Bernice entered the hospital room in the post-partum unit, congratulating members of a family on their newest addition before introducing herself as a community coordinator for New York City, there to discuss the topic of safe sleep for the baby girl. The warmth, compassion, and authority she exudes aimed to put the family at ease.

As Bernice demonstrated safe sleep techniques, such as placing the child on her back in an empty crib, she encountered some resistance from the infant’s grandmother, who expressed that her own children had slept on their stomachs without issue. After acknowledging the grandmother’s experience and sharing her own personal history of using similar sleep practices with her children, Bernice explained that research over the past decade has revealed the risks associated with bed sharing, excessive bedding, and putting infants to sleep on their stomachs. Bernice kept her tone positive and described the reasoning behind why families should follow such guidelines. By the end of her visit, the family members, including the grandmother, were receptive to modifying their behaviors in support of safe sleep practices for the baby girl.

Bernice’s personable, strengths-based approach reflects what research supports about engaging families to promote better health outcomes for their children. Handing out a flyer about safe sleep is not enough to change health behaviors since parents, and especially mothers, tend to follow the parenting traditions endorsed by family members they trust.¹ This can be particularly true in under-resourced neighborhoods where residents may not trust government agencies. What can work is a combination of public awareness, intensive engagement in the community, and education of parents and family members who influence parents.

Safe sleep practices also can be addressed by addressing issues related to poverty. For example, if families lack room for a crib or cannot afford one, they may be compelled to place their infant in bed with them or on an unsafe sleeping surface, such as a couch or air mattress. If families live in substandard housing that lacks adequate heat, they may need to put more blankets in the infant’s crib for warmth. Homes that have pest infestation problems also may be a factor in where families decide that their infant should sleep. All of these poverty-related situations can lead to decisions that unintentionally put their infant at higher risk for sleep-related injury or death.

This brief shares how New York City’s Administration for Children’s Services (ACS) has partnered with agencies across the city to reduce infant sleep-related injuries and deaths through education and support, a strategy for high-quality prevention and early intervention recommended by the National Commission to End Child Abuse and Neglect Fatalities.

By the numbers

In 2020, the sleep-related injury death rate in the U.S. was 25 per 100,000 live births.² In New York City, this rate averaged 32.9 per 100,000 live births from 2016 to 2020.³  During this same five-year span, 185 sleep-related injury deaths occurred among infants, most frequently among those younger than 4 months old.4 Though all 185 were sleep-related injury infant deaths, 139 (75%) were of an undetermined specific cause of death, and 46 (25%) were from “accidental suffocation & strangulation in bed; unspecified threat to breathing.” Among infants who died from any sleep-related injuries in 2016-2020, the infant’s mother was more likely to be young (under 20 years old), have no more than a high school education, be a Medicaid or WIC Nutrition Program recipient, and was more likely to be Black or Hispanic than white or Asian. In neighborhoods with very high levels of poverty, the rate of sleep-related injury deaths was 52.6 per 100,000 live births, compared to 17.7 in neighborhoods with low levels of poverty.⁵

Educating the public

ACS began engaging in infant safe sleep awareness activities in 2004, raising awareness and providing families with tools to keep their children safe. In 2015, ACS launched a more comprehensive, community-wide approach to further spread the safe sleep message and educate the community about the importance of safe sleep practices by partnering with five city agencies: Department of Health and Mental Hygiene (known colloquially as NYC Health); Homeless Services; Department for the Aging; Health + Hospitals (which operates the city’s public hospitals and health clinics); and the Office of the Chief Medical Examiner. These agencies engaged in high-level educational strategies, including videos and public service announcements, targeted education of families involved with child welfare, and trained community partners. The relationship between ACS and NYC Health deepened during this time as they adopted a public health approach to the work — one that centers equity, involves the whole community in identifying children and families most at risk, and intervenes early and often to educate families about the importance of safe sleep practices.

In 2015, New York City Mayor Bill de Blasio launched a formal NYC Infant Safe Sleep Initiative to further advance the city’s efforts. A coalition of partners from various disciplines, known as the Safe Sleep Stakeholders Coalition, came together to spread safe sleep messages using a public health model.⁶ A growing network of more than 130 partners have identified a common language and a shared set of strategies with which to disseminate safe sleep messaging in the areas of the city with the highest rates of infant mortality. In addition to the citywide coalition, an ACS citywide Safe Sleep Initiative Unit was formed, adding five full-time community coordinators — such as hospital visitor Bernice — who engage directly with parents, caregivers, and other community members to educate them around safe sleep practices. With a clear governance structure in place, the collaboration became more formalized. ACS and NYC Health led the development of a common agenda and language, consistently emphasizing that the safety of infants is the collective responsibility of all city agencies.

