The Practice of Infant Sleep Position among Mothers in Jimma Town Public Health Institutions,Jimma,Oromia,South West Ethiopia,2022

Abstract

Background

One of the important interventions in the infantile period is the selection of appropriate infant sleeping position. Unsafe infant sleep position is associated with sudden unexpected death in infancy. Yet, little is known about the practice of infant sleep position in Ethiopia. This study aimed to assess the practice of infant sleep position among mothers attending mother and child health service in Jimma town public health institutions, South West Ethiopia, 2022.

Methods

An institutional based cross-sectional study design was conducted on 409 women attending Maternal and child health service in Jimma town public health facilities. The data were collected using a pre-tested and semi- structured questionnaire. Binary Logistic regression was used to analyze the association between the practice infant sleeping positions and explanatory variables. The strength of association was evaluated using an odds ratio at a 95% confidence interval and a P-value ≤ .05 was considered to declare significant associations.

Results

Four hundred nine women participated in the study, with a response rate of 97%. The practice of recommended infant sleeping position (supine position) in this study was 33.5% [95% CI (28.9% - 38.6%)]. Being married Adjusted odds ratio (AOR) 2.6; 95% CI (1.04-6.48)), residence (AOR 1.88; 95% CI (1.1-3.31)) multi gravidity (AOR 1.6; 95% CI (1.02-2.59)) and having good knowledge of sleeping position (AOR 1.55; 95% CI (1.01-2.38)) were significantly associated with the practice of infant sleep position

Conclusion

The practice of medically recommended infant sleep position in this study was low. Being married, residence, multi gravidity and having good knowledge of sleeping position were significantly associated with the practice of infant sleep position. Therefore, considering these associated factors during health care provision and disseminating information on safe sleep practices for mothers is needed. Also, different stakeholders, including the federal ministry of health, health professionals, and health institutions at different levels, need to give attention to such problems in addition to the service to reduce infant mortality

Keywords

infant sleeping position infant practice sleeping position

Introduction

The selection of an appropriate sleeping environment and arrangement is one of the important interventions in the infantile period. Safe infant sleeping arrangements refers to the arrangements provided by the mother or the primary caregiver in order to avoid injury and /promoting the general health of the child.^1,2

Unsafe infant sleep position is related to sudden unexpected death in infancy (SUDI) and other sleep-related deaths.³ Non-supine baby sleep position was known as a crucial modifiable risk issue for sudden surprising death in infancy. There was a decrease in infant mortality rates from SUDI in several countries after the success of international public health campaigns advising on the safe baby sleep position.^1,4 According to the guidelines given by the American Academy of Pediatrics(AAP), the arrangements that are considered to be safe for the infants are, use of firm surface, regular parental care, breast feeding, appropriate position, safe place, and safe home environment.⁵

According to the American Academy of Pediatrics, the recommended sleeping position for infants aged one year or less is supine position. The main justification for recommending that babies sleep on their back and not on their side is that the tendency infants have to roll over onto the tummy while sleeping on the side; thereby placing them at increased risk of SIDs.³

Sleeping other than supine position, like prone position by infants has been related to increased risk of SIDS. The SIDS refers to the unexpected and unexplained death of children under 1 year of age, even after reviewing the clinical history, assessing the circumstances of the place of death and a postmortem examination.³ Death from SIDS can occur anytime during a baby's first year, and the peak incidence is between 2 and 4 months of age, but the majority (90%) of SIDS deaths occurs before a baby reaches 6 months of age. It occurs more often in males than females.^4,6

Even though there is a huge decrease in infant mortality rate from an estimated rate of 65 deaths per1000 live births in 1990 to 29 deaths per 1000 live births in 2018 globally, Africa is still showing the big number which is 47.45 as of African macro trend report.⁷

Ethiopia is one of the countries with a high infant mortality rate. Like many developing countries there is no deep study regarding mortality related to SIDS which is directly associated with infant sleeping position as a result of infant sleeping position, as choosing infant sleeping position is related to maternal knowledge and practice there is no much study assessing those factors in Africa especially in Ethiopia distinctly in Jimma Town. In addition, there is no single research in Ethiopia neither at national nor regional level which delineates the magnitude of unsafe infant sleeping position practice being practiced among mothers despite having high under one year population.

