed and room-sharing, while separate-room sleeping motivations centered on caregiver sleep quality. Adherence to guidelines is complex. Caregiver characteristics were associated with potential sleep-related risk. Findings support safe sleep interventions tailored to caregivers' practical and socioeconomic circumstances, particularly for unemployed and single caregivers.