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Introduction
Sudden infant death syndrome (SIDS) is often the most prevalent preventable cause of infant mortality in high-income countries [1]. In the United States, about 3,400 infants die due to SIDS each year. In 2019, 1250 deaths were reported due to SIDS [2]. However, in the Middle East, where high infant mortality is widespread, very few research have examined the burden of SIDS [1]. SIDS occurs when a newborn dies, while the cause of death is yet unknown [3]. Intensified efforts were made to identify modifiable risk factors and then translate them into guidance for parents as a result of the rising numbers of reported cases [4]. After effective implementation of mother-educational initiatives in response to associations between SIDS and the prone sleeping position, smoking during pregnancy, and overheating, the SIDS rate has significantly decreased over the past few decades [5]. In many countries, the midwife and health visitor positions are currently assigned the sole regular, national SIDS risk reduction intervention. This interaction typically takes the shape of a quick face-to-face conversation with mothers who have either just given birth or are taking antenatal sessions that include safer sleeping practices [4].
By teaching parents of infants about safe sleeping habits and appropriate responses in situations of emergency, the chances of SIDS can be decreased. The medical staff, such as nurses and physicians, family members, and the Internet, are sources of information for parents of infants about SIDS [6]. 
The knowledge and attitudes of the families who are most at risk for SIDS are not well understood, yet. If we are to continuously help families in making safer baby care decisions, we must look for ways to close knowledge and comprehension gaps. 
The current study aims to evaluate the mothers’ practices regarding SIDS prevention in Holy Karbala City and find out the relationship between the mothers’ practices regarding the prevention of SIDS with demographic variables. 

Materials and Methods

Study design
This descriptive study (cross-sectional) was conducted from September 26, 2022 to May 28, 2023. The study was carried out in the primary healthcare centers (PHCCs) in Holy Karbala City in Iraq, to assess mothers’ practices in the prevention of SIDS.

Study sample 
Using nonprobability (convenience) sampling, a total of 300 mothers of children who attend PHCCs was chosen as a percentage (10%) from the average of [3] prior monthly visits by mothers to the immunization units. The study was conducted in sections of primary health care in Holy Karbala City including the central sector and Al-Hur sectors. A total of 5 main PHCCs distributed in Holy Karbala City were selected randomly as 20% from each sector. Central sector accounts for 14 PHCCs and Al-Hur sector accounts for 8 PHCCs. From the central sector, three PHCCs including Bab Baghdad, Abbasia Algharbia, and Al-Eskan were chosen; also, from the Al-Hur sector, two PHCCs including Al-Hur and Al-Yarmouk were chosen. The sample size was determined according to previous Iraqi researchers [7]. All the PHCCs were written on identical pieces of paper, sealed, and stirred well in a container, and three pieces were drawn. PHCCs from the central sector were chosen. The study evaluated mothers’ behaviors not considering if their infants were healthy or had disabilities. Four newborns had neuropathy (Erbes’ palsy), three had myopathies, and seven had cerebral palsy (birth asphyxia).

The study instrument 
A questionnaire was constructed by an investigator for the study. The questionnaire is based on the investigator’s experiences, American Academy of Pediatrics (AAP) recommendations, and some questions that were relevant to the scope of this study and applicable to the study population sample, as well as previous studies [2, 3, 7-9], The majority of the Iraqi nursing staff also had a good level of knowledge about it. A team of nursing staff (6 nurses) was hired who expressed their desire to cooperate in this research with a likable personality and a pleasant manner of dealing. The research methodology and the method of evaluating and determining the exact answer for each item in the questionnaire were explained. It was also agreed in advance to select phrases and questions of precise meaning, with a dialect and phrases very close to the expected cultural level of the sample of mothers.
The following variables were chosen to evaluate mothers’ level of knowledge, thus the questionnaire format included two parts, the first was sociodemographic characteristics of the mothers (age, number of children, residency, level of education, occupation status, smoking status, and socioeconomic status) whereas the second part reported practices about safe sleep for the child. This section evaluated mothers’ reported practices regarding SIDS. It includes 11 close-ended questions, in which the mother is required to indicate her practices regarding the prevention of SIDS by selecting one of three options (never, always, or sometimes). The responses to these questions are rated and scored on a Likert scale (three levels) as follows: Never=0, always=2, sometimes=1. The total practice scores of mothers were calculated by adding up the scores for each question in the test. 

