Health Reports
Infant bed sharing in Canada

by Heather Gilmour, Pamela L. Ramage-Morin and Suzy L. Wong

Release date: July 17, 2019

DOI: https://www.doi.org/10.25318/82-003-x201900700002-eng

There continues to be debate about bed sharing—the practice of an infant sharing a sleep surface with an adult or other child. Some studies suggest there is an increased risk of infant death, while others find no increased risk in the absence of hazards such as soft surfaces, extra bedding or pillows, smoking, impairment or sleeping with a non-caregiver.Note 1Note 2Note 3 Proponents of bed sharing point to potential physical and psychological benefits, such as facilitating breastfeeding and promoting bonding.Note 3Note 4 Some guidelines aim to eliminate the risks by advising against any form of bed sharing.Note 5 Others focus on harm reduction by educating parents so that they can make informed decisions to minimize the risks associated with bed sharing.Note 6Note 7

In Canada, the 2011 Joint Statement on Safe Sleep identified bed sharing as a factor associated with unsafe sleep environments and an increased risk of Sudden Infant Death Syndrome (SIDS), entrapment, overlay and suffocation, and advised parents not to bed share.Note 8

Studies in Canada,Note 9Note 10Note 11Note 12Note 13 the United States,Note 14Note 15 Great Britain,Note 16 Australia,Note 5Note 10Note 17 New Zealand,Note 10 parts of EuropeNote 10Note 18 and AsiaNote 10 have used varying definitions of infant bed sharing and reported prevalences of between 12% and 88%. Canadian studies were based on small samples or focused on specific subpopulationsNote 9Note 10Note 11Note 12Note 13 and therefore the results cannot be generalized to the overall population.

For the first time, the 2015 and 2016 Canadian Community Health Survey (CCHS) collected national data on bed sharing. This study uses these data to examine the prevalence and frequency of bed sharing in Canada by selected characteristics of the mother, as well as reported reasons for this practice.

Methods

Data source

The cross-sectional CCHS collects information related to health status, health care utilization and health determinants for Canadians aged 12 years or older. Excluded from the survey's coverage are: persons living on reserves and Aboriginal settlements in the provinces; full-time members of the Canadian Armed Forces; youth aged 12 to 17 living in foster homes; the institutionalized population; and persons living in the Quebec health regions of Région du Nunavik and Région des Terres-Cries-de-la-Baie-James. These exclusions represent less than 3% of the target population. CCHS data were collected from January 2015 through December 2016. The overall response rate was 59.5%, for a final sample of 110,095. The analytical sample includes 5,329 women aged 15 to 55 who had given birth in the past five years, representing a population of 1.5 million.

Definitions

Women aged 15 to 55 who reported that they had given birth (excluding stillbirths) in the past five years were asked the date of birth of their last child and how often the child slept in the same bed as the mother (respondent) or anyone else when the child was an infant (younger than 1 year of age). Bed sharing responses were classified as “frequent” (every day or almost every day), “occasional” (once or twice a week, a few times a month, or less than once a month) or “never.”

Mothers whose infants had bed shared identified the main reason for doing so. The following response categories were used: to breastfeed, so the baby would sleep / so I could get some sleep, believe that bed sharing was best for my child, child was sick, did not have room for a crib, could not afford a crib or other (unspecified).

Sociodemographic characteristics

The mother’s age at the birth of her last child was calculated by dividing the number of days between the mother’s and infant’s birth dates by 365.25.

The highest level of household education was categorized as either postsecondary graduation or less than postsecondary.

In the analytical sample, household income and main source of income were determined from either tax records (41%), respondent-provided data (40%) or imputed data (19%). Main source of income was used to identify people of limited means. Sources included wages and salaries; self-employment income; dividends and interest (e.g., on bonds and savings); employment insurance; worker’s compensation; Canada or Quebec Pension Plan benefits; retirement pensions, superannuation and annuities; Registered Retirement Savings Plans and Registered Retirement Income Funds; Old Age Security (OAS) and the Guaranteed Income Supplement (GIS); the Child Tax Benefit and family allowances; provincial or municipal social assistance and welfare; child support; alimony; other (e.g., rental income, scholarships); or none. Respondents who cited OAS and the GIS or provincial or municipal social assistance or welfare were grouped together and compared with those relying on other income sources.

Dwelling ownership was categorized as either owned by a member of the household (even if it is still being paid for) or rented (even if no cash rent is paid).

