Intended for healthcare professionals


Evaluation of government's compaign to reduce risk of cot death

BMJ 1994; 309 doi: (Published 17 September 1994) Cite this as: BMJ 1994;309:703
  1. C M H Hiley,
  2. C Morley
  1. Department of Paediatrics, University of Cambridge, Box 116, Addenbrooke's Hospital, Cambridge CB2 2QQ
  1. Correspondence to: Dr Morley.
  • Accepted 18 May 1994

In December 1991 the Department of Health's “Back to Sleep” campaign advised that babies should not sleep on their front, be exposed to cigarette smoke, or be overheated.1 Since then cot deaths have halved, from 912 in 1991 to 456 in 1992.2 This has been attributed to the campaign,3 with little evidence that child care practice has in fact changed. This study compared the way mothers cared for their infants before and after the campaign.

Subjects, methods, and results

Questionnaires were sent to two randomly selected groups of 450 mothers of normal term babies born in Cambridge, Huntingdon, or Bury St Edmunds. The first group gave birth at least eight months before the campaign. The second group gave birth after the campaign and received the questionnaire when their baby was six months old. Tog values were calculated using similar methods to those of Fleming et al.4 Approximately equal numbers of babies were chosen from each month and hospital.

The first group returned 385 (86%) completed questionnaires and the second 399 (89%). The high response rate adds robustness to this study. There were no social or demographic differences between the groups and results were consistent from all three districts.

Babies' sleeping positions changed after the campaign at the three ages studied (table). Sleeping position also changed with age, older babies being more likely to sleep on their backs than on their sides. There was no influence of mothers' education, social class, marital status, or parity.

Results of survey to evaluate government's “Back to Sleep” campaign to reduce risk of cot death. Values are numbers (percentages) of babies.

View this table:

Although duvets or quilts were used less after the campaign, their use increased with the infant's age. The use of more than three blankets increased, younger babies using more blankets than older babies. The tog value for the babies' coverings were unchanged. After the campaign mothers having their first baby were less likely to use a duvet than were mothers with other children (for newborn babies 51/182 (28%) v 156/217 (72%), P<0.0002; for infants of 3 months 62/182 (34%) v 143/217 (66%), P<0.001; and for infants of 6 months 62/182 (34%) v 143/217 (66%), P<0.0001). After the campaign mothers became less concerned that their babies might get cold and more concerned that they might get too hot. Use of a room thermometer doubled and was higher among first time mothers than mothers with other children (65/182 (36%) v 22/217 (10%), P<0.00001).

More babies of 3 months and over slept in their parents' room after the campaign, but there was no change in breast feeding. The campaign had no effect on the prevalence of smoking by mothers or other members of the household, but more mothers claimed that there was no smoking near the baby.


The Department of Health's campaign was associated with improvements in sleeping position, use of bed coverings, and attitudes to heating. More babies shared a room with their parents and slept in their parents' bed. Sadly, the campaign did not influence the prevalence of smoking or breast feeding. Although duvets or quilts were used less after the campaign, their continued use on half of the babies by the age of 6 months is worrying. The increase in babies sleeping near their mothers may be beneficial. McKenna et al have suggested that proximity rather than merely increased vigilance may help to reduce the risk of cot death.5

The first group were exposed to the campaign before being recruited to our study. If the campaign influenced their answers it is most likely to have reduced differences between the groups. We do not know whether the increased time of recall influenced their response, but in our experience mothers accurately remember how they cared for their babies for a long time. Although the incidence of cot death has decreased dramatically, the risks have not been reduced for all babies. The momentum of this important campaign must not be lost.

We acknowledge the help of the mothers who meticulously completed the questionnaires, and support from the East Anglian Regional Health Authority Audit Committee and the Foundation for the Study of Infant Deaths.


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