Threads of Counsel

When We Talk About Safe Sleep Without Cultural Humility, We Miss the Point

At this year’s National Student Nurses’ Association (NSNA) Annual Convention, a resolution was adopted encouraging nursing programs to enhance education around “safe sleep” practices to help prevent SIDS. As a member of the Resolutions Committee, I upheld our role of neutrality and did not speak publicly on the motion. Still, the conversation has stayed with me—and I’ve been reflecting on it deeply ever since.

Like many well-meaning public health interventions, the resolution focused on parent behavior. It assumed that SIDS-related deaths result from a lack of education, and that if nurses are trained to deliver the right messages, families will comply, and infants will be safe. But it didn’t ask: Whose behaviors are we targeting? Whose cultural practices are being labeled unsafe? And what would it look like to approach this work with cultural humility instead of clinical certainty?

Co-Sleeping Isn’t the Problem

Co-sleeping, meaning an infant and caregiver sharing a sleep surface, is often treated in U.S. medical contexts as inherently dangerous. Many nurses are taught to intervene the moment they see it. But co-sleeping isn’t inherently unsafe. Risk comes from specific circumstances: alcohol use, sedating medications, smoking, soft bedding, unsafe furniture like couches or recliners (Caraballo et al., 2022).

When co-sleeping is done intentionally – on a firm surface, by an alert breastfeeding parent, in a smoke-free home – it aligns with what researchers like James McKenna and organizations like La Leche League have long documented as low-risk or even protective (McKenna & Gettler, 2020; Ball & Volpe, 2013). This model is embedded in the “Safe Sleep Seven,” which emphasizes concrete safety conditions rather than blanket prohibitions.

Globally, co-sleeping is not a fringe or desperate choice. It is the norm. Families in Japan, Sweden, Egypt, and many other countries practice bedsharing in ways that support breastfeeding, bonding, and infant regulation. In Japan, where co-sleeping is common, the SIDS rate is approximately 0.16 per 1,000 live births. Sweden reports a rate around 0.23. In contrast, the United States sees a rate closer to 0.54 per 1,000 (Nakayama et al., 2006; Högberg & Thorell, 2015; CDC, 2023). These countries also offer structural supports that the U.S. does not. The problem isn’t co-sleeping. The problem is that U.S. institutions refuse to see it as valid.

Policing Isn’t Prevention

In the U.S., co-sleeping is regularly treated as a sign of neglect, especially when practiced by poor, Black, immigrant, or disabled families. One family’s tradition is another family’s risk factor, and the line dividing the two is often race, class, or perceived competence.

This plays out in hospitals and classrooms alike. Student nurses are taught to intervene if they see a baby resting on a parent’s chest. They’re told co-sleeping kills. But they’re rarely taught why some families co-sleep, how it can be done safely, or what it means to show up in relationship rather than enforcement. They aren’t trained to ask questions before assuming authority.

This approach – like many before it – emboldens that posture. It adds more messaging, more “education,” but leaves little room for curiosity, nuance, or cultural difference. It doesn’t equip nurses to meet families where they are. It equips them to surveil.

This Is a Vulnerable Window

The hours after birth are among the most fragile and formative moments in a family’s life. Most new parents want to get it right. Most are afraid they’re already getting it wrong. That fear is real even under ideal circumstances. Now layer in the pressure of being Black, postpartum, and under the gaze of a predominantly white healthcare workforce.

Picture this: you’re 12 hours postpartum, bleeding, leaking, exhausted, and holding your baby skin-to-skin. You’re trying to regulate their breathing, initiate breastfeeding, and stay present through the overwhelm. A nurse walks in and says, “Your baby could die from Sudden Infant Death Syndrome if they sleep on your chest.”

That kind of statement, delivered without context or relationship, hits like a threat. It may as well be, “You’re going to kill your baby.” And it sticks.

It shapes whether that parent asks for help. Whether they feel safe being honest. Whether they come back for postpartum care. Whether they bring their child to the pediatrician when something feels off. A single moment can set the tone for every healthcare interaction that follows.

When nurses are taught to correct rather than connect, we cause harm in the short term and set patterns of mistrust that carry forward.

Let’s Be Honest About What We’re Teaching

We often say the goal is safety, but what we teach nurses is compliance. And what we call education is often closer to discipline. This is especially true in communities where historical trauma, institutional neglect, and over-surveillance are already layered onto every medical interaction.

The U.S. does not fail to reduce SIDS because parents are stubborn or uneducated. It fails because we’ve built a healthcare system on individual blame rather than structural care. Paid leave is unavailable for most families (Burtle & Bezruchka, 2016). Universal postpartum care is still not a reality (Daw et al., 2022). Cribs are pushed as a standard, but when families ask for help getting one, they’re often met with silence, judgment, or worse: a CPS report.

