Exploring Gaps in Maternal Knowledge Regarding Sudden Infant Death Syndrome and Its Risk Factors

Amal Ahmed Elbilgahy

Maternal & Child Health Nursing Department, Faculty of Nursing, Northern Border University, Arar 73213, Saudi Arabia; Paediatric Nursing Department, Faculty of Nursing, Mansoura University, Dakahlia Governorate 35516, Egypt

Corresponding Author’s Email: amal_ahmed568@yahoo.com

ABSTRACT

Background: Sudden Infant Death Syndrome (SIDS) remains a leading cause of infant mortality. Understanding maternal knowledge and attitudes towards SIDS is essential for prevention. This study aims to explore gaps in maternal knowledge regarding SIDS and its associated risk factors among mothers in Arar, Saudi Arabia. Methods: A cross-sectional exploratory design was employed, involving 135 mothers of infants under one year. Data was gathered over the course of one month, beginning in January 2025, through a structured questionnaire that evaluated knowledge and attitudes regarding SIDS. Results: Most mothers (74.1%) recognised the definition of SIDS, yet only 58.5% identified the highest risk age. Knowledge of preventive practices was low, with only 23.7% understanding the role of pacifiers. A significant proportion (65.2%) acknowledged smoking around infants as a risk factor. Statistical analysis revealed that higher educational attainment and maternal age positively correlated with better knowledge and attitudes towards SIDS prevention. Conclusion: There is a critical gap in maternal knowledge regarding SIDS prevention despite high awareness of the syndrome. Targeted educational interventions are necessary to enhance understanding and promote safe sleep practices among mothers.

Keywords: Educational Interventions; Maternal Knowledge; Prevention; Risk Factors; Sudden Infant Death Syndrome

INTRODUCTION

Sufficient sleep is essential for the growth and development of infants, who require a consistent bedtime routine and a safe sleeping environment. However, an improperly arranged sleep environment can pose risks to an infant’s life. SIDS is a leading cause of infant mortality in socio- economically advanced countries (Saasa et al., 2025). It is crucial for primary caregivers to understand the risks associated with sleep-related deaths, especially sudden infant death syndrome (SIDS), which can affect healthy infants within their first year and has an unclear cause (CDC, 2017). Sudden Infant Death Syndrome, commonly referred to as crib death, is the sudden and unexplained death of a seemingly healthy infant during sleep, primarily occurring within the first 12 months of life (Spinelli et al., 2017).

Research aimed at preventing unexpected and unexplained infant deaths has decreased the rates in England and Wales to a low of 0.27 per 1,000 live births in 2021. However, babies born to families in lower socio-economic groups continue to face a disproportionately higher risk, with the rate for 2021 being 0.38 per 1,000 live births among those in the lowest socio-economic classification (ONS, 2021; Pease et al., 2025). Several non-modifiable factors have been associated with SIDS, including prematurity, low birth weight, and the infant's gender (Mohamed, Abusaad & El-agamy, 2021; Gemble et al., 2020). From 1990 to 2019, the prevalence of SIDS was found to be higher in males than in females (Park et al., 2022), with the highest incidence occurring between two and four months of age and 90% of cases happening before six months (Oden et al., 2010). Numerous studies show that SIDS prevalence varies significantly by country and ethnicity. For instance, in 2003, the SIDS rate was 2.08 per 1,000 births among African Americans, compared to 0.65 per 1,000 for non-African Americans. Despite a decline in SIDS rates during the late 1980s and 1990s due to educational initiatives like the Back to Sleep Campaign, SIDS remains a leading cause of infant mortality in the U.S. (Rollins, 2017; Goldberg et al., 2018).

