Bed-sharing or co-sleeping in the family bed was widely practiced in Peru (75%) and less so in Brazil (48%). Other studies in South America indicate that far fewer slept in the supine position only 24% in Brazil, and 36% in Peru reported placing infants on their back to sleep. More recently researchers in Argentina reported 7% of all infant deaths younger than 1 year were attributed to SUIDs, and in 2010 almost 60% of Argentinian infants slept in the supine position. In 2002 investigators assessed sleep position recommendations medical professionals gave to new parents in 16 countries in Latin America and the Caribbean and found that only 25.7% recommended supine sleep position in the home. Supine sleeping was later widely promoted globally and adopted in the United States (US) as were other sleep environment recommendations to reduce SUID, but less is known about SUID rates and safe infant sleep practices in other parts of the Americas. These strategies led to a dramatic reduction in infant deaths and increased scrutiny of the sleep environment in other countries. In the late 1980s and early 1990s researchers in several European countries and New Zealand found many SUIDs were linked to the prone sleep position, which was followed by mass public health campaigns promoting “Back to Sleep”, whereby parents and care givers were instructed to place their infants in a supine or face up position to sleep. In high income countries SUIDs tend to be inequitably distributed, where the burden is greater in populations with numerous health disparities specifically those with socioeconomic, racial/ethnic, and educational disparities are most at risk of SUIDs. Those where the causes of death are investigated and remain of unknown etiology, make up the majority of SUIDs and are categorized as sudden infant death syndrome (SIDS) and 90% of these deaths occur prior to 6 months of age. Sudden Unexpected Infant Deaths (SUIDs) that are sleep-environment related are diagnosed as suffocation, entrapment, or unknown etiology. The University of Kentucky Office of Research Integrity also approved the study, IRB # 42965). The University of San Francisco Quito, Research Ethics Committee in Human Beings approved the study, #2017- 127 M. (Clinical Trial Registry, per : not applicable under 42 CFR 11.22(b) as the study Facility Location was not in the United States (took place in Ecuador), does not involve FDA IND or IDE, and does not involve a drug, biological or device product that is manufactured in and exported from the US for study in another country. This suggests the baby box may have served as an important prompt towards safer infant sleep practice. While not all participants used the box regularly, the mothers who received the box were more likely to practice safe sleep at 1 month and 6 months. The group difference was also present at 6-months post-birth: those in the baby box group were 2.9 times more likely to report safe sleep practices compared with those in the diaper bag group ( OR = 2.86 and 95% CI: 1.16–7.05 χ 2 = 5.2, p = .022). Those in the baby box group were 2.5 times more likely to report safe sleep practices compared with mothers in the diaper bag group at 1 month (odds ratio = 2.45 and 95% confidence interval : 1.03–5.86 χ 2 = 4.1, p = .043). Four infant sleep practices (room sharing, bed sharing/co-sleeping, position, and soft items in the sleep environment) were assessed at 1 month and 1 months post-delivery during a home visit where safe sleep education was also reinforced with both groups. This was followed by randomization into two groups the control received a diaper bag and newborn gifts, and the intervention group received a baby box and the same gifts at each timepoint. In this longitudinal randomized controlled trial all participants received the same safe sleep education in their third trimester of pregnancy ( n = 100). The purpose of the study was to evaluate whether the provision of a Finnish-style baby box reinforced safe infant sleep practice in the home in a low-resource community in Ecuador. While infant mortality rates have generally improved after the maternity package was introduced, little is known about whether the provision of the baby box increased safe sleep practices. The provision of baby boxes with a mattress and infant supplies has been part of a larger anti-poverty social justice maternity package for decades in Finland. Modifying the infant sleep environment to promote safe sleep is the most effective risk reduction strategy to reduce SUID. Sudden Unexpected Infant Deaths (SUID) can occur between 1 month and 1 year of age and are inequitably distributed with a greater burden in populations with numerous health disparities.
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