Marital status was categorized as married; common-law; or single, widowed, separated or divorced.

Indigenous identity was self-reported in response to the question: “Are you an Aboriginal person, that is, First Nations, Métis or Inuk (Inuit)? First Nations includes Status and Non-Status Indians.”

The immigrant category includes landed immigrants and non-permanent residents, versus Canadian-born respondents. Mother’s birth country was categorized into regions based on the 2010 Standard Classification of Countries and Areas of Interest.

Having a regular health care provider was self-reported in response to the question: “Do you have a regular health care provider? By this, we mean one health professional that you regularly see or talk to when you need care or advice for your health.”

Respondents were asked if they breastfed or gave their infant breast milk and for how long, as well as about the introduction of other liquids and solid food. The following categories were used: exclusively for six months or longer, exclusively for less than six months (duration less than six months and/or the introduction of other liquids or solids before six months), and did not breastfeed or give breast milk. Mothers with infants younger than 6 months whose exclusive breastfeeding was ongoing (duration could not be established) or who did not respond to the question were excluded from prevalence estimates, but kept in the multivariate analysis; results for this category were not shown.

Analytical techniques

Weighted frequencies and cross-tabulations were calculated to examine the prevalence of bed sharing by selected characteristics of the mother and the reasons for doing so. Multivariate logistic regression was used to determine factors independently associated with bed sharing. Bootstrap weights were applied using SAS-Callable SUDAAN 11.0 to account for the underestimation of standard errors resulting from the complex survey design.Note 19

Results

Prevalence of infant bed sharing

Based on the 2015 and 2016 CCHS, an estimated 497,000 women (33%) aged 15 to 55 who had given birth in the past five years reported that their infant child had frequently shared a bed (Table 1). An estimated 27% (95% confidence interval [CI] 26 to 29) had occasionally shared a bed and 40% (95% CI 38 to 42) had never bed shared.

Infants of mothers aged 15 to 24 at the time of birth were more likely than those of mothers aged 25 to 29 (38% vs. 29%) to be frequent bed sharers. Furthermore, mothers from households with lower annual incomes (less than $80,000) and renters were more likely than those from higher-income households and homeowners to report frequent bed sharing. Bed sharing was more prevalent among married (35%) or single, widowed, separated or divorced (36%) mothers, compared with those in common-law relationships (23%), and less common among those with a regular health care provider (32%) than those without (41%).

Frequent bed sharing was significantly higher than in the rest of the country in Manitoba (41%), British Columbia (45%), Yukon (67%), the Northwest Territories (51%) and Nunavut (67%). Percentages were significantly lower in New Brunswick (11%) and Quebec (23%).

Infants of immigrant mothers were more likely to bed share frequently than infants of Canadian-born mothers (47% vs. 26%). In particular, the practice was more prevalent among mothers born in Asia, compared with mothers born in North America (57% vs. 26%).

Mothers who breastfed or gave their infants breast milk were two to three times more likely than those who never did so to report that their infants frequently bed shared. Furthermore, exclusive breastfeeding for a longer period (six months or more) was associated with a higher likelihood of frequent infant bed sharing.

There were no significant differences in the prevalence of frequent bed sharing by household education, main source of household income or Indigenous identity. However, in the territories the practice was significantly more prevalent among Indigenous people than non-Indigenous people (67% vs. 49%) (Table 2).

Reasons for bed sharing

Breastfeeding was the most commonly cited reason for infant bed sharing (39%), followed by facilitating sleep for the infant or mother (29%) (Figure 1). Frequent bed sharers were more likely than occasional bed sharers to do so to breastfeed (46% vs. 31%) or because they believe that bed sharing is best for the child (13% vs. 2%). Occasional bed sharers were more likely to do so to sleep (35% vs. 24%) or because the child was sick (15% vs. 1%). Few reported not having or being able to afford a crib as the reason for bed sharing (1%).

Multivariate analysis

When socioeconomic, demographic and health characteristics were considered together in multivariate analysis (Table 3), infants of mothers who were 25 to 29 years of age at the time of birth remained significantly less likely to bed share frequently, as did residents of New Brunswick. Women who were single, widowed, separated or divorced had greater odds of frequent infant bed sharing, as did residents of British Columbia, Yukon and Nunavut; women born in South or Central America and the Caribbean or in Asia; and those who exclusively breastfed.

