At this year’s National Student Nurses’ Association Annual Convention, delegates adopted a resolution encouraging nursing programs to expand education on safe sleep practices to prevent SIDS. I sat on the Resolutions Committee, where our role is neutrality, so I did not speak on the motion. The conversation has stayed with me since.
Like a lot of well-meaning public health interventions, the resolution focused on parent behavior. It assumed SIDS deaths follow from a lack of education, and that if nurses are trained to deliver the right messages, families will comply and infants will be safe. It did not ask whose behaviors we are targeting, whose cultural practices get labeled unsafe, or what this work would look like approached with cultural humility instead of clinical certainty.
Co-Sleeping Isn’t the Problem
U.S. medical contexts treat co-sleeping, meaning an infant and caregiver sharing a sleep surface, as dangerous in itself, and many nurses are taught to intervene the moment they see it. The risk is not in the arrangement. It concentrates in specific conditions: infants under four months, prematurity, maternal smoking, parental impairment from alcohol or sedating medications, soft bedding, and sleep surfaces that were never meant for sleeping. The AAP’s own technical report puts the risk of couches and armchairs at up to sixty-seven times that of a safe surface, with or without another person present (Moon, Carlin, & Hand, 2022). A sofa is not a bed, and the two get collapsed together every time we say “co-sleeping kills.”
Done intentionally, on a firm surface, by an alert breastfeeding parent in a smoke-free home, bedsharing looks different. That is the logic of the Safe Sleep Seven, which specifies conditions instead of issuing a prohibition. A group of researchers including James McKenna and Helen Ball has gone further, arguing that bedsharing may partly explain why breastfed infants have lower rates of sleep-related death, that breastfeeding dyads position themselves protectively and arouse more readily, and that suffocation among breastfeeding bedsharing infants is rare in the absence of hazards (Bartick et al., 2022).
The AAP does not accept this. Its 2022 recommendations advise against bedsharing under any circumstances, including for breastfeeding dyads with no other risk factors, partly on the reasoning that a conditional message is hard to deliver and easy to misapply. That is a live disagreement among serious people, and it is worth saying so rather than pretending the evidence runs one direction. What is not in dispute is the shape of the risk. The hazards cluster in identifiable conditions, and those conditions are the things a nurse could actually help a family change.
Globally, bedsharing is the norm rather than a fringe or desperate choice. In western Sweden, 44.2% of infants shared a parent’s bed during the first three months, bedsharing was more common among breastfed infants, and 2.8% of mothers had smoked during pregnancy (Strömberg Celind et al., 2017). That is a population where bedsharing is ordinary, hazards are rare, and infant mortality is among the lowest in the world.
Comparing national SIDS rates is harder than it looks. Reported SIDS rates across high-income countries have ranged from about 0.05 per 1,000 live births in Sweden to 0.39 in the United States, and epidemiologists at the CDC attribute most of that spread to differences in how countries code unexplained infant deaths rather than to differences in how many infants die (Shapiro-Mendoza et al., 2018). One international comparison found that no ICD code or grouping of codes was applied consistently across eight wealthy countries (Taylor et al., 2015).
The coding problem is worse than a technicality, because the classification rules already encode the conclusion. The New York City medical examiner’s office has held that a death cannot be classified as SIDS if the infant was found in an unsafe sleep environment, and a shared sleep surface counts. In a 2003 UK survey, more than two-thirds of pathologists said that sharing a sleep surface with an adult was reason enough to certify a death as unascertained rather than SIDS (Shapiro-Mendoza et al., 2018). Bedsharing deaths get sorted out of the unexplained category by rule. Then the resulting statistics are used to prove that bedsharing is what makes deaths unexplained.
The more honest comparison is inside our own data. Bedsharing in the U.S. is reported more often by Hispanic parents, Black parents, and Asian and Pacific Islander parents than by white parents, and more often by parents who breastfeed and parents with low incomes (Lahr, Rosenberg, & Lapidus, 2007). In 2022, the sudden unexpected infant death rate was 31.5 per 100,000 live births for non-Hispanic Asian infants and 61.6 for Hispanic infants, against 83.2 for non-Hispanic white infants, 244.0 for non-Hispanic Black infants, and 229.4 for non-Hispanic American Indian and Alaska Native infants (CDC). Two of the groups that bedshare most have the lowest death rates in the country. If the practice itself were the driver, the numbers would not fall that way.
What does track the gradient is the company bedsharing keeps. In the Oregon data, bedsharing Black, American Indian and Alaska Native, and white infants were far more likely to have a mother who smoked than bedsharing Hispanic or Asian and Pacific Islander infants. The hazard is the hazard. It is not the bed.
Policing Isn’t Prevention
In the U.S., co-sleeping gets read as a sign of neglect, especially when the family is poor, Black, immigrant, or disabled. One family’s tradition is another family’s risk factor, and the line between them usually runs along race, class, or perceived competence.