The American Academy of Paediatrics (AAP) promotes a safe sleep environment to reduce the risk of sleep-related deaths in infants, including SIDS, suffocation, and asphyxia. Their guidelines focus on educating caregivers, parents and healthcare providers about safe infant care. Additionally, they emphasise the need to inform mothers about risky behaviours during pregnancy, such as smoking, which significantly increases SIDS risk (Moon & Hauck, 2016). To reduce SIDS risk, key recommendations include placing infants on their backs for sleep, using a firm surface, offering a pacifier at bedtime, allowing tummy time while awake, avoiding bed-sharing, keeping the sleep area free of loose bedding, and preventing smoke exposure or overheating. Nurses are crucial in demonstrating safe sleep practices and educating caregivers about these strategies as families prepare to go home (Dowling, Garratt & Manias, 2025). It's important to distinguish between "bed-sharing" and "co-sleeping". Room-sharing, as recommended by the American Academy of Paediatrics, involves sleeping in the same room but not the same bed, reducing SIDS risk by nearly 50%. While bed-sharing is common for cultural reasons, it does not protect against SIDS. Instead, breastfeeding and pacifier use are recommended to help lower the risk (Task Force on Sudden Infant Death Syndrome, 2016; Elbilgahy et al., 2019). Neo-natal nurses play a crucial role in shaping best practices for SIDS prevention. They are uniquely positioned to educate caregivers about safe sleep practices and provide guidance on reducing the risk of SIDS. By offering training and support, nurses help ensure that families are well-informed and equipped to create a safe sleeping environment for their infants.

Significance of the Study

SIDS is a complex condition with largely unknown causes. Research suggests that certain developmental stages, especially those involving brain abnormalities or genetic factors, may increase SIDS risk. The highest risk period is between 2 to 4 months, with 90% of cases occurring before six months. Vulnerability can be heightened by external stressors, including risk factors such as prone sleeping positions, bed sharing, soft sleeping surfaces, overheating, exposure to smoke, low socioeconomic status, limited parental education, maternal age under 20, and single- parent households (Carlin & Moon, 2017). With rising concerns about SIDS prevalence, many studies emphasise multifactorial issues affecting mothers' awareness of SIDS, which is crucial for reducing risk. Key sociodemographic factors such as maternal age, education, employment status, residence, marital status, and number of children impact this awareness (Algwaiz et al., 2021). Implementing safe sleep practices is essential, as maternal behaviours related to infant sleep, like breastfeeding, pacifier use, smoking, bed-sharing, overheating, and sleep positioning, can be protective or pose risks (Alzahrani et al., 2020; Gemble et al., 2020; Ruiz et al., 2020). This study aims to identify gaps in maternal knowledge regarding SIDS prevention and associated risk factors.

METHODOLOGY

Research Design

The current study utilised a cross-sectional exploratory research design

Study Setting and Participant

This study was conducted in the paediatric ward, paediatric emergency department & outpatient department (OPD) at the Maternity & Children’s Hospital, affiliated with the Ministry of Health in Arar, Saudi Arabia. The author employed a non-probability convenience sampling design to recruit 135 mothers with infants under one year of age. Participants were invited through announcements in various WhatsApp groups, as well as on Facebook and Twitter, which included the study's objectives and a link to the questionnaire. Initially, the author directly invited mothers visiting the hospital, then expanded our outreach using snowball sampling, encouraging participants to share the study link within their networks. Based on literature data (Antony & Saldanha, 2022), with a significance level of 5% and a power of 80%, the sample size was calculated using the formula below:

Where Z1-α/2 = is the standard normal variate, at 5% type 1 error, it is 1.96, SD = standard deviation of variable and d = absolute error or precision. So,

Based on the above formula, the total sample size required for the study is 135.

Instrument for Data Collection

Mothers' Knowledge and Attitudes Toward Sudden Infant Death Syndrome: Risk Factors and Prevention Structured Questionnaire

This questionnaire was created by the researcher after conducting an extensive review of relevant literature, including studies by Alanezi, Almusalam and Afify (2023) and Elbilgahy et al. (2019). It consists of various question formats, such as open-ended and multiple-choice questions. To enhance accessibility, the questionnaire was translated into Arabic for the participating mothers. The instrument is structured into three distinct sections: Part I: Characteristics of mothers; this section includes questions related to the mother's age, educational background, marital status, smoking habits or exposure to smoke, and the number of children. Part II: This part features questions on the definition of sudden infant death syndrome (SIDS), associated risk factors, appropriate infant sleeping positions, and the use of pacifiers and respiratory control devices to help prevent SIDS. Additionally, mothers were questioned about safe sleep practices and preventive measures they can implement at home. Part III: Evaluation of mothers' attitudes toward SIDS and its prevention; this final section features statements assessed using a three-point Likert scale ranging from "strongly agree" to "disagree".