Method and Materials

Study Area

The study was conducted in Jimma town public health institutions, Jimma, Oromia regional state, south-west Ethiopia. Jimma town is 346 kilometers from Addis Ababa. In the town, there are five public health centers and two hospitals that provide services for the community, such as curative, preventive, and admission services. According to the 2007 census of Ethiopia, the total population of Jimma is 182 942 with 91 771 males and 91 171 females. There are seven public health care institutions in Jimma town. From the seven, two are hospitals, and the rest are health centers.

Study Design and Period

An institutional based cross-sectional study design was conducted in those selected health institutions. The study was conducted from June 01-July 1 2022.

Population

Source population

All women who gave birth in the past year and attended MCH served in Jimma Town public health institutions were the source population.

Study population

Mothers who gave birth in the past 1 year and attended MCH serve in selected Jimma town health care institutions during the data collection period were the study population.

Sampling Technique and Sample Size

Sample size

The sample size was determined by the assumption that 50% prevalence considering the absence of previous data on specific study population and with 5% margin of error, 95% confidence interval (CI) and a non-response rate 10%. Based on this assumption the actual sample size of the study was determined using the formula for single population proportion.

n = \frac{{(Z_{α} / 2)}^{2} p (1 - p)}{d^{2}}

Where n = Sample size /the desired sample size)

Zα/2 Standard (1.96)

P = expected proportion of infant sleeping position = 50% = 0.5

d = margin of error = 5% = 0.05

Therefore

n = \frac{{(1.96)}^{2} 0.5 (1 - 0.5)}{{(0.05)}^{2}} = 384

n = 384 + 10% of the sample size for substitution of non-respondent client = 422.4. Therefore, the final sample sizes for this study were 422.

Sampling Techniques

From all 7 public health care institutions (5 HC and 2 hospitals) found in Jimma Town, the three public health care institutions (2 HC and 1 hospital) were selected by lottery method, and then proportional allocation was done for the health institutions in terms of the previous monthly report number of their MCH service. A systematic sampling technique was used to select study subjects who attended MCH services during the data collection period. The previous monthly report number of MCH services in selected public health care institutions was taken as a total population, which is 2430. Then, to obtain the sampling interval (k-value), use the formula k = N/n, where k is the constant value, N is the previous monthly report number of MCH service, and n is the sample size. The first study subject was selected by lottery method. Data were collected for every sixth woman who attends MCH services in the selected health care institution.

Study Variables

Dependent variable

The practice of Infant sleeping position

Independent variables

Socio demographic related characteristics: Age, Religion, Ethnicity, Educational status women, educational status husband, marital status, and occupation.

Obstetric related characteristics: parity, gravid, ANC visit, complication, place of delivery, personnel who conduct delivery.

Operational Definition

Maternal knowledge: Maternal knowledge was assessed through 10 knowledge questions, which were adopted in English from different published literatures.^6,8,9 Each question responded with right answer was allotted a scoring of one and every wrong answer was given a score of zero. The total attainable score in knowledge questionnaire is 10. In order to identify a respondent as having good or poor knowledge, the group was divided into 2 categories based on the scores attained So, Respondents who answered greater than the mean score of questions provided for them regarding knowledge were considered as having good knowledge. While those answers below the mean score are those with poor knowledge.

Primi gravida: defined as a woman who conceives for the first time

Multi gravida: a woman who is pregnant for at least the third time

Data Collection Methods and Instrument

Data were collected by face-to-face interview using a pre-tested, semi-structured questionnaire from the respondents. The tool was first prepared in English and then translated to the local language (Afan Oromo). The tool comprises socio-demographic, obstetrics characteristics, relationship to the infant, knowledge of women regarding sleep position, source of information, and practice of sleeping position. Three bachelor of sciences (BSc) and one master of sciences (MSc) midwife professionals were selected for data collection and supervision, respectively. A one-day training was given for both data collectors and supervisors about the methodology and questionnaire by the investigators.

Data Quality Control

The qualities of data were assured before data collection, during data collection and after data collection. Prior to the data collection, the questionnaire was pre-tested on 5% of the sample size. And day training was given for data collectors and supervisors. During data collection, close follow up was done by supervisor and principal investigator. After data collection, data was checked for completeness and using epi data also helps to automatically detect errors made during data entry.

