Losing Sleep: Risk, Responsibility, and Infant Sleep Safety 9781479801206

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Losing Sleep

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Losing Sleep Risk, Responsibility, and Infant Sleep Safety

Laura Harrison

NEW YORK UNIVERSIT Y PRESS New York

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N EW YOR K U N I V ER SI T Y PR E S S New York www.nyupress.org © 2022 by New York University All rights reserved References to Internet websites (URLs) were accurate at the time of writing. Neither the author nor New York University Press is responsible for URLs that may have expired or changed since the manuscript was prepared. Library of Congress Cataloging-in-Publication Data Names: Harrison, Laura, 1983–  author. Title: Losing sleep : risk, responsibility, and infant sleep safety / Laura Harrison. Description: New York : New York University Press, [2022] | Includes bibliographical references and index. Identifiers: LCCN 2021046819 | ISBN 9781479801145 (hardback ; alk. paper) | ISBN 9781479801152 (paperback ; alk. paper) | ISBN 9781479801183 (ebook) | ISBN 9781479801206 (ebook other) Subjects: LCSH: Infants—Sleep—United States. | Infants—Care—UnitedStates. | Sleeping customs—United States. | Infants—Mortality—UnitedStates. | Maternal and infant welfare—United States. | Discrimination in medical care—United States. Classification: LCC RJ506.S55 H356 2022 | DDC 616.8/4982—dc23 LC record available at https://lccn.loc.gov/2021046819 New York University Press books are printed on acid-­free paper, and their binding materials are chosen for strength and durability. We strive to use environmentally responsible suppliers and materials to the greatest extent possible in publishing our books. Manufactured in the United States of America 10 9 8 7 6 5 4 3 2 1 Also available as an ebook

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Contents

Introduction

1

1. “Sleep Like a Baby” and Other Historical Fallacies

25

2. Making and Unmaking a Safe Sleep Environment: From the AAP to the Rock ‘n Play Recall

53

3. What’s Best for Baby? Co-­Sleeping and the Politics of Inequality

82

4. “Everybody Loses”: Parents as Perpetrators

120

5. Advertising Infant Safety: Gender, Risk, and the Good Parent

161

Conclusion: Rethinking the Safe Sleep Environment

189

Acknowledgments 201 Notes 203 References 233 Index 257 About the Author 273

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Introduction

New parents are inundated with advice and products that purport to keep their baby safe, even beginning pre-­conception.1 Many “baby-­ proof ” their home by installing gates or socket protectors before their newborn can even roll over. Despite these precautions, the question of where and in what position the baby will sleep is much more immediate, and often quite controversial. The specter of Sudden Infant Death Syndrome can cast a shadow over the early days at home with a new baby, keeping parents up at night, pacing back and forth to the nursery or glued to the monitor to check the baby’s breathing. Sharing a room, or even a bed, with a new baby could ostensibly offer more immediate assurance. However, one pervasive tenet of safe sleep discourse is that it is risky for parents to co-­sleep, or share a bed, with their infant. While co-­sleeping is common—­more than half of parents surveyed in the United States report doing so—­leading pediatric organizations also label it a risk factor for infant death.2 The messages that parents receive from family members, the media, and even their doctors create a great deal of anxiety about sleep-­related infant death, often resulting in one-­size-­fits-­ all narratives about how a good parent responsibly manages safe sleep. This book argues that infant sleep safety is a socially constructed paradigm, and that the neoliberal model of health-­as-­individual-­ responsibility has come to permeate our understanding of what constitutes safe sleep. In other words, what is necessary to make infant sleep safe has changed over time and across cultures; what makes infant sleep risky, or how to manage that risk, is a point of contestation. Understanding how neoliberalism shapes messages about infant sleep safety is important because safe sleep rhetoric impacts systems, including public health policy and law, that have the power to stigmatize or even criminalize parenting practices. It also shapes broader cultural beliefs about responsibility and risk that impact individuals at an intimate level, including whether they view themselves as posing as an embodied risk 1