Validity and Reliability

The data collection instruments were carefully developed, translated, and modified and subsequently underwent a content validity assessment carried out by five experts in paediatric nursing. These specialists conducted a thorough review of the tools in alignment with the study's objectives prior to the commencement of data collection, and their insightful recommendations were thoughtfully integrated into the final instruments. Furthermore, the reliability of these instruments was assessed using Cronbach's alpha, which produced an impressive score of 0.89, indicating a high level of consistency.

Pilot Study

A pilot study involving 13 mothers, representing 10% of the calculated sample size, was carried out to assess the clarity, validity, and reliability of the tool within our specific context. This preliminary study aimed solely at validating the applicability of the questionnaire and did not include any interventions. The mothers reported no concerns or issues regarding the questionnaire, indicating its effectiveness for the intended purpose.

Statistical Analysis

Data was verified before being entered into the computer. The Statistical Package for the Social Sciences (SPSS), version 21.0, was utilised for this process, followed by data analysis and tabulation. Descriptive statistics were employed, including frequency, percentage, mean, and standard deviation. A significance level of p < 0.05 and p < 0.001 was established as the threshold for determining statistical significance.

Ethical Consideration

The study was ethically approved by the Research Ethics Committee at Northern Border University, Saudi Arabia, with reference number HAP-09-A-043 on 27th November, 2024. The research adhered to the principles outlined in the "Declaration of Helsinki." Written consent was obtained from the mothers, who were thoroughly informed about the study's details, including the confidentiality of their data and their right to withdraw at any time.

RESULTS

Table 1 summarises the demographic characteristics of the 135 surveyed mothers. Most are aged 40-50, with 45.9% between 45 and 50. A majority (79.3%) hold university degrees, and 92.6% are married. Notably, 30.4% report exposure to smoking. Families tend to be larger, with over half (54.1%) having 4-6 children. Additionally, 96.3% reported no previous infant deaths, although 25.9% indicated a family history of infant death.

Table 1: Demographic Characteristics of Mothers Studied

Figure 1 shows the most common risk factors for SIDS as reported by mothers. The highest percentages are linked to smoking around the infant (65.2%) and sleeping the infant on the abdomen (59.3%). Equal percentage 48.1% are linked to prematurity, low birth weight and sleeping on a shared bed.

Figure 1: Most Common Risk Factors for SIDS

In Table 2 it is shown that knowledge levels among mothers regarding SIDS are mixed. While 74.1% can define SIDS, only 58.5% recognise the highest risk age. Alarmingly, knowledge of preventive practices is low: only 23.7% understand the role of pacifiers, and 27.4% know the recommended sleeping position. Additionally, 46.7% are aware of the relationship between breastfeeding and SIDS risk.

Table 2: Mothers’ Knowledge about SIDS and Its Prevention

Figure 2 illustrates the total level of mothers' knowledge about SIDS. The distribution of knowledge levels shows that a significant portion of mothers have poor knowledge (44.4%), while only 34.1% have good knowledge.

Figure 2: Total Level of Mothers Knowledge about SIDS and Its Prevention

Table 3 shows mothers’ attitude about SIDS and its prevention. The attitudes towards SIDS prevention reveal a generally negative trend, with 89.6% disagreeing that infants should sleep near their parents in a separate bed. Positive attitudes are more prevalent regarding the use of pacifiers, as reported with agreement by 48.1% of mothers. Additionally, most mothers (83%) agree that SIDS can be prevented by changing the type of clothing the baby wears (boys wearing girls' clothes and vice versa).

Table 3: Mothers’ Attitude about SIDS and Its Prevention

Figure 3 illustrates the total level of mothers' attitude about SIDS. A total of 54.8% of mothers exhibiting a positive attitude compared to 45.2% had negative attitude about SIDS.

