Safe Sleep Advice to Safe Sleep Action: Pilot of the Pepi-Pod Program in Indigenous Communities

Monday, 28 July 2014: 7:20 AM

Jeanine Young, PhD, BSc (Hons), RN1
Leanne Craigie, BSc, GradDipEduc, GradDipIndgHlthPromo2
Lauren Kearney, PhD, IBCLC, GradDipClinNsg (ChAdolHlth), BSN1
Karen L Watson, RN, GradDipCritCr, MS1
Stephanie Cowan, MEd, BSc, Dip (Tch)3
(1)School of Nursing and Midwifery, University of the Sunshine Coast, SIPPY DOWNS QLD, Australia
(2)Pepi-pod Research Project, Children's Health Queensland Hospital and Health Service, Brisbane, Australia
(3)Change for our Children, Change for our Children, Christchurch, New Zealand


Background:Sharing sleep spaces with babies is a common infant care practice in Australia [1], and the cultural norm in many Indigenous communities [2]. While forms of co-sleeping may reduce risk of sudden unexpected death in infancy (SUDI) and enhance breastfeeding in some cultural groups, some shared sleep environments are extremely hazardous for infants [3]. Aboriginal and Torres Strait Islander babies currently die suddenly and unexpectedly at a rate almost four times higher than non-Aboriginal and Torres Strait Islander infants (252.1 deaths per 100,000 compared with 66.4 deaths per 100,000 respectively). A considerable proportion of infant deaths are associated with co-sleeping environments [3]. Innovative strategies which allow for the benefits of bed-sharing, respect cultural norms and infant care practices, whilst also enabling the infant to sleep in a safe environment are necessary if a reduction in SUDI is to be achieved amongst Aboriginal and Torres Strait Islander communities.

The Pēpi-pod Program is a safe sleep space combined within a targeted safe sleeping health promotion initiative for families with known risk factors for SUDI. Cowan and colleagues, who implemented the Pēpi-pod Program in New Zealand amongst a sample of Maori families displaced during the Christchurch earthquakes (n=642) have reported positive interim findings [4]. Feedback from participants (n=100) identified that the Pēpi-pod Program was beneficial for: having baby close; peace of mind; safe bed-sharing; portability and infant settling. The program in New Zealand has been expanded to include 4000 vulnerable families throughout selected health boards across the country. Acceptability or effectiveness of portable sleep spaces for co-sleeping Indigenous families have not been previously reported but is an area Indigenous families have identified as being important for investigation [5].

Aim:The purpose of this study was to determine the acceptability of the Pēpi-pod Program, a portable infant sleep space embedded within safe sleep health promotion, within a sample of Aboriginal and Torres Strait Islander families in Queensland, Australia. 


Design:An exploratory descriptive design was used to report parent experiences of using the Pēpi-pod Program to support safe infant sleep practices.

Population, Sample and Participant Selection: Families were purposively selected through four health services in Queensland which provide antenatal and maternity care services to Aboriginal and Torres Strait Islander families. These services include metropolitan, rural and remote areas of Queensland:

1)       Ngarrama Antenatal and Birthing Project

2)       Townsville-Mackay Medicare Local – New Directions: Bubba’s Business

3)       Woorabinda Multi-Purpose Health Service  

4)       Logan Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) Mums and Bubs Clinic

 Eligible participants were parent/s and/or carers of a baby (ideally <1 month of age) with the presence of one or more known SUDI risk factors [3] including:

  • identification as Aboriginal and/or Torres Strait Islander (at least one parent)
  • maternal smoking, during pregnancy and/or post-natal
  • intention to bed-share (regularly/irregularly)
  • recent drug use, including prescribed medications that may affect consciousness
  • alcohol use
  • pre-term birth (≤36 weeks)
  • low-birth weight (<2500 grams).

 Eligible families were identified by their health care worker through usual health assessments and referred to the Pēpi-pod Program facilitator, with family permission. Eligible families were provided with an information sheet and if willing to participate in the study, consent form to complete. Ideally families were identified prior to their baby’s birth, however were recruited up to an infant age of 8 weeks or 2 weeks post discharge from hospital if born prematurely.

