In October of last year, a 2-month-old infant from Kiowa County died after co-sleeping with her parents.
Her mother woke up to find her father's arm partially obscuring her face, according to an autopsy report, which attributed her death to probable asphyxiation due to “overlay.”
In May of last year, a 6-month-old Tulsa County infant died from suffocation after co-sleeping with an adult and a sibling on an adult bed. The baby was found unresponsive between the mattress and wall with his face in a pillow.
Three months earlier, a 5-month-old Oklahoma City infant was found dead in her crib with her 1-year-old sibling lying on top of her.
Despite more than two decades of national and state safe-sleep campaigns, unsafe sleeping practices are playing a significant role in dozens of infant deaths across Oklahoma each year.
An Oklahoma Watch review of autopsy reports from 2014 to 2016 found that 149 children under age 1, or around 50 a year, died in circumstances in which co-sleeping, sleeping in unsafe sleep environments, or both, were involved or suspected at the time of their deaths.
The deaths comprised about 12 percent of all infant deaths in the state during the three years, but they made up 64 percent of cases in which autopsies were performed. The infant deaths, many of which appear to have been preventable, contributed to Oklahoma's relatively high infant mortality rate.
Co-sleeping is when infants sleep in beds or on couches or other surfaces with adults or other children. Unsafe sleep environments include couches, adult beds, cribs, bassinets or playpens that contain items that raise the likelihood of suffocation, such as stuffed animals, pillows or blankets. Sleeping in swings and car seats also can be dangerous.
State data suggests that many mothers in the state co-sleep with their infant children. A 2014 Oklahoma State Department of Health report, based on earlier survey data, found that nearly 75 percent of mothers reported co-sleeping at least some of the time. (The analysis looked only at first-time mothers who breastfed for at least eight weeks, in order to reduce potential bias from previous breastfeeding and infant-sleep experiences.)
“That's a major issue, and … most people feel like they're being nurturing by sleeping with their infant, not realizing that it's really dangerous,” said Joyce Marshall, director of maternal and child health services for the state health department.
Along with maternal tobacco use, unsafe sleeping is a significant issue in infant mortality, said Kelli McNeal, who oversees maternal and child health outreach and fetal and infant mortality review for the Oklahoma City-County Health Department.
“We know babies should be placed on their back to sleep, but there are a lot of other issues surrounding infant safe sleep that people just aren't aware of, like what the crib should look like, the fact that infants really should be … hopefully room-sharing with parents that first year,” McNeal said.
The American Academy of Pediatrics warns against co-sleeping, which is associated with increased risks of suffocation, Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Infant Death (SUID). The latter encompasses SIDS, accidental suffocation and strangulation, and deaths due to unknown causes.
Despite the warnings, many parents and some health experts argue that co-sleeping in a bed with an infant can be done safely and promotes breastfeeding and mother-child bonding.
An invisible toll
Pathologists for the state medical examiner rarely list co-sleeping or unsafe sleep practices as the cause of death. Instead their reports often cite Sudden Unexplained Infant Death, asphyxia, an illness such as bronchitis or undetermined.
The references to sleeping are noted as “other significant medical conditions” or a contributing factor. But many reports offer details that are stark and tragic.
A 7-month-old Pushmataha County boy is found dead lying face down in a crib with blankets, a bumper pad, a stuffed animal, clothes and pacifiers, all of which pose risks of suffocation.
A 3-month-old child in Choctaw County dies after co-sleeping with two adults and two older children in an adult bed.
A 7-month-old Tulsa County infant with a respiratory illness dies while co-sleeping on her stomach with her father on a couch.
Some deaths involve suspected use of drugs or neglect or mistreatment by a parent. But many reflect the risk of what seem to be simple loving gestures on the part of parents, who perhaps are tired or become careless in seeking warmth for, or closeness with, their children. Many parents may not even know what's safe or what isn't.
Many families whose children died live in lower-income areas, often in apartments, autopsy reports and Census Bureau data show. Two infants died while sleeping in day care centers — one in a carrier, the other lying prone.