Validity of the current study 
To make the instrument of research more valid, it was current to a panel of (18) clinical and research-oriented nurse experts in the different fields related to the study title. These specialists were requested to evaluate the study’s instrumentation. 
Internal consistency reliability of the study (coefficient α)
The average of all possible split-half reliability coefficients for each data set of the current study was 0.89, this reflects an acceptable homogeneity of the measurements. As well, the Cronbach α coefficients were used to test the reliability of the current study instrument, which was also acceptable (0.829). 

Data collection
Both the face-to-face interview and the questionnaire formats were employed as methods of data collection. The questionnaire was filled out by the mothers themselves, and if any paragraphs were unclear, more explanation was given. The researchers went further than usual to explain and present the data from the questionnaire in a way that was acceptable to the mothers’ educational and cultural backgrounds. All inquiries were also handled in this manner. This made it easier to get beyond any linguistic or cultural barriers that might have existed and made sure the mothers understood the questions asked during the interviews.
After obtaining approval from the primary healthcare sector and receiving mothers’ consent to participate in the study interview, mothers who were receiving care from PHCCs completed the questionnaire. The study was carried out between January 10 and February 12, 2023, when many mothers were expected to visit PHCCs to immunize their children. The mothers who agreed to participate in the interview were then given a brief explanation of the study’s objective. The researcher filled out the questionnaire’s format while being watched over by their mothers if they were unable to read or write. The researcher gathered this data within or outside of the immunization units located at PHCCs since the bulk of the women visited PHCCs in the morning. All of the data was gathered in the same location because the immunization unit, where the data collection process took place, contains both a waiting area for mothers and the main hall where vaccinations are administered, considering that all PHCCs have the same building design. Although the researchers made great efforts to give the material in a way that would drive them to participate in the study, we were unable to persuade all of the mothers who were questioned, and some did not respond to the survey. Due to the difficulty of gathering information in the immunization hall because of momentum, the difficulty of movement, lack of workflow for carers, and the greatest number of mothers in a short period, the researcher distributed the questionnaire to mothers and collected it in both the immunization halls and the waiting hall. The average amount of time to complete the questionnaire assessing their practices regarding SIDS prevention was 10 minutes.

Data analysis 
The SPSS software, version 26 was used to analyze and interpret the data. Numbers, percentages, and Mean±SD  were used for descriptive statistical data analysis. Spearmen’s correlation coefficient was used to evaluate the relationships between the study variables. No adjustments were made for multiple comparisons when interpreting the significance thresholds. The P was 0.05 at the significant threshold.

Results
Table 1 shows the distribution of mothers according to their demographic characteristics. The mother’s age highest percentage was (44%) for the age group 20-29 years and the lowest percentage was 5% for the age group ≤19 years. The number of children of participant mothers was from 1–3 recurrence (75%).



Regarding residency, a greater number of the study sample reported they were from urban areas (86.3%), while other participants were from rural recurrence (13.7%). Concerning the level of education for mothers, a high percentage indicates that mothers graduated with (a diploma degree (26.7%) (Figure 1). Regarding the mother’s occupational status, more than half of mothers were housewives (51.7%), and other participants’ mothers were government employees (49.3%). Regarding smoking status, 59.4% of parents were not smokers, and only 40.3% of the study sample reported that their husbands were smoking. Regarding family socioeconomic status, the highest percentage of the study sample revealed a sufficient status.



Table 2 displays that 75.3% of mothers show a good level of practice about safe sleep for children as prevention of SIDS (16.6±2.7). 
There is no significant relationship between mothers’ practices and their age (P>0.05), the number of children in the family, residency, and socioeconomic status. There is a highly significant relationship (positive strong) between mothers’ practices and their level of education (P=0.001), occupational status, and smoking status.



Discussion
Significant global interest exists in learning how families receive and implement safe sleep public health recommendations, as well as the modern infant sleep practices used by families with young infants, as shown by the numerous research, carried out abroad.
The current study primarily aimed to assess mothers’ opinions and current knowledge of the recommendations for lowering the risk of SIDS. The main results of this study were that mothers had an excellent degree of practice in preventing SIDS, with a total score of good practice (14.9-22) and a Mean±SD of 16.6±2.7. Regarding their degree of education, employment status, and smoking habits, mothers’ practices are significantly correlated (P=0.001) with these factors. However, there is no association between the mothers’ practices and socioeconomic position, residency, age, or the number of children (P>0.05).
The findings of the current study showed that 75.3% of mothers exhibit an excellent level of practice for safe sleep for children according to the overall assessment of mothers’ stated practices about the prevention of SIDS. These results concur with those of Antony et al. who demonstrated that a high level of practice was shown in mothers caring for their newborns to prevent SIDS [2]. In this study, 30.8% of the moms had knowledge levels that were average to low which is noteworthy and demands attention [2]. However, the results of the present study, disagree with those of an earlier study conducted in Egypt, which found that more than 75% of the mothers were unaware of SIDS and had limited knowledge of the illness [10]. Similarly, more than 75% of the mothers said they had never heard of SIDS and knew little about it. Additionally, almost half of the mothers showed a subpar degree of practice in preventing SIDS [11]. Another Saudi recent study demonstrated a significant variance, indicating a better understanding of the prevalence of childcare practices and knowledge of SIDS risk factors among mothers [12]. 