Figure 3: Total Level of Mothers Attitude about SIDS & Its Prevention

Table 4 illustrates statistically significant associations between age, education, number of children, and knowledge about SIDS prevention. Higher educational attainment, being over 50 years old, and having more children correlate with better knowledge of SIDS prevention (p=0.006 & <0.001).

Table 4: Association between Mothers’ Socio-Demographic Characteristics and Level of Total Knowledge Score about SIDS and its Prevention

**Highly statistically significant

Table 5 shows statistically significant associations between education, number of children, and attitudes toward SIDS prevention. Higher educational attainment, being over 50 years old, and having more children correlate with better attitudes regarding SIDS prevention (p < 0.001).

Table 5: Association between the Socio-Demographic Characteristics of the Mothers’ and Total Level of Attitude about SIDS

**Highly statistically significant

Figure 4 shows the correlation between mothers' overall knowledge and their attitudes. The data indicates a positive relationship with a statistically significant difference, suggesting that as mothers’ knowledge increases, their attitudes tend to improve as well.

Figure 4: Correlation between Mothers’ Total Knowledge and Attitude Levels

DISCUSSION

The present study was conducted among mothers of infants in Arar city, Northern Border region of Saudi Arabia. Its primary objective was to investigate gaps in maternal knowledge regarding the prevention of sudden infant death syndrome (SIDS) and its risk factors. Findings revealed that a significant proportion of mothers were 40 years and older, with older mothers showing a better understanding of SIDS and its prevention. However, a study by Hajian et al. (2024) indicated that 81% of mothers over 35 years had declining knowledge about SIDS. The current study found that 46.7% of mothers correctly identified the role of breastfeeding in preventing SIDS, while Alanezi, Almusalam and Afify (2023) reported that 58% acknowledged its protective effect. This discrepancy underscores the need for further education on breastfeeding's benefits related to SIDS prevention. Parental smoking, especially maternal smoking during pregnancy and after birth, is a strong predictor of SIDS risk (Miladinia, Baraz & Mousavi Nouri, 2015). In this study, 65.2% of mothers identified smoking around infants as a key risk factor for SIDS. Only 20% reported that their husbands smoked, indicating reduced exposure to smoke. Miladinia, Baraz and Mousavi Nouri (2015) found that paternal smoking rates were 30.86% before and after birth, while maternal smoking was 5.23% during pregnancy and 2.39% after birth, lower than in other countries. These findings emphasise the need for ongoing education and intervention to reduce smoking rates among parents and protect infant health. Research shows that sleeping position is crucial for preventing SIDS. Infants under six months placed on their stomachs are three to nine times more likely to experience SIDS compared to those sleeping on their backs. This emphasises the need for correct sleep positioning to reduce SIDS risk (Anselmo et al., 2023; Elbilgahy et al., 2019). The current study revealed that over three-quarters of mothers were unaware of proper positioning to prevent SIDS. In contrast, Anselmo et al. (2023) found that more than 90% of mothers in their sample knew the correct sleep position, believing it could help prevent drowning or choking. This discrepancy highlights the need for targeted educational interventions to improve maternal awareness of SIDS prevention strategies. Additionally, Shouli et al. (2025) reported that only 26.7% of participants had satisfactory knowledge about SIDS, with just 18.7% identifying supine sleeping as an effective preventive measure.