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2 | Introduction

to their child. Unsurprisingly, messages about infant sleep safety affect parents differently based on their social location. At the same time that infant sleep safety (and infant mortality more broadly) is positioned as the responsibility of individual parents, the state is taking an increasingly visible role in policing and surveilling parental decision making, including criminalizing the parents of children who die in their sleep. This book examines how the problem of sleep-­related infant death is and historically has been framed in relation to parental decision making and biomedical authority, and argues that “infant sleep safety” is a social construction that has evolved in ways that privilege certain types of parenting practice. This project brings together scholarship on health, risk, reproductive justice, and neoliberalism. As Anna Kirkland and Jonathan Metzl argue in Against Health: How Health Became the New Morality, when a behavior is categorized as a health risk, then those who “choose” to engage in it are viewed as opening the door to a broad condemnation of their morality and ethics.3 When these “risky” health behaviors are associated with parenting, then individual parents are stigmatized as bad choice-­ makers who are morally suspect, selfish, and dangers to their children. This ignores the institutional and historical violence experienced by low-­income people and people of color, often at the hands of the same systems (medicine, government, police) that are creating, codifying, and enforcing health-­related norms. Feminist science studies also inform this analysis; safe sleep guidelines and the policies informed by them are not constructed in a vacuum. Who is authorized to produce knowledge about sleep safety—­medical researchers? Pediatricians? Public health officials? Parents? What technologies are created to solve the “problem” of infant sleep safety, who determines what the problem is, and what groups benefit? How are health disparities in infant sleep linked to historical patterns of discrimination and oppression? Consumer culture also contributes to and reflects the neoliberal emphasis on individual control over health; the infant safety industry is valued at more than $325 million a year in part by creating products that claim to reduce the risk of illness, accidents, and even death, often with an authoritative veneer that belies limited or absent government oversight and regulation.4 This book will point to neoliberal ideologies and policies as factors that shift attention from the role of the state in main-

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Introduction | 3

taining wellness to the responsibility of the individual. Yet as feminist theorist Leela Fernandes argues, the state has not ceded all authority to the market; it continues to utilize policing and surveillance as mechanisms of social control. Indeed, the free market and the state may have similar interests as pertains to infant sleep safety.5 The message that all “unsafe sleep” deaths are preventable normalizes the criminalization of families who “choose” not to follow safe sleep guidelines, while the market purports to solve the problem through the sale of technology and devices that promise peace of mind for parents. This narrative is complicated further by the fact that at its core, safe sleep is about preventing infant mortality, and infant mortality rates in the United States differ widely by race and are linked to socioeconomic status. Infant mortality is defined by the Centers for Disease Control and Prevention as the death of an infant before their first birthday, and is assessed as a significant measure of the health of a nation. The United States ranks fifty-­first in the world for infant mortality, largely because of racial disparities.6 While the overall infant mortality rate in the United States is 5.9 deaths per 1,000 live births, major disparities in infant mortality fall along the lines of race, with African Americans experiencing the highest rates (11.3), and Asian Americans/Pacific Islanders the lowest (4.2).7 Even as overall infant mortality rates are falling across ethnic groups, the disparity in deaths between white and Black infants has more than doubled in the last decade.8 The focus on infant sleep safety suggests that individual parents have the agency to protect their own children from unexpected infant death, if only they would make the right choices about safe sleep. However, children’s health is interconnected with multiple factors both internal and external, including whether they were born full term, their mother’s lifetime exposure to chronic stress, and environmental hazards in their home and community.9 These are among what are termed the “social determinants of health” or “the conditions in which people live (shaped by the distribution of resources, such as money and political and economic power) at global, national, and local levels.”10 The social determinants of health include access to health care, affordable day care, safe housing, and the broader effects of poverty and structural racism. Infant sleep safety is not commonly framed as a reproductive justice issue, but this book will demonstrate that safe sleep guidelines are

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implicitly modeled on a white, middle-­/upper-­class norm that assumes access to resources without providing the support for safe sleep equity. It also taps into deeply held beliefs about gender, and women’s responsibility as primary caretakers. This matters because poor women and women of color are more likely to be implicated as bad decision makers, and to be surveilled, policed, and criminalized. This book demonstrates that infant sleep safety is an intersectional issue, and that creating the conditions for safe sleep for all infants requires starting with the needs and involvement of communities of color. Finally, I will argue that what is conveniently pushed aside in the focus on individual choices is the systemic ill effects of poverty and racism on the health of mothers and babies. Which babies are born with access to safe sleep in United States? Who decides?