Harmonious to previous studies, a positive significant correlation between mothers’ practices and their degree of education, employment status, and smoking habits was reported by several researchers [2, 13, 14]. However, there have been many revisions suggesting that maternal smoking is considered one of the most significant risk factors for SIDS [11, 15]. Contrarily, mothers’ education, employment status, and smoking status were not significantly associated with SIDS in line with a study in Saudia Arabia [12, 16]. 
Similar to what Ibrahim et al. found, the current statistics show that the majority of mothers were in the 20–29 and 30-39 age groups, comprising 44 and 40.7% of all mothers, respectively [10]. Regarding the number of children, the present study showed that about 75% of the studied moms had between one and three children. This result is consistent with a study published by Nigerian researchers which reported higher rates (88.7%) [17]. 
There was no association between SIDS and residency. Other researchers who claimed that just 10.3% of the study participants lived in rural areas obtained contradictory findings [12]. However, this is not the case for the outcomes of prior reports [18].
More than half of the mothers in the current study were homemakers, which is in line with a study from Egypt [7] in which more than half of the mothers did not work. The socioeconomic background of the participants had little impact on mothers’ SIDS prevention practices. The mothers’ average “diploma degree” rate of 26.7% confirms findings from an earlier study [19]. The economic status of 29% of the studied families in the present study was sufficient to support the results of a recent study [20].
According to the current study, there is no statistically significant correlation between mothers’ practices and their age. These results contradict those of another study [21], indicating a significant correlation between a mother›s age and the sleeping position of the child. Likewise, 69.1% of the analyzed mothers within the age range of 25–34 years place their children in the supine position while they sleep, but the pattern varied across age ranges (P=0.003). It disagrees with an analysis that demonstrates a statistically significant link (P=0.001) between self-reported practice and mothers’ ages [2].
The study’s conclusions show that there is no relationship between mothers’ attitudes and the number of kids living in the home, which is consistent with previous research showing no association between mothers’ total practice scores both before and after the introduction of educational programs and the number of children they had [10].
The authors recommend to raise public awareness of the prevention of SIDS, a comprehensive health education program should be put in place. Staff at primary health care clinics can provide it through mass media and booklets. Additionally, because they serve as role models for parents who leave the newborn intensive care unit (NICU), nurses must adhere to safe sleep standards, notably the supine posture. They should especially educate new and inexperienced mothers [22, 23] during the antenatal period and after delivery. Centers for women and children should implement public health initiatives and educational programs to raise parental and carer awareness of SIDS, its risk factors, preventive measures, and safe sleep recommendations.

Conclusion
The study concludes that mothers had good practices in SIDS prevention, and there is an anon-significant relationship between the practices of mothers and the age, number of children, residency, and socioeconomic status. Meanwhile, there is a significant correlation between mothers’ practices and their educational level, occupation, and smoking habits.

Ethical Considerations

Compliance with ethical guidelines
The protocol of study and official permission for the study has been independently reviewed and approved by the College of Nursing, University of Karbala to conduct the study (Code: IRB: CN-2022-0023-MN). The College of Nursing’s Ethics Committee assessed the study tools (questionnaire) and agreed to proceed with the study after receiving the title and the questionnaire. The survey was undertaken with the understanding and written consent of each subject according to the above-mentioned principles as well as the protection of human subjects in research projects, and criteria for IRB were under consideration. The entire study protocol adhered to the Helsinki Declaration.

Funding
This research did not receive any grant from funding  agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization, supervision, project administration, review and editing: Zeki Sabah Musihb; Research, data collection, writing the manuscript and statistical analyses: Alaa Mahdi Abd Ali; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
The authors gratefully acknowledge the generous assistance of the mothers and families.





References