City agencies and community-based partners made a commitment to work together to address various social conditions that serve as barriers to infant safe sleep, such as housing, access to healthcare, and other resources that allow families and children to thrive. It also framed and unified priorities, strategies, and messaging to effectively promote key infant safe sleep practices citywide.

In 2021, ACS established the Office of Child Safety and Injury Prevention (OCSIP) within the Division of Child and Family Well-Being, an entity parallel to — but separate from — child protection services. OCSIP supports a variety of efforts to reduce or eliminate preventable child injuries and fatalities. Given the office’s focus on preventing unintentional injuries using public health approaches, it became the logical new home for the NYC Infant Safe Sleep Initiative.

No silver bullet

Instead of adopting a single intervention, New York City has implemented a constellation of interwoven strategies to reach and support families.

Use effective messaging

ACS and NYC Health were diligent in learning what could be improved upon and solicited community feedback to test the effectiveness of new messaging and imagery. Community members emphasized that the materials should be conveyed in a nonjudgmental tone and focus on the positive, recommendations that were subsequently integrated into the initiative’s informational materials and videos. In 2017, ACS and NYC Health produced a safe sleep brochure — offered in 10 languages — and launched a public awareness campaign, which included social media ads, and ads tailored for bus shelters, health and social services agencies, WIC centers, hospitals, and community-based organizations in areas with the highest rates of sleep-related injury deaths.⁷ In 2018, ACS created a video, “Breath of Life: The How and Why of Safe Sleep,” which explains the “why” behind safe sleep recommendations and offers solutions to everyday challenges. In 2020, this video was translated into Spanish and close-captioned for the deaf and hard of hearing.

Meet families where they are

“Information sharing alone is not sufficient,” says Dale Joseph, associate commissioner of ACS’ Office of Community Engagement and Partnerships. “This work needs to be about real behavioral change. It’s not about passing out a flyer — it’s about building a relationship so trust grows and the community can hear and hopefully respond to the information.”

The Citywide Stakeholders Coalition takes a multipronged approach to community engagement. Since every community is different, safe sleep community coordinators map out the unique strengths and opportunities in each area and identify which partners are most likely to care about and be connected to this issue. To start, they build on existing relationships with community organizations. The faith-based community has been a critical ally in this work, given its scope of influence, credibility, and influence on young parents who hold its advice in high regard. The local business community can reach a large and diverse audience, and has assisted by putting up safe sleep ads in places of business. In addition, hospitals are a safe and trusting place to engage with expectant and new mothers during a time when they are most motivated to learn how to safely care for their infants.

The community coordinator positions within the ACS Safe Sleep Unit are critical to authentic engagement. Each of the five coordinators is assigned to under-resourced neighborhoods, becoming intimately acquainted with their borough where they develop collaborative relationships, engage the community, and build credibility with residents. They emphasize the importance of being nonjudgmental and building trust in the community, so parents don’t feel as if child welfare workers are trying to catch them doing something wrong, but rather view them as a resource. Their community engagement strategies include grassroots organizing and education activities located in the core of the neighborhood, such as hosting a table in community centers, presenting at events, and visiting hospital rooms, among others. Community coordinators are trained to be sensitive to the cultural needs of the diverse populations they serve and to explain the ‘why’ behind recommended behavior changes. The families that they serve speak a variety of languages. Three of the four community coordinators and the unit director are fluent in Spanish, but many other languages are spoken in the community, and coordinators don’t always have access to an appropriate interpreter.

Utilizing the public health approach of empowering community members to develop solutions for the issues that affect them, NYC Health leveraged influential residents to take on the role of safe sleep ambassadors through the Champions Pilot Project. This project, now concluded, engaged community members through Neighborhood Health Action Centers to recruit and train grandparents and other trusted community members to demonstrate safe sleep practices and educate their own informal networks and faith-based circles.