This plays out in hospitals and classrooms alike. Student nurses are taught to intervene when they see a baby resting on a parent’s chest. They are told co-sleeping kills. They are 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. Nobody trains them to ask questions before assuming authority.
There is also evidence that the message does not work. Reviewing two decades of sleep-location campaigns, Ball and Volpe concluded that bedsharing is not the kind of practice that risk education and simple recommendations can modify, and that ignoring what sleep location means to a family’s ethnic and cultural identity has produced messages their target populations reject (Ball & Volpe, 2013). The Oregon researchers reached the same place from a different direction: crib giveaway campaigns will have limited reach when families bedshare because of cultural norms rather than lack of a crib (Lahr et al., 2007).
A resolution like this one adds more messaging and more education while leaving little room for curiosity, nuance, or cultural difference. It does not prepare nurses to meet families where they are. It prepares them to surveil.
This Is a Vulnerable Window
The hours after birth are among the most fragile and formative in a family’s life. Most new parents want to get it right. Most are afraid they have already gotten it wrong. That fear is real under ideal circumstances. Add the pressure of being Black, postpartum, and under the gaze of a predominantly white healthcare workforce.
Picture it. You are 12 hours postpartum, bleeding, leaking, exhausted, holding your baby skin to skin. You are trying to regulate their breathing, start breastfeeding, and stay present through the overwhelm. A nurse walks in and tells you your baby could die of Sudden Infant Death Syndrome if they sleep on your chest.
Delivered without context or relationship, that lands like a threat. It may as well be “you are going to kill your baby.” And it sticks.
It shapes whether that parent asks for help. Whether they are honest with the next clinician. Whether they come back for postpartum care, or bring the baby in when something feels off. One moment can set the tone for every healthcare interaction that follows.
Nurses taught to correct rather than connect cause harm in the moment and seed a mistrust that carries forward.
Let’s Be Honest About What We’re Teaching
We say the goal is safety and we teach compliance. What we call education is often closer to discipline, and that is most true in communities already carrying historical trauma, institutional neglect, and over-surveillance into every medical interaction.
The U.S. does not fail to reduce SIDS because parents are stubborn or uneducated. It fails because we built a healthcare system on individual blame instead of structural care. The U.S. remains the only wealthy country with no formal guarantee of paid leave for new parents (Burtle & Bezruchka, 2016). Postpartum coverage is a cliff rather than a continuum, and a substantial share of birthing people lose insurance in the months after delivery (Cohen & Daw, 2021). Cribs get pushed as the standard, and families who ask for help getting one meet silence, judgment, or a CPS report.
Even that framing concedes too much. Families are not co-sleeping because nobody told them about cribs. They co-sleep because they value closeness, because it supports breastfeeding and regulation, or because it works.
Structural Neglect Makes Parenting Harder
Unsafe sleep conditions exist and we have to name them. We also have to be precise about what creates the risk. Working multiple jobs without paid leave produces chronic sleep deprivation. No access to behavioral and mental health support means more substance use and more unaddressed trauma. Overcrowded or unstable housing limits safe sleep surfaces. Shelters often lack privacy and safety. Incarceration or separation from a co-parent creates isolation. A parent in crisis without a support network or resources finds every part of caregiving harder.
The geography of these deaths tells on us. From 2018 through 2022, the SUID rate in Mississippi was 221.9 per 100,000 live births, nearly five times the rate in Massachusetts at 45.0 (CDC). Nothing about that gap is explained by Mississippi parents knowing less about infant sleep. It is explained by what surrounds them: Medicaid policy, housing, smoking prevalence, poverty, and the density of prenatal and postpartum care available within driving distance.
These conditions are not the result of bad choices. They are the result of policy decisions. When families respond to them in creative, adaptive ways, like holding a baby close at night, that is resilience.
The danger is not co-sleeping. It is parenting in survival mode without tools, community, or care, inside a system that reads adaptation as deviance instead of asking what support is missing.
Centering co-sleeping as the problem ignores what families are actually solving for. It shames parents doing their best with what they have. It turns acts of love and intuition into grounds for surveillance.
Cultural Humility Is a Clinical Skill
Reducing SIDS will take more than better messaging. Information alone does not build trust, and compliance does not produce safety. It takes deeper listening, fuller context, and accountability that reaches past individual behavior to the systems that constrain what families can choose.
Nursing education should prepare students to walk into a postpartum room with reverence, with their biases named and checked, ready to listen and learn and hold space. Teach students to pause before correcting and to ask what they do not yet understand about this family, what traditions and traumas are in the room, how this family has survived.
Cultural humility means teaching students to witness pain without rushing to fix it, and to read a postpartum body for signs of trust, fear, connection, and exhaustion alongside the clinical signs. It means seeing how racism, ableism, poverty, and language barriers shape the interaction, then doing the work to dismantle those barriers rather than reinforce them.
