Closing the Gaps in Safe Sleep Education in Underserved Populations

This series focuses on how states are reaching underserved populations as part of the Collaborative Improvement and Innovation Network to Reduce Infant Mortality.

While the country's rate of sudden infant death syndrome (SIDS) has dropped by more than 50 percent over the past two decades, SIDS continues to claim the lives of about 1,500 U.S. infants each year. SIDS is the leading cause of death for infants and is highly correlated with unsafe sleep practices, which is why the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN) has made safe sleep practices one of its six focus areas. By helping to eliminate persistent but avoidable disparities in SIDS rates, addressing unsafe sleep practice with underserved populations can reduce infant mortality for all.

Incarcerated Women

With the number of incarcerated women in the U.S. growing by more than 700 percent in recent decades, members of the Washington, D.C.-based IM CoIIN team have brought safe sleep education to pregnant inmates at the district's correctional treatment facility.

Launched in late 2015, a collaboration between the Women in Prison Program and the District of Columbia Department of Health's Safe Sleep Program offers monthly workshops to inmates scheduled for release prior to their expected delivery date. The workshops are open to grandparents as well. 

"We want to make sure that this population gets all the information and support they need to provide infants with safe sleep practices once the mothers are back home," says Piia Hanson, MSPH, chief of the Perinatal and Infant Health Bureau at the DC Department of Health.

Based on PowerPoint presentations and educational DVDs, the inmate-centered workshops include instructions for the safe use of portable cribs. Once released, workshop participants can receive a complimentary portable crib of their own. 

"We know that life is very hectic for these women when they're first re-establishing themselves in their communities, so we allow for any family member to come to the Department of Health, get an overview of sleep practices, and take the Pack ‘n Play back home to the mother," explains Sharon Brandon, the Department of Health's safe sleep program coordinator.

The D.C. team is now gathering data on knowledge acquired through the inmate-centered workshops, with plans to share the data later this summer.

Spanish Speakers

Washington, D.C., has one of the largest Hispanic populations in the U.S. and one of the nation's worst rates of infant mortality . But when members of the IM CoIIN D.C. team recently reviewed educational materials used in the Department of Health's safe sleep classes, they discovered that PowerPoint presentations created for Spanish speakers lacked a written component detailing crucial information on safe sleep practices.

"We found that Spanish-speaking populations weren't receiving the same educational content as English-speaking populations," says Brandon. "We then standardized both presentations in order to guarantee that every participant would receive the same message."

A two-hour workshop held weekly at the Department of Health (and also available at 37 partner agencies, including local hospitals, daycare centers and community organizations), the classes provide participants with a complimentary portable crib once they've completed a post-workshop exam on safe sleep knowledge. With changes implemented by members of the D.C. team in January 2016, classes geared toward Spanish speakers now feature a Spanish-language safe sleep DVD and informational brochures complete with the do's and don'ts of safe sleep.

Thanks in part to an increase in the number of Spanish-language classes offered at the Department of Health's partner agencies, Spanish speakers currently make up about 40 percent of safe sleep workshops. 

"As more people learn about the safe sleep program, more agencies want to get on board, so it's really grown by leaps and bounds," says Hanson. "It's a great way to engage the community and make sure that all families are receiving the same message about safe sleep."

Word-of-mouth among Spanish-speakers has also significantly boosted workshop participation, according to Hanson. "The Latina community tends to be very close-knit, so we're finding that a mom will come in to attend a workshop, and then come back later with a family member or a friend who's having a baby of her own," she says. "Having those women out there spreading the word about the workshop has really been our best promotion."

As with the inmate-centered workshops, the D.C. team has started collecting data to gauge the impact of safe sleep classes on knowledge levels among Spanish-speaking participants, and plans to share their results in late summer.


For the IM CoIIN D.C. team, the city's homeless population has proven one of the most challenging areas of focus in promoting safe sleep.

Working with the Virginia Williams Family Resource Center (D.C.'s central resource center for homeless families with minor and/or dependent children), the D.C. team has brought safe sleep education and distribution of portable cribs to a number of local shelters. But because of the transient nature of homeless populations, maintaining contact with these families can be complicated.

"If someone falls off our radar—if she leaves the facility and goes to stay with a relative or a friend, for example—there's usually no way of tracking her down again," says Brandon. "Unless she's let a case manager know where she's going, then there's no way for us to follow up with her."

Homeless populations may also struggle with adherence to certain key safe sleep practices, notes Hanson. "One of the problems we've discovered is that women in the shelters tend to feel that the baby's safest when sleeping next to them," she says. "It makes perfect sense: if there are a lot of people in the room and you don't know what's happening around you, the instinct is to keep the baby right beside you."

In an effort to reduce bed-sharing (a major risk factor for SIDS), the team recently began performing site visits at shelters and working to acclimate homeless families to proper use of portable cribs.


In California, 269 infants died suddenly and unexpectedly in 2013, with most deaths occurring when the infant was sleeping . There is a significant disparity in sleep-related deaths or Sudden Unexpected Infant Death (SUID) between non-Hispanic Black infants and all other race/ethnicities.

In partnership with the California Black Infant Health Program (BIH), the California IM CoIIN Safe Sleep Team leveraged on the existing program infrastructure to enhance infant safe sleep practices among   health care professionals and BIH participants using an evidence-based approach known as participant engagement. 

Participant engagement, an evidence-based approach, has been demonstrated to be effective among the MCAH population due to its collaborative conversational style to strengthen a person's own motivation and commitment to change. It is participant-centered, with a strong focus on building a relationship between the health care professional and the participant. In addition, participant engagement approach supports culturally competent communication, which ultimately has the ability to empower and educate participants from their own unique experiences. 

"The participant engagement approach allows health care professionals to meet participants where they are at while learning from the participant about what information they need to help them to make decisions," explains Martha E. Dominguez, MA, MPH, program consultant for the California Department of Public Health's Maternal, Child and Adolescent Health Division. So rather than simply providing information on safe sleep practices, health care professionals strive to cultivate a mutual relationship to increase the participant's sense of empowerment and autonomy. 

To assess the impact of their efforts in safe sleep practices by using participant engagement, the California Safe Sleep Team is now evaluating data and conducting feedback sessions with the BIH pilot sites: Sacramento and Alameda counties.