The average age of death for the 149 children was a little over 4 months.
Infant deaths are rarely reported in the news media, further obscuring the widespread problem of unsafe sleeping.
A public health concern
Encouraging safe sleep remains an active public health campaign.
The Oklahoma Child Death Review Board recommended last year that all hospitals that deliver babies educate families on safe sleeping practices after a birth. In 2015, the board, which reviews all child deaths in the state, studied 112 deaths over multiple years related to unsafe sleep environments.
“I think people, really most Oklahomans, want their baby to be safe, but it's hard getting the message out and understanding what is safe for a baby and what is not, because some of those recommendations have changed over the years,” Marshall said.
Until a few decades ago, doctors and other medical professionals told parents to place their babies on their stomachs to sleep. In the early 1990s, the American Academy of Pediatrics began recommending that caregivers place infants on their backs instead, which led to a dramatic decrease in SIDS cases. The national SIDS rate has continued to decline, in part because deaths that had been reported as SIDS began to be recorded as accidental suffocation or having an unknown cause, the Centers for Disease Control and Prevention reports.
Alora Brinkley, a Yukon mother of five, briefly became the unwitting public face of co-sleeping earlier this year after a Facebook post of her lying next to her infant daughter and 2-year-old son went viral and made international news.
Her husband, David Brinkley, took the picture and posted it on Facebook, praising his wife for being a loving mother. Soon anti-co-sleeping commenters criticized or scorned the couple, telling them they were terrible parents or should have their children taken away.
“Parent shaming” is what Alora Brinkley calls it. “We literally live in a world where you can't love your kids too much.”
She said she supports mothers' decisions about co-sleeping and expects them to support hers. Even among her moms' group, no one agrees on every parenting choice the others make, she said.
The Brinkleys began co-sleeping when they had their fourth child. They didn't want to miss out on what they felt was a meaningful parenting experience. When they had their fifth, co-sleeping was a given.
Brinkley said she researched co-sleeping and spoke to her pediatrician, who encouraged her to use a co-sleeping bed. Sweeping prohibitions against co-sleeping don't take into account individual parents' needs, Brinkley said.
“I just don't think that there can be any logical science behind it necessarily, because every situation is different,” she said.
Brinkley, who is Vietnamese, said co-sleeping is common in countries such as Vietnam. Multiple families often live under the same roof, so there's no room to spare, she said.
“People have been doing it since the caveman era,” she said.
Alternatives to bed-sharing
Many other parents and some health experts believe co-sleeping is beneficial and can be done safely. But top state and local health officials and the American Academy of Pediatrics disagree, saying all co-sleeping is dangerous. Even secure sleepers for adult beds are not recommended because research on their safety is lacking. Instead, experts recommend room-sharing.
“It's not safe to ever sleep with your infant,” said McNeal, of the Oklahoma City-County Health Department. “I think there's a lot of misunderstanding about that. Of course, we want you to be close to your baby. Of course, we want you to breastfeed your baby, but then we really want you to have them in their own sleep space. That allows you to sleep better and ultimately allows them to sleep better.”
For some families, the issue is money: They can't afford a crib or cribs.
The state health department began a pilot program in 2015 to provide portable cribs and sleep sacks, a wearable blanket similar to a sleeping bag, to new parents who are lower income. In its first year, the program gave away 364 cribs, Marshall said.
“The need has been significantly higher than realized,” she said.
The program, funded with a $45,000 grant from the Robert Wood Johnson Foundation, led to a 30 percent drop in co-sleeping from January 2016 to February 2017, surveys show. The program ended in April, but the state obtained federal block grant funds to continue the project, which is ongoing.
Data journalist Thomas Thoren contributed to this story.
Oklahoma Watch is a nonprofit, nonpartisan media organization that produces in-depth and investigative content on public-policy issues facing the state. For more Oklahoma Watch content, go to oklahomawatch.org.