Integrate into agencies’ existing programs

NYC Health has trained more than 8,000 home visitors, community health workers, and parents in safe sleep practices, prioritizing communities that have been most impacted by these infant deaths.⁸ The agency integrated safe sleep education and crib distribution into existing home visiting programs offered to young mothers who have low incomes. The city’s two home visiting programs — the Newborn Home Visiting Program and the Nurse Family Partnership — provide home visits to mothers regardless of age or immigration status in neighborhoods considered high-risk (Brooklyn, Harlem, and the Bronx) as well as any mothers in foster care, homeless shelters, prisons, or juvenile justice facilities. The home visitor works with the family to assess any barriers — practical or philosophical — to safe sleep and then develops solutions in partnership with them. The home visitors focus on parental concerns, problem-solve with families, and provide tools and tips to help keep their infants safe. The home visitor may help the family address housing quality issues, provide a Pack ‘N Play portable crib, or work with the family to reorganize furniture and streamline belongings to make room for a crib.

The city’s Department of Homeless Services adopted a new safe sleep policy for families with infants living in shelters, which included new training requirements for staff on how to effectively deliver safe sleep information to families. The policy outlines staff responsibilities at the different touch points in the system, from showing videos and providing educational materials at intake to assisting new mothers in installing cribs and portable playpens.

To ensure information was being distributed broadly, NYC Health includes safe sleep flyers with all birth certificate mailings. ACS partners with New York City’s Health + Hospitals agency, which operates the city’s public hospitals and clinics, to distribute Safe Sleep Toolkits to every discharging maternity patient at all 11 public hospitals. About 17,000 toolkits are distributed each year.

Community reach and impact

Since its inception, the NYC Infant Safe Sleep Initiative team has engaged directly with nearly 70,000 families across all five boroughs, providing education, support, and referrals. The team has trained nearly 22,000 child welfare frontline staff, city workers, parents, and other caregivers in safe sleep practices. The team began offering virtual trainings during the COVID-19 pandemic, and they continue today. ACS launched Communicating Infant Safe Sleep Practices, an interactive e-learning course specifically for child welfare professionals. The team also delivered a train-the-trainer course to experienced safe sleep trainers at hospitals, city agencies, and community-based organizations to build a larger pool of competent instructors. In communities with the highest rates of sleep-related infant deaths, the safe sleep team has trained thousands of fatherhood groups, faith-based organizations, expectant teens, health care professionals, formerly incarcerated mothers, public housing residents, and homeless families.

It is difficult to isolate and measure the impact that collaborative, preventive, and community-wide efforts have on a single outcome like sleep related injury deaths, which are infrequent and defined differently among various entities. While the sleep-related injury death rate in New York City has remained relatively stable over the past several years,⁹ it is much lower than the statewide rate for New York.¹⁰

1 Content for this brief was informed by email correspondence with Michele Maye, assistant commissioner of the ACS Office of Child Safety and Injury Prevention, which houses the NYC Safe Sleep Initiative, on April 18, 2023; and from conversations with Michele Maye and Marilyn Melgar, director of the ACS Office of Child Safety and Injury Prevention, on September 14, 2023.

2 Centers for Disease Control and Prevention. (2023). Sudden Unexpected Infant Death and Sudden Infant Death Syndrome – Data and Statistics. Retrieved from: www.cdc.gov/sids/data.htm.

3 ACS Office of Child Safety and Injury Prevention. Data presented at the Child Safety and Injury Prevention Summit on June 14, 2023.

4 NYC Health. Sleep Related Infant Death Data 2016-2020. Retrieved from: www.nyc.gov/assets/doh/downloads/pdf/ip/sleep-related-infant-death-data-2016-2020.pdf

5 NYC Health. Sleep Related Infant Death Data 2016-2020.

6 Partners include the American Academy of Pediatrics, the New York City Office of the Chief Medical Examiner, Greater NY Hospital Association, Human Resource Association, and the New York City Departments of Homeless Services, Education, and Police.

7 See: www1.nyc.gov/assets/acs/pdf/PressReleases/2017/0524.pdf

8 Information provided by email correspondence with New York City Department of Health and Mental Hygiene on November 20, 2023.

9 Yearly rates per 100,000 live births have been: 29.9 (2016, 2017), 35.9 (2018), 37.1 (2019), 32.0 (2020). ACS Office of Child Safety and Injury Prevention. June 14, 2023. Infant Safe Sleep and Shaken Baby Syndrome. 2023 Child Safety and Injury Prevention Summit.

10 From 2017 to 2021, the rate of sleep-related injury deaths for the State of New York ranged from .91-1.06 per 100,000 total population, while for New York City it ranged from .42-.47.