Safe Sleep, Sudden Infant Death, and Co-­Sleeping In order to examine the social construction of infant sleep safety, it is vital to understand how a safe sleep environment is defined and what it is meant to protect against, namely unexpected infant death. This section will begin to unpack the meaning of safe sleep, a project that will be ongoing throughout this book. It will also introduce key medical terms like Sudden Infant Death Syndrome, Sudden Unexpected Infant Death, and accidental suffocation or asphyxia.11 The development of these classifications is significant because they play a role in shaping the discourse of infant sleep safety, including the culpability of parents for managing risk. Co-­sleeping is also introduced in this section, because co-­sleeping is frequently characterized as a violation of safe sleep guidelines and as a risk factor for unexpected infant death. “Safe sleep” is a loaded term. It is normative in that it implies an idealized environment for children and an approved set of behaviors by caregivers. It is prescriptive in that it implies a singular model of safety that all caregivers should follow, and because its binary opposite (“unsafe sleep”) carries the moral weight of potential harm to an infant. And, like a lot of childrearing norms and guidelines, safe sleep is a social construct that has changed significantly over time and continues to vary across cultures. While humans have evolved to sleep, the way that we format and structure sleep is both shaped by and shapes the structure of

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Introduction | 5

our lives, including reproductive labor, education, and work responsibilities.12 Contemporary norms concerning “safe sleep” are inseparable from broader cultural beliefs about the sanctity and importance of uninterrupted sleep, the belief that “good” or “bad” sleep impacts our health, the association between sleep and morality (for example, the belief that “early to bed, early to rise” is a sign of productivity and hard work), and expectations of privacy or companionship during sleep. Many of these social norms transfer to infant sleep: New parents often feel intensely judged by questions about how their baby is sleeping, with the unspoken assumption that a “good baby” sleeps through the night, and that parents are responsible for “training” their baby to sleep alone and for uninterrupted stretches of time. Likewise, parents who do not follow all safe sleep guidelines—­such as allowing their infants to nap on their stomachs, or co-­sleeping—­may hesitate to share this information with pediatricians or peers for fear of negative responses.13 Judgments about sleep thus travel in multiple directions, implicating “good” (or “bad”) babies, and “good” (or “bad”) parents. In this book, safe sleep refers primarily to a set of guidelines that are meant to prevent deaths that occur during sleep to infants under the age of one. As will be discussed further in chapter 2, the most authoritative safe sleep standards in the United States are set by the American Academy of Pediatrics (AAP), a professional organization of pediatricians that creates guidelines for children’s health; in addition to safe sleep, the AAP publishes recommended limits on screen time, vaccination schedules, and car seat standards, among other day-­to-­day parental concerns. The AAP’s most recent safe sleep recommendations include that babies should always sleep on their back, on a firm surface, sharing a room (but not a bed) with their parents until at least six months of age, but preferably a year.14 Chapter 2 will analyze how these recommendations have changed over time and the role of the AAP and other medical professionals in shaping safe sleep discourse. The Centers for Disease Control and Prevention tracks the number of unexpected infant deaths that occur in the United States each year. As of 2017, roughly 3,600 deaths annually fell under the umbrella category of Sudden Unexpected Infant Death (SUID). SUID encompasses death attributed to SIDS, accidental suffocation and strangulation in bed, and those designated as “unknown cause.” Sudden Infant Death Syndrome

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(SIDS) was first formally defined in 1969 as “the sudden death of any infant or young child, which is unexpected by history, and in which a thorough postmortem examination fails to demonstrate an adequate cause for death.”15 In 1991, the National Institute of Child Health and Human Development revised the definition to include an age limit (that SIDS is only applicable to children under the age of one) and added that an autopsy and a death scene investigation must be completed. Most recently, the journal Pediatrics published an updated definition in 2004 that defines SIDS as “[T]he sudden unexpected death of an infant