Data Analysis

The collected data were analyzed descriptively and by binary logistic regression using SPSS version 25. Descriptive statistics were done and presented using narratives, tables, and figures. Binary logistic regression was used to find the crude association between the practice of infant sleep position and explanatory variables. Explanatory variables that had a P-value of less than .25 and fulfill the assumption of logistic regression from bi-variable logistic regression were considered for the multivariable logistic regression model. The strength of association was evaluated using an odds ratio at a 95% confidence interval and a P-value ≤ .05 was considered to declare significant associations.

Ethical consideration

Ethical clearance and permission were obtained from the Ethical review committee of Jimma University, school of midwifery. Study participants were informed about the objectives, benefits, risks and their right to the decision of participating in the study. Also, the study subjects were informed their responses will be coded and used only for only research purposes. Participants name was made anonymous to affirm confidentiality throughout the study. Moreover, informed written consent was taken before data collection started.

Results

Socio Demographic Characteristics

Four hundred nine mothers were participated in this study, giving a response rate of 97%. The mean age of the mothers were 26.8 ± 4.78 standard deviation (SD) years, with a minimum of 18 and a maximum of 48 years. The majority of respondent's religion were Muslim (52.6%), followed by Orthodox (28.8%). The educational status of the respondents varies from illiterate to graduate and post-graduate. While seventy-five (18.3%) of them were illiterate, three hundred and thirty-four (81.7%) of the mothers could at least read and write, and of those, 98 (29.3%) had graduated from higher education institutions. Concerning occupation, (53.3%) of respondents were housewives. Three hundred twenty-eight (77.8%) lived in urban areas, whereas eighty-one (22.2%) lived in rural areas (Table 1).

Table 1.

Socio-Demographic Characteristics of Mothers Attending Mother and Child Health Service in Jimma Town Public Health Institutions, Ethiopia 2022.

Variables		Frequency (%)	Percentage
Age	18 and under	5	1.2
	19-24	122	29.8
	25-30	212	51.8
	31-36	55	13.4
	37 and older	15	3.7
Religion	Muslim	215	52.6
	Orthodox	118	28.8
	Protestant	72	17.6
	Others	4	1
Marital status	Single	39	9.5
Marital status	Married	370	90.5
Educational status(respondents)	Can’t read and write	75	18.3
	Can read and write	104	25.4
	Up to high school	65	15.9
	Preparatory school	67	16.4
	Graduate or post graduate	98	24
Educational status (Husbands)	Can’t read and write	45	11.0
	Can read and write	106	25.9
	Up to high school	85	20.8
	Graduate or post graduate	173	42.3
Job/ occupation	Governmental employee	67	16.4
	Self employed	77	18.8
	Student	24	5.9
	House wife	218	53.3
	Others	23	5.6
Residence	Rural	91	22.2
Residence	Urban	318	77.8
Family size	1-4	215	52.6
	5-8	169	41.3
	9 and above	25	6.1

Obstetric History of the Study Participants

One hundred twenty (29.3%) of the mothers were prim gravida and376 (91.9) study participants had at least one ANC visit during their pregnancy. Three hundred seventy four respondents give birth at health institutions (Table 2).

Table 2.

Obstetric History of Mothers Attending MCH Service in Jimma Town Public Health Institutions, Ethiopia 2022.

Variables		Frequency	Percentage
Gravidity	Primi-gravida	120	29.3
Gravidity	Multigravida	289	70.7
Parity	Primi-para	166	40.6
	Multi para	211	51.6
	Grand multipara	32	7.8
ANC follow up during last pregnancy	Yes	376	91.9
ANC follow up during last pregnancy	No	33	8.1
How many ANC visit	One visit	7	1.7
	2-4 visits	258	63.1
	5 and more	111	27.1
Place of birth for recent pregnancy	home	35	8.6
Place of birth for recent pregnancy	At health institutions	374	91.4
Sex of your baby	Male	192	46.9
Sex of your baby	Female	217	53.1
How many children	1-4	380	92.9
	5-8	27	6.6
	9 and above	2	0.2
Pregnancy related complications	Preterm	20	4.9
	Hypertension	56	13.7
	Miscarriage	25	6.1
	Diabetes	6	1.5
	Other	4	1

Table 3.