Even that misses the point. Families aren’t co-sleeping because they don’t know about cribs. They’re co-sleeping because they value closeness, breastfeeding, regulation, or simply because it works.

Structural Neglect Makes Parenting Harder

Unsafe sleep conditions exist, and we must name them. But we need to be precise about what actually creates risk. Working multiple jobs without paid leave creates chronic sleep deprivation. Lack of access to behavioral and mental health support increases substance use and unaddressed trauma. Overcrowded or unstable housing limits safe sleep surfaces. Shelter settings often lack privacy and safety. Incarceration or separation from a co-parent creates isolation. When a parent is in crisis, without a support network or resources, every part of caregiving becomes harder.

These conditions are not the result of bad choices. They are the result of policy decisions. And when families respond to these conditions in creative, adaptive ways – like holding a baby close at night – we should see that as resilience, not risk.

Co-sleeping itself is not the danger. The danger is being forced to parent in survival mode without tools, community, or care. The danger is a system that treats adaptive responses as deviant behaviors instead of asking what support is missing.

When we center co-sleeping as the problem, we ignore what families are trying to solve. We risk shaming parents who are doing their best with what they have. We turn acts of love and intuition into grounds for surveillance.

Cultural Humility Is a Clinical Skill

If we want to reduce SIDS, we have to stop pretending that more messaging is enough. Information alone does not build trust. Safety is not created by compliance. We need deeper listening, fuller context, and real accountability that moves beyond individual behavior and examines the systems that constrain choice.

Nursing education should prepare students to walk into a postpartum room with reverence. With their biases named and checked. With a readiness to listen, learn, and hold space. We should teach students to pause before correcting, to ask: What do I not yet understand about this family? What traditions and traumas are in this room? How has this family survived?

Cultural humility means teaching students how to witness pain without rushing to fix it. How to read a postpartum body not just for clinical signs, but for signs of trust, fear, connection, and exhaustion. It means recognizing how racism, ableism, poverty, and language barriers shape interactions – and doing the work to dismantle those barriers, not reinforce them.

We should be training nurses to build relationships before delivering information. To co-create care plans. To treat parenting as a culturally grounded act, not a standardized protocol. This doesn’t mean compromising safety. It means redefining what safety looks like in relationship, not in isolation.

Families do not need more warnings. They need more respect. They need systems that believe in their wisdom. They need clinicians who see care as relational work, not just procedural work.

Cultural humility is a clinical foundation. It shapes whether a nurse enters a space with curiosity or control – and that shift can change everything.

For Further Reading

Safe Sleep Seven (SS7) Resources

Mandatory Reporting and Cultural Competency

Understanding Postpartum Vulnerability

Cultural Perspectives on Co-Sleeping

References

Ball, H. L., & Volpe, L. E. (2013). Sudden infant death syndrome (SIDS) risk reduction and infant sleep location—Moving the discussion forward. Social Science & Medicine, 79, 84–91. https://doi.org/10.1016/j.socscimed.2012.07.035

Burtle, A., & Bezruchka, S. (2016). Population health and paid parental leave: What the United States can learn from two decades of research. Healthcare, 4(2), 30. https://doi.org/10.3390/healthcare4020030

Caraballo, M. A., Shapiro-Mendoza, C. K., & Colson, E. R. (2022). Evidence base for 2022 updated recommendations for a safe infant sleeping environment. Pediatrics, 150(1), e2022057991. https://doi.org/10.1542/peds.2022-057991

Daw, J. R., Winkelman, T. N. A., Dalton, V. K., Kozhimannil, K. B., & Admon, L. K. (2022). Medicaid and preconception health: Evidence from the population-level analysis of insurance coverage. JAMA Health Forum, 3(5), e221153. https://doi.org/10.1001/jamahealthforum.2022.1153

Högberg, U., & Thorell, M. (2015). Updated Swedish advice on reducing the risk of sudden infant death syndrome. Acta Paediatrica, 104(6), 1–6. https://doi.org/10.1111/apa.13018

McKenna, J. J., & Gettler, L. T. (2020). There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatrica, 109(11), 2016–2028. https://doi.org/10.1111/apa.15420

Nakayama, M., Suganuma, H., & Takahashi, S. (2006). Sudden infant death syndrome in Japan: Epidemiology and trends. Pediatrics International, 48(3), 274–280. https://doi.org/10.1111/j.1442-200X.2006.02295.x

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