Is bedsharing safer than my midwife said it was?

Picture taken from the ISIS co-sleeping image archive
Picture taken from the ISIS co-sleeping image archive

You’ve probably read in the media that sharing a bed with your baby is dangerous and increases the risk of SIDS.  Your midwife has probably mentioned it or will mention it as part of the checklist that is completed prior to discharge from hospital.  You’ll probably be given this leaflet on reducing the risk of SIDS and this leaflet Caring for Your Baby at Night.  Both these leaflets advise that the safest place for your baby is in his own cot, next to your bed for at least the first six months.

Does the research actually suggest that bedsharing is risky, though? 

Many have argued that the existing evidence isn’t clear cut, because the methodology used isn’t particularly good.  I’m not even going to start to go into an in depth analysis of the research but if you want to read a very good critique, this is a good place to start.  One point to consider though, is that often known risk factors for SIDS are not taken into account when looking at how safe it is, so for example, SIDS deaths attributed to bedsharing may have occurred where there were known risk factors such as smoking or drug use and therefore, are not a clear reflection of the absolute risk of SIDS in “safe” bedsharing, where known risks are excluded. Interestingly, even though the leaflet Caring for your Baby at Night states that the safest place for your baby is in his own cot, Unicef (who published the leaflet) also point out in the Health Professional Guide to: Caring for Your Baby at Night that: “Although there is an association between bedsharing and SIDS, increasingly the evidence suggests that it is not bed-sharing per se that is a risk factor, but the circumstances in which it occurs. Furthermore, there are advantages to bedsharing for both the mother and baby that need to be taken into account.”1 These advantages of bedsharing (mothers more aware of their babies at nighttime, babies breastfeeding for a longer duration, and mothers more likely to room share for at least six months) are protective factors in and of themselves for reducing the risk of SIDS, so it is difficult to assess the absolute risk of SIDS in bedsharing.2

I’ve even seen a few people state that bedsharing is safer.  I think this may come from a confusion in reading the literature which equates co-sleeping with rooming in.  In the UK co-sleeping is often interchangeable with bedsharing, to mean sharing a sleeping space with your baby.  In the US literature co-sleeping often seems to be used to describe “rooming in”, in other words the baby sleeps in his own space in your room3.  And yes, this definition of co-sleeping is absolutely safer than a baby sleeping in his own room, it is proven to reduce the incidence of SIDS, which is why the recommendations are to share a room with your baby for at least six months.  It may also be people who say that bedsharing is safer is because they equate bedsharing as having benefits (baby sleeps more soundly, mum is more likely to breastfeed for a longer period of time, mum gets more sleep) as being more safe, but just because there are advantages to a course of action does not necessarily make it safer.

So… the evidence for bedsharing being dangerous isn’t as straightforward as it might appear.

Let’s take a sidewise step at this point… From a biological perspective it makes sense that babies are going to be happiest and most content when in very close proximity with their mother or another adult.  Babies are helpless and unable to provide for their own needs and therefore are “programmed” to need to be in contact with a parent for their survival, so the environment in which they will truly feel safe and secure and maximise their potential for development is their mother, who supplies all their needs (food, warmth, safety, mobility, comfort).2 Obviously, this means night time as well since babies don’t stop having these needs at night-time.  So, from a biological perspective it would appear that bed-sharing should be an extension of that close contact a baby needs from a parent during the day.  So why are there so many warnings against it?

I think first and foremost we need to acknowledge that bed sharing is Not The Done Thing in western societies.  It is seen as “normal” for babies to sleep in their own space from birth and in their own room as soon as possible.  When I was a student midwife I travelled to Guatemala.  I met with some amazing birth attendants there and we had some very interesting conversations.  I remember telling them that in the UK babies sleep in their own cots and mothers get up to feed them during the night.  This was met with much hilarity and incredulity.  They honestly thought this was the stupidest thing they’d ever heard, because babies just slept in bed with them, and when they needed fed, you stuck a nipple in their mouth and went back to sleep.  Why would you get up to feed them? When I travelled to India when my daughter was 4 months old (my husband is Indian) we weren’t even asked by my in-laws if we needed a cot.  The assumption was that she would sleep in our bed with us.  It is a very Western notion that babies need their own sleeping space.  Interestingly, both Hong Kong and Japan have a culture of bedsharing yet have very low rates of SIDS2,3   so perhaps reducing the risk of SIDS has more to do with a culture of “safe” bedsharing rather than a straightforward ban on bedsharing.

I think it’s important to understand the cultural notions we have with regards to bedsharing, because I think it has a huge impact on what happens in practice.  Now, in all my 13 years as a midwife, I have never gone in to someone’s house and had someone admit that they were planning to bedshare or that they already bedshared.  When I start my little “reducing the risk of SIDS” speech, invariably Mum and Dad nod earnestly and say, “Oh, yes, we’d never sleep with our baby in our bed.”  So… what’s the big problem with that?  Well, the problem with that is that a significant proportion of parents at some point do bring their baby into bed with them.1  Most of my friends have, at some point, brought their baby into bed and slept with them.  They maybe don’t plan to, it maybe even happens by accident.  Baby might be going through a growth spurt and feeding a lot, or is just unsettled, mum brings baby into bed and falls asleep without meaning to.  Or perhaps, parents have decided that they do want to bedshare but don’t feel that they can “admit” this to the midwife.  So… if we don’t have a culture of bedsharing, and bedsharing isn’t discussed beyond “Don’t bring your baby into bed with you as it isn’t safe”, then there isn’t an honest discussion around bedsharing and the reality of what actually happens or ways to minimise the risks, and I do think we need to acknowledge the risks.  If we don’t, then there is the potential for one of the following to happen:

Accidental co-sleeping In one scenario, a parent may choose to get up to feed or comfort a baby on a sofa or chair in order to avoid falling asleep in bed with their baby and then inadvertently fall asleep.  Sleeping with a baby on a sofa or chair is known to increase the risk of SIDS significantly and this risk is actually higher than if a parent was bedsharing in the first place.  So by avoiding bedsharing, the risk of SIDS is actually increased.  Alternatively, a parent may bring a baby into bed, and fall asleep without meaning too, and because he/she didn’t plan to bedshare, there are risk factors present (e.g. baby is covered with a duvet, or placed up on a pillow next to mum).

Not knowing how to minimise the risks when bedsharing  I think this is particularly relevant here in the UK, because we don’t have a culture of bedsharing, therefore we have very little information on how to make it as safe as possible.  Interestingly, most articles on bedsharing don’t include pictures of babies bedsharing in ways that meet the current recommendations, so much so that Infant Sleep Information Source (with the rather unfortunate acronym ISIS) specifically have a database of “safe” bedsharing photos that people can use.4  Basically, if your only frame of reference is an article on bedsharing and even the photo used doesn’t show the safest way to do it, then how can you be expected to do it safely yourself?  Furthermore, if your midwife and health visitor haven’t actually discussed with you how to make it as safe as possible, then where do you get your information from? You may end up turning to parenting groups or forums to get your information.  You may get great information or resources in these groups, but you may be just as likely to get someone recommend that you do what they did, rather than what is known to be safe. I think that because often there is no discussion with health care professionals around bedsharing and instead they often take an authoritarian view (You Must Not Bedshare), those who have a tendency to be dismissive or sceptical of medical advice may also dismiss the recommendations for bedsharing safely as well; or perhaps because some people know that the research on bedsharing is flawed, there is a tendency to dismiss the other recommendations for reducing the risk of bedsharing, even though there is strong evidence for these risks.  I’m in a few parenting groups and I’ve seen that some people ignore the recommendations for bedsharing safely; so they may place baby on their tummy to sleep in their bed, or they may also co-sleep with a toddler or older child, or another behaviour which is known to increase the risk to the baby. So, perhaps these groups are not the best source of information for safe bedsharing.

shutterstock_238672270

So, should you bedshare?

The biggest thing for me, I think, is that the environment for bedsharing is not something you can control 100%.  I bedshared as safely as I could and there were still a few times when I woke up to find my daughter had rolled over onto her face, or the duvet I was using for myself had moved and was covering her.  I probably “got lucky” more than once.  Undoubtedly, a cot by your bed is an environment which is easier to control and less likely to result in potential risky scenarios, see here for a safe cot environment.  I can’t decide for you whether you should bedshare or not, but if you decide to breastfeed, you may find that bedsharing makes it much easier to feed at night and you breastfeed for longer.  Even if you decide that you aren’t going to bedshare, it might be worthwhile looking at your sleeping environment and making it as safe as possible, just in case you accidentally end up bedsharing.  You will never be as tired as in those first few weeks after your baby is born and sometimes you end up doing things you hadn’t intended to do.  The important thing is that you’ve got all the information, you’ve thought it through and you make the right decision for you and your baby and it’s as safe as possible.

Making bedsharing as safe as possible

The Caring for Your Baby at Night leaflet has the following information:

caringforyourbaby

 

Additionally, Dr James McKenna who has researched and written extensively on the subject of bedsharing, has published a booklet entitled A Quick Guide to Safely Sleeping with Your Baby.5  I find it interesting that this booklet has even stricter guidelines for safely sharing a bed with your baby, yet he is also a very strong advovate for bedsharing.  I have some copies of these booklets to borrow if you come to my classes, but some of the additional guidance he offers is:

  • Bedsharing should only occur if a mum is breastfeeding, as breastfeeding mums are generally more aware of their baby in bed and also assume a safer posture with regards to their baby in bed.
  • Bedsharing shouldn’t occur if mum is obese, to avoid overlaying.
  • Ensure long hair is tied up out of the way and there are no drawstrings, laces etc on bedclothes, to avoid strangulation.
  • Placing the mattress in the middle of the floor and sleeping there rather than in a bedframe.
  • Avoid “in bed” baskets and nests, as they can lull parents into a false sense of security and they may be less aware of their baby in bed.

Further information:

http://www.lullabytrust.org.uk/file/—–internal-documents/Fact-sheet-Bedsharing.pdf

https://www.isisonline.org.uk/where_babies_sleep/parents_bed/

References:

  1. http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/HPs_Guide_to_Coping_At_Night_Final.pdf accessed 10/6/16
  2. http://www.naturalchild.org/james_mckenna/biological.html accessed 12/6/16
  3. McKenna, J and McDade, T, (2005) Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breastfeeding, Paediatric Respiratory Reviews, 6, 134-152
  4. https://www.isisonline.org.uk/image-archive/ accessed 13/6/16
  5. McKenna, J (2013) A Quick Guide to Sleeping With Your Baby, Platypus media, Washington, DC

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Rebecca

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