Factor Associated with Practice of Infant Sleeping Position among Mothers Attending MCH Service in Jimma Town Public Health Institutions, Ethiopia 2022.

Variables		Practice		COR	AOR	P- value
Variables		unsafe	Safe	COR	AOR	P- value
Marital status	Single	33	6	1		.04*
Marital status	Married	239	131	3.01(1.23-7.38)	2.6(1.04-6.48)	.04*
Residence	Rural	70	21	1		.02*
Residence	Urban	202	116	1.9(1.12-3.28)	1.88(1.1-3.31)	.02*
Anc visit	Yes	244	28	1		.12
Anc visit	No	132	5	.33(0.12-0.87)	0.44(.15-1.26)	.12
Gravida	Primi	90	30	1		.05*
Gravida	Multi	183	106	1.74(1.07-2.80)	1.6(1.02-2.59)	.05*
Place of birth	Home	29	6	1		.14
Place of birth	Health facility	243	131	2.6(1.05-6.44)	2.1(.79-5.4)	.14
Knowledge	Poor	162	61	1		.05*
Knowledge	Good	111	75	1.8(1.18-2.72)	1.5(1.01-2.36)	.05*
Number of children	One	121	48	1		.53
Number of children	More than 1	152	88	1.46(1.05-2.23)	1.14(.75-1.73)	.53

*Statistically significant at P < .05, 1 = reference category.

From the table those have * shows that variables which had a significant association with practice of sleeping position in multivariate logistic regression.

Knowledge of Sleeping Position

One hundred eighty six (45.5%) of study participants had a good knowledge about sleeping position while the other 223(54.5%) had a poor knowledge (Figure 1).

The practice of infant sleep position

The practice of recommended sleeping position (supine position) in this study was 33.5% [95% CI (28.9% – 38.6%)].While the other 272(66.5%) of respondents reported that they had not practiced the recommended infant sleep position (Figure 2).

Factors Associated with the Practice of Infant Sleeping Position

In bivariate logistic regressions six variables include: Marital status crude odds ratio (COR) = 3.01(1.23-7.38), residence COR = 1.9(1.12-3.28), not having ANC visit COR = .33(0.12-0.87), gravidity COR = 1.74(1.07-2.80), Place of birth COR = 2.6(1.05-6.44), Number of children COR = 1.46(1.05-2.23) and having good knowledge of sleeping position, COR = 1.8(1.18-2.72) were significantly associated with the practice of sleeping position. However, in multivariate logistic regressions only four variables, being married Adjusted odds ratio (AOR) 2.6; 95% CI (1.04-6.48)) P- value 0.04, residence (AOR 1.88; 95% CI (1.1-3.31)) P- value .02, multi gravidity (AOR 1.6; 95% CI (1.02-2.59)) P- value .05 and having good knowledge of sleeping position (AOR 1.55; 95% CI (1.01-2.38)) P- value .05 were significantly associated with the practice of infant sleep position (Table 3).

Discussion

The practice of medically recommended infant sleeping position (supine position) in this study was 33.5% [95% CI (28.9% – 38.6%)]. The finding was lower than a studies conducted in Istanbul, Turkey (46%),¹⁰ in United States(61%),¹¹ in Riyadh, Saudi Arabia (61.9%)¹² and in Brazil (55.4%).¹³ This variation is possible due to variation in study design, socioeconomic and cultural differences in the populations assessed in these studies. The current study was conducted in cross sectional study, but the study conducted in Brazil was cohort and the data come from a population-based study with a high follow-up rate. On the contrary, the finding of the current study was higher than the study conducted in Pediatric Outpatient and Well– baby clinics of the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria (18.1%).⁹ This variation is possible due to variation in year of study, the sample size, socioeconomic and cultural differences in the populations assessed in these studies.

The current study indicated that there was a strong association between being married marital status and the practice of medically recommended infant sleeping position. Married respondents were 2.6 times more likely to have good practice of infant sleep position than their counterparties. The finding was supported by a study conducted in Cheyenne, United States.¹⁴ These findings could possibly be due to involvement of a partner in acquiring health education and choosing infant sleep position.