Numerous observational studies have indicated a relationship between pacifier use and a reduction in SIDS incidence if mothers adhere to the proper guidelines recommended by the AAP (American Academy of Pediatrics). These guidelines suggest that mothers should offer a pacifier to their infants at nap time and bedtime but should never force the pacifier if the infant refuses it (Badke et al., 2018; Psaila et al., 2017). In the current study, three-quarters of mothers provided incorrect responses regarding the use of pacifiers for SIDS prevention. This contrasts with the findings of Qasim and Alrabaty (2017), who reported that more than two-thirds of mothers in their study allowed their infants to use a pacifier during sleep. Bed-sharing is associated with higher SIDS rates due to risks like soft surfaces, overheating, and accidental smothering. These risks increase if the infant is premature, under 11 weeks old, or if parents smoke, consume alcohol, or use drowsiness-inducing drugs. Sleeping on non-bed surfaces, like sofas, also heightens the danger. In contrast, having the infant sleep in the same room but on a separate surface can reduce SIDS risk by up to 50%. Experts recommend this arrangement, especially during the first year of life. Despite these guidelines, bed-sharing remains common in some cultures, often influenced by socioeconomic factors and the benefits it provides for breastfeeding (Oliveira et al., 2020; Carlin & Moon, 2017; Moon et al., 2016).

The results of the current study align with the literature review, revealing that roughly half of the mothers identified bed-sharing as a significant risk factor for SIDS. Furthermore, over two-thirds of the mothers provided accurate responses in the knowledge assessment, acknowledging that bed- sharing elevates the risk of developing SIDS. However, a contrasting perspective is presented by Oliveira et al. (2020), who noted that the living conditions among the studied population often involve inadequate physical space, making it challenging for parents to provide a separate sleeping area for the infants in their shared living quarters. This highlights the complexities surrounding the issue of bed-sharing in various socioeconomic contexts. The study found that mothers have varying levels of knowledge about SIDS and its prevention. Over one-third demonstrated good knowledge, while a quarter had an average understanding, and fewer scored poorly. In contrast, Mohamed, Abusaad and El-agamy (2021) reported that over three-quarters of mothers had poor knowledge, potentially due to differences in educational backgrounds, as most participants in our study were university-educated. Additionally, our study identified correlations between mothers' attitudes toward SIDS and factors like age, education level, and number of siblings.

However, Abd Ali and Musihb (2024) found no significant relationship between attitudes and the number of children in the household. Alanezi, Almusalam, and Afify (2023) noted that mothers' qualifications, income, and locality significantly influenced their SIDS knowledge. Overall, sociodemographic factors and maternal attributes were significantly linked to participants' attitudes. Finally, raising public awareness and enhancing mothers' knowledge about SIDS is vital. Clear communication and effective educational programmes have successfully promoted safe sleep practices, with hospitals and clinics playing a key role. Safe sleep education should extend to all caregivers, including parents, nurses, and babysitters. By equipping them with essential knowledge, the author can significantly reduce the risk of SIDS and ensure safer sleeping environments for infants.

Limitation

The limitations identified in this study include the small sample size and the reliance on self- reported questionnaires, which may introduce bias. Participants might have given socially desirable responses rather than reflecting their true beliefs or practices regarding SIDS. Additionally, cultural beliefs and varying access to health information could further influence their understanding and attitudes towards SIDS.

CONCLUSION

The study highlights significant gaps in mothers' knowledge and attitudes regarding SIDS. While many mothers are aware of SIDS, they lack a comprehensive understanding of its preventive measures. Education level significantly influences knowledge and attitudes, with those having higher education showing better awareness. This indicates a need for targeted educational interventions to address disparities. The high number of mothers unaware of critical preventive practices calls for urgent public health initiatives. Additionally, first-time mothers may benefit more from educational resources than those with multiple children, who might be complacent due to past experiences. Future qualitative studies are advised to provide a deeper understanding of mothers' beliefs and attitudes toward SIDS, which could help shape more effective educational strategies. Additionally, it would be beneficial to examine how technology, including mobile apps and social media campaigns, can be utilised to spread information about SIDS prevention and assess their effectiveness in reaching mothers.

Recommendation

The researcher recommends developing comprehensive educational programmes for mothers on SIDS prevention, tailored to various educational levels and using accessible language. Online resources like videos and webinars, as well as mobile apps with safe sleep reminders, can further support new parents. Additionally, launching community-based initiatives to raise awareness in areas with lower educational attainment through diverse media platforms is essential.

Conflict of Interest

The author declares that they have no competing interests.

ACKNOWLEDGMENT

The author is thankful to all the mothers for their invaluable contributions towards this study.

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