It also means teaching the conditional message rather than the flat one. A nurse who can say what actually raises risk, and help a family get closer to a safer version of what they were going to do anyway, protects more infants than a nurse who delivers a prohibition and watches the family stop talking.
Train nurses to build the relationship before delivering the information. To co-create care plans. To treat parenting as a culturally grounded act rather than a standardized protocol. None of that compromises safety. It locates safety in relationship.
Families do not need more warnings. They need clinicians who treat care as relational work and systems that credit their wisdom.
Cultural humility is a clinical foundation. It determines whether a nurse enters the room with curiosity or with control.
For Further Reading
Safe Sleep Seven (SS7) Resources
La Leche League International, Safe Sleep Seven. A guide detailing seven criteria for safer bedsharing, emphasizing breastfeeding and parental awareness. https://llli.org/news/the-safe-sleep-seven/
Mandatory Reporting and Cultural Competency
Beyond Mandated Reporting Participant Toolkit, Washington State DSHS. Explores the implications of mandatory reporting and offers strategies for culturally competent practice. https://www.dshs.wa.gov/sites/default/files/DDA/dda/documents/training/Beyond%20Mandated%20Reporting%20Participant%20Toolkit.pdf
Mandatory Reporting is Not Neutral. A resource challenging the neutrality of mandatory reporting and its impact on marginalized communities. https://mandatoryreportingisnotneutral.squarespace.com/
Understanding Postpartum Vulnerability
Vulnerabilities and Reparative Strategies During Pregnancy, Childbirth, and the Postnatal Period, The Lancet. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00441-8/fulltext
Postpartum Care of the New Mother, StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK565875/
Cultural Perspectives on Co-Sleeping
Cosleeping: Cultural Norms Around the World and in the U.S., Hey Sleepy Baby. https://heysleepybaby.com/cosleeping-cultural-norms-around-the-world-and-in-the-us/
Infant Sleeping Arrangements and Cultural Values Among Contemporary Japanese Mothers, Frontiers in Psychology. https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2014.00718/full
Revisiting Safe Sleep Recommendations for African-American Infants, Maternal and Child Health Journal. https://health.maryland.gov/phpa/mch/Documents/Revisiting%20safe%20sleep%20recommendations%20for%20AA%20infants%20(Mat%20Child%20Health%20J%202014).pdf
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.2012.03.025
Bartick, M., Young, M., Louis-Jacques, A., McKenna, J. J., & Ball, H. L. (2022). Bedsharing may partially explain the reduced risk of sleep-related death in breastfed infants. Frontiers in Pediatrics, 10, 1081028. https://doi.org/10.3389/fped.2022.1081028
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
Centers for Disease Control and Prevention. (2024). Data and statistics for SUID and SIDS. https://www.cdc.gov/sudden-infant-death/data-research/data/index.html
Cohen, J. L., & Daw, J. R. (2021). Postpartum cliffs: Missed opportunities to promote maternal health in the United States. JAMA Health Forum, 2(12), e214164. https://doi.org/10.1001/jamahealthforum.2021.4164
Lahr, M. B., Rosenberg, K. D., & Lapidus, J. A. (2007). Maternal-infant bedsharing: Risk factors for bedsharing in a population-based survey of new mothers and implications for SIDS risk reduction. Maternal and Child Health Journal, 11(3), 277–286. https://doi.org/10.1007/s10995-006-0166-z
McKenna, J. J., & Gettler, L. T. (2016). There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping. Acta Paediatrica, 105(1), 17–21. https://doi.org/10.1111/apa.13161
Moon, R. Y., Carlin, R. F., & Hand, I. (2022). Evidence base for 2022 updated recommendations for a safe infant sleeping environment to reduce the risk of sleep-related infant deaths. Pediatrics, 150(1), e2022057991. https://doi.org/10.1542/peds.2022-057991
Shapiro-Mendoza, C. K., Parks, S., Erck Lambert, A., Camperlengo, L., Cottengim, C., & Olson, C. (2018). The epidemiology of sudden infant death syndrome and sudden unexpected infant deaths: Diagnostic shift and other temporal changes. In J. R. Duncan & R. W. Byard (Eds.), SIDS sudden infant and early childhood death: The past, the present and the future (Ch. 13). University of Adelaide Press. https://www.ncbi.nlm.nih.gov/books/NBK513373/
Strömberg Celind, F., Wennergren, G., Möllborg, P., Goksör, E., & Alm, B. (2017). Area-based study shows most parents follow advice to reduce risk of sudden infant death syndrome. Acta Paediatrica, 106(4), 579–585. https://doi.org/10.1111/apa.13711
Taylor, B. J., Garstang, J., Engelberts, A., Obonai, T., Cote, A., Freemantle, J., et al. (2015). International comparison of sudden unexpected death in infancy rates using a newly proposed set of cause-of-death codes. Archives of Disease in Childhood, 100(11), 1018–1023. https://doi.org/10.1136/archdischild-2015-308239
Threads of Counsel 