In this study there was a strong association between women's residency and the practice of medically recommended infant sleep position. Women living in urban areas were two times more likely to practice medically recommended infant sleep position than those living in rural areas (AOR 1.88; 95% CI (1.1-3.31)). The finding was supported by a study conducted in Canadian Maternity Experiences Survey.¹⁵ This is probably due to the accessibility of better information and awareness about infant sleep position in urban areas than in rural areas. Therefore, the ministry of health and/or other stakeholders should focus to address health information's for the rural community.

Another independent variable which had significant association with the practice of medically recommended infant sleep position was Gravida. Multigravida women were 1.6 times more likely to practice medically recommended infant sleep position than prim gravida (AOR 1.6; 95% CI (1.02-2.59)). This is possible because multigravida women's had an experience on how to sleep their infant as compared to primipara.¹⁶

In this study having good knowledge of sleeping position were significantly associated with the practicing safe sleeping position. This study was supported by previous studies and the AAP recommendations.^3,17 Additionally, study conducted on African-American mothers, it was found that receiving information of correct sleep position from multiple sources was significantly correlated with correct practice.¹¹ Also study conducted in Georgia showed a high correlation between the knowledge of the recommended infant sleep position and the practice of “back to sleep”.¹⁸

Limitations

Being the first study to assess the situation in Ethiopia and the study area in particular is the major strength of this study. In addition, the study tried to include public health facilities where most pregnant women in Ethiopia receive maternal and child health care services. However, the study was limited to addressing mothers who attended MCH services at private health care institutions. Additionally, this study does not include the health care providers’ view and analysis of parents’ sleep positions (supine vs not) with qualitative data as a mixed methods approach.

Conclusions

The practice of the medically recommended infant sleep position was very low compared with the previous studies and global recommendation. Nearly two-thirds of study participants do not practice the internationally recommended infant sleep position. Being married, residence, being multi-gravid, and having good knowledge of sleeping positions were significantly associated with the practice of infant sleep positioning. Therefore, considering these associated factors during health care provision and disseminating information on safe sleep practices for mothers is needed. Also, different stakeholders, including the federal ministry of health, health professionals, and health institutions at different levels, need to give attention to such problems in addition to the service to reduce infant mortality.

Figure 1.

Knowledge of mothers attending mother and child health service regarding infant sleeping position in Jimma town public health institutions, Ethiopia 2022.

Figure 2.

Infant's sleeping position practice among mothers attending mother and child health service in jimma town public health institutions, Ethiopia 2022.

Footnotes

Abbreviation and Acronyms

Author's Contributions

All authors contributed to the study conception and design. AY, BT and TB drafted the manuscript and analyzed the data while BF, YD and YD has critically reviewed the draft for the intellect and rewritten the entire manuscript the way it is currently presented. All authors had approved the final version.

Availability of Data and Supporting Material

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Consideration

Funding

Institution of health science, Jimma University. In this study, the funders did not have any role in the study design, data collection, analysis, or interpretation of the data, or in the writing of the manuscript.

ORCID iDs

Aynalem Yetwale

Tsegaw Biyazin

Belete Fenta

Yalemtsehay Dagnaw

Author Biographies

Aynalem Yetwale, Lecturer at school of midwifery, Faculty of Health Sciences, Institute of Health, Jimma University, Jimma, Ethiopia, MSc in Clinical Midwifery.

Bilen Tigstu, Midwife at Jimma university medical center, Jimma, P. O. Box: 378, Ethiopia.

Tsegaw Biyazin, Lecturer at school of midwifery, Faculty of Health Sciences, Institute of Health, Jimma University, Jimma, Ethiopia, MSc in Maternity Health.

Belete Fenta, Lecturer at school of midwifery, Faculty of Health Sciences, Institute of Health, Jimma University, Jimma, Ethiopia, MSc in Maternity Health.

Yalemtsehay Dagnaw, Lecturer at department of Nursing, Mizan-Tepi University, Mizan Tapi: P. O. Box: 260, Ethiopia.

Yaregal Dessalew, Lecturer at school of midwifery, Faculty of Health Sciences, Institute of Health, Assossa University, Assossa, Ethiopia.

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