Discussion

For the first time, national population-based data on bed sharing in Canada are available. From the 2015 and 2016 CCHS, 33% of mothers reported that their infants had frequently shared a bed, while 27% had done so occasionally. Comparisons with previous Canadian studies are problematic because of variations in how bed sharing was measured (e.g., age of child, frequency) and because studies related to specific subpopulations or were not otherwise representative. For example, in a Cree community north of Edmonton, 80% of mothers bed shared.Note 9 A survey in Manitoba found that at 3 to 4 months of age, 43% of infants shared a bed at least three times per week and 30% did so occasionally.Note 11 Another study in Manitoba found that 23% of infants were bed sharing at 3 months of age,Note 10 and an Internet-based survey found that 12% of Canadian children between 0 and 36 months of age had bed shared in the previous two weeks.Note 12

When other sociodemographic variables were controlled, infants of mothers who were single, widowed, separated or divorced had significantly higher odds of bed sharing than those with married mothers. Furthermore, several variations in the prevalence of bed sharing by province and territory of residence persisted in multivariate analysis: infants in New Brunswick had significantly lower odds of bed sharing, while those in British Columbia, Yukon and Nunavut had higher odds.

Socioeconomic status (SES), as measured by household education and income, was not significantly associated with frequent bed sharing. This is consistent with some previous studies,Note 11Note 15Note 20 but in contrast to others that found lower SES to be related to bed sharingNote 14Note 21Note 22 or studies that found an association with higher SES.Note 5Note 16

The prevalence of frequent bed sharing was significantly higher among the Indigenous population than among the non-Indigenous population only within the territories. Infants of mothers born in Asia or in South or Central America and the Caribbean had higher odds of bed sharing than those whose mothers were born in North America. Consistent with previous studies these findings suggest that cultural background may play a role in the decision to bed share. Bed sharing has been reported as a common practice among particular cultural groups, including African Americans, Asians, Hispanics and Inuit.Note 10Note 13Note 14Note 23

Public health messages related to infant sleep are concerned with safety awareness and the prevention of infant death, and with the promotion of breastfeeding.Note 24 These messages may seem to be in conflict as it is thought that bed sharing can encourage longer duration of breastfeeding but may increase the risk of infant injury or death.Note 2Note 3 While some research has found a positive association between breastfeeding and bed sharing,Note 3Note 4Note 5Note 16Note 25Note 26Note 27 other studies in specific at-risk populations have not.Note 28Note 29 In this study, mothers of frequent bed sharers were more likely than those of occasional bed sharers to cite breastfeeding as the reason and to have breastfed exclusively.

Strengths and limitations

A strength of this analysis is the large, population-based sample. However, several limitations must be acknowledged. The bed sharing questions were limited to women who had given birth in the past five years; men and adoptive and foster parents were not included. It is not known with whom the infant bed shares. Evidence suggests that bed sharing with anyone who is not the infant’s parent, including non-parental caregivers and other children, increases the risks associated with this practice.Note 29 Recall bias may be an issue, as women who had children up to five years ago were asked to recall details about bed sharing when their child was younger than 1 year of age. The extent to which social desirability may affect responses to questions about bed sharing and breastfeeding is unknown. Respondents with bed sharing infants were asked to specify one main reason with no way to indicate whether the reason changed during the child’s infancy. Breastfeeding was a response option, but bottle feeding was not. Mothers with infants who never bed shared were not asked to provide a reason for their decision. Some factors in combination with bed sharing that pose an increased risk of SIDS could not be assessed in this study, including bed sharing with a preterm or low birth weight infant or an infant younger than 4 months; being a smoker; being impaired; bed sharing with someone who is not the infant’s parent; and bed sharing on soft surfaces such as waterbeds, sofas or armchairs or with soft accessories such as pillows or blankets.Note 29 Several sociodemographic characteristics of the mother, such as income, education, dwelling ownership, main source of income, province or territory of residence and marital status, reflect their circumstances at the time of the interview, which could be up to five years after the birth of their last child and may have changed during that time.

Conclusion

The results of this study provide baseline data on bed sharing and will help to inform policies and programs related to safe sleep practices. Future research could look at changes in the prevalence of bed sharing over time, examine types of bed sharing surfaces, assess overcrowding as a possible reason for bed sharing, and further investigate reasons for not bed sharing among the group who never did so.

References
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