Intervention: The Pēpi-pod program

The Pēpi-pod Program was delivered as three interlinked components:

1) Safe Space: was a general purpose polypropylene box transformed into an infant bed through addition of a culturally suitable fabric cover, an upholstery-density, fabric covered, tight fitting mattress; and bedding: mattress protector, base slip-on sheet, wrap around sheet, light blanket. The Pēpi-pod provides a zone of physical protection around baby wherever they sleep where suffocation risk is heightened, e.g. on adult beds, couches or makeshift beds.

2)  Safe Care: parent education includes a ‘Rules of Protection’ [1] safety briefing and practical safe infant sleeping information for families to adapt for their family situation. Safe Space + Safe Care = Protection. Rules of Protection Messages included a poem for parents to facilitate recall of the messages:  On the back, face clear; Only baby in here; Every sleep, everywhere; Always breathing, smoke free air; Drugs and drinking nowhere near; Own space, best care.

3)  Role of family: families were asked to make a commitment to spread what they had learned about protecting babies as they sleep. Giving families a role as well as the Pēpi-pod Sleep Space is intended to empower, entrust and extend the influence of the program within priority networks [5,6].

Data Collection

Data collection included acceptability and use of the Pēpi-pod Sleep Space.  Parent questionnaires were administered face to face or by telephone [6] within 2 weeks of receiving the Pēpi-pod; then monthly thereafter until pod use ceased at approximately 4-6 months dependent upon baby’s growth and development. Questions included:

·         Knowledge of SUDI risk factors and strategies to enhance safety

·         Circumstances of pod utilisation

·         Usual baby care ‘yesterday’ and ‘last night’

·         Infant care enhanced by pod use

·         Limitations/adverse events associated with pod



The target of five eligible families (infant age 8 days to 9 weeks) were recruited and followed up each month to pilot study methods and documentation. Demographic characteristics included; 3 of the 5 families were partnered; all were of Aboriginal background apart from one mother who identified as Maori whose partner was Aboriginal; all families had the intention or need to bed share and the presence of two or more risk factors for SUDI. Four of the five families identified that they had utilised the Pēpi-pod as an infant sleep space. The acceptability of the Pēpi-pod as a safe sleep space for babies was supported by parent responses that related to three key themes: safety, convenience and portability. Examples of parent reports related to these themes are provided by the following quotes under these three headings.


“Can have it (the Pēpi-pod with baby) in the bed and not worry” (mother of baby 8 week 3 days)


“Easy to pack away”

 “Baby can be in Pēpi-pod on the couch until falls asleep; I find this convenient – don’t have to

disturb him”; “..don’t have to touch him”; .father can carry him into bedroom without waking


“Baby can be in Pēpi-pod while Mother cleaning in the lounge or “doing stuff” – “don’t always

have a bouncer”  (Mother of baby 8 weeks)                 


“Can take to (baby’s mother’s) mother’s house”

“Especially good when they go out to friends BBQ (for example) – they live out of town a bit.” (Mother of baby 8 weeks, 6 days)


One mother indicated that knowing about the Pēpi-pod as soon as possible would have been useful:

“Like it, would have been good to know about it sooner than I did. Good to have known about it

earlier to have straight out of hospital” (Mother of baby 8 weeks)


The Pēpi-pod program was accepted as a portable sleep space for infants and used appropriately by parents living in several communities in Queensland. Responses relating to use, acceptability, convenience and safety of the infant sleep space were positive. Pilot results from this study have informed the design of a larger trial (n=300) of the Pēpi-pod Program within six communities across Queensland being conducted during 2013-2014.

Implications for practice: Health services have a responsibility to follow through from simply informing about safe infant sleep practice to enabling safe infant sleep action. Evaluating innovative and culturally respectful strategies to reduce SUDI risk will better inform the evidence-base used by educators, clinicians, researchers and policy makers in supporting parents to use safe infant sleeping strategies.