Alabama Department of
Child Abuse and Neglect Prevention
Children’s Trust Fund of Alabama


Alabama Department of
Child Abuse and Neglect Prevention
Children’s Trust Fund of Alabama


When Infant Mortality is a Case of “I Love You…..To Death”

The death of a child in the first year of life is an unimaginable tragedy. Alabama has the second highest infant mortality in the nation, with more than nine in 1000 newborns dying before their first birthday.

Some of these children die because of extreme prematurity, others because of birth defects. Unsafe sleeping practices, however, are the cause of at least twenty-four percent of these deaths – deaths that are completely preventable. Every single loss of a baby is a tragedy both for a family and for our state. It is especially shocking when the baby is healthy and thriving the day before death.

I have been a pediatrician in Alabama for thirty-eight years. I count it as a personal loss every time I hear of another infant dying as a result of sleeping with an adult, on a sofa, in a lounge chair, in a baby bouncer, face down against a bumper pad, or surrounded by soft bedding. Years ago, a personal friend of mine lost her baby while sleeping on a waterbed.

I have worked on policies in my local hospital to teach new parents about safe sleeping. I have handed out an untold number of pamphlets designed for new moms, dads, grandparents, Latino parents, and African-American parents. I have placed posters in my community and attended many state meetings to discuss the problem. In desperation, I even once told a new mother that if she is going to sleep with her baby, she will have to find another doctor. I can’t deal with another senseless death.

More that twenty-five years of experience and research has led to the development of the “ABCs” of safe sleeping: Alone, on the Back, and in a Crib. Every leadership group I have worked with over the years continues to blame lack of education or cultural issues as drivers of this continued loss of life.

Recently, however, I had an “ah-ha” moment. This is not an education issue. This is not a cultural issue. This is a matter of the heart; not the head.

The revelation hit me after attending my county’s child death review meeting, followed a week later by the Fetal and Infant Mortality review for Southwest Alabama. The fact is, mothers who sleep with their babies are much more likely to have suffered from adverse childhood experiences (ACEs).

An ongoing research study conducted by Kaiser Permanente and the Center for Disease Control shows that adult illnesses (such as heart disease, liver disease, diabetes, tobacco use, substance abuse, suicide, asthma, autoimmune diseases, and even early death) are directly linked to what happens during childhood. The study surveys ten types of childhood trauma, including neglect, physical/emotional/sexual abuse, absence of a parent through divorce/death/abandonment, a family member diagnosed with a mental illness, domestic violence, incarceration of a parent/guardian, and drug/alcohol abuse in the family.

If a child suffers four or more adverse experiences, he is  32 times more likely to have learning and behavioral problems in school. As an adult, a person with four or more ACEs has a marked increase in chronic pulmonary disease, hepatitis, depression and suicide as well as many other physical and mental illnesses. (It is also worth noting that the research suggests that having a caring adult who loves the child unconditionally can buffer the effects of ACEs and lead to resilience.)

After our county Child Death Review meeting, the Forensic interviewer from our Child Advocacy Center shared that three of the mothers who slept with their babies had in previous years been victims of child sexual abuse. One had also experienced the suicide of the offending relative. A fourth one suffered from mental illness and drug abuse. At least three of these mothers had been found sleeping with their infants while still in the hospital after delivery. They received extensive education on safe sleeping and even signed a form saying they understood.

The following week, at the Fetal and Infant Mortality Review meeting for SW Alabama, social histories of the mothers who lost a child while sleeping together revealed that one had been a foster child, one had suffered severe child abuse, and another had been raped twice.

My first thought was that perhaps these mothers felt the need to protect the baby by holding them close – as much and as often as possible. But one of the experienced nurses on the team suggested that these moms have a deep desire for someone to love them in return. Their emotional needs drive them to crave a physical closeness to their child.  It is not that that they intentionally disregarded recommended safe sleeping practices. It has everything to do with what happened to them earlier in life that drives this need for touch.

Smart people with this information can design new ways to prevent these senseless deaths. Give the ACEs questionnaire to expectant moms. Identify those at risk. Refer them to a nurse-family partnership program. Discuss ways to have that closeness without bed-sharing. I feel sure there are other ways to intervene. Together let’s look for the answers.


Marsha D. Raulerson MEd.  MD  FAAP

Pediatrician, Teacher and Child Advocate

Brewton, Alabama