BETHEL -- On beds and couches, in cribs and on the floor, across Alaska babies are dying where they sleep. They become wedged behind mattresses or sofa cushions. They are laid belly-down when they should be face-up. A fluffy comforter intended to keep babies warm becomes a deadly cocoon.
Sometimes, their mother or father cuddles up with them, only to accidentally smother them in the night. Sometimes, the parent has been drinking.
State public health officials now are putting attention on a troubling spike in Alaska's sleep-related infant deaths.
They are trying fresh education strategies and may finesse the current message that recommends babies sleep alone, on their back and in a crib. In one promising experiment, new parents in Ketchikan are being given a box stuffed with baby goodies that converts to a tiny bassinet.
The nuanced response is being driven by data. State health officials counted 53 sleep-related infant deaths in a recent 33-month study period. Then came a new spike of 10 more infant deaths in a six-week stretch, many of them sleep-related, the state's child protection head said earlier this month.
The number shoots up and down: from a modern high of 35 in 2009, then a drop to 12 the next year, then nine in 2011 before the count began to rise again. The alarm sounded anew last July, when at least five babies died from sleep-related circumstances in a single month. On average over the last decade, the number per month has been just two, according to public health officials.
In July, an Anchorage father awoke to find his 7-month-old son wedged between his bed and the wall and no longer breathing, according to a summary of recent Anchorage baby deaths provided by police in response to a public information request.
The mother of a 2-month old in Anchorage fell asleep bottle-feeding him in bed and woke up to find herself lying partly over her son, smothering him in his sleep. A couple of other children were in the bed, too.
Another Anchorage mother in July told police she had drunk a couple of glasses of wine and taken a few puffs of marijuana the night before. She woke up in the middle of the night to find her 5-week-old baby boy next to her in bed and not breathing.
It's a challenging, sensitive area for public health officials who want to prevent such deaths and change behaviors deeply rooted in family tradition, culture and convenience.
The affected families often have signs of dysfunction or chaos. Some lived in squalid conditions. Ten babies died in rooms where authorities noted bugs, mold, bad smells or standing water, according to a review by epidemiologists in the state Division of Public Health.
"You don't blame the parent for this kind of situation," said Matthew Hirschfeld, a pediatrician who is director of the maternal and child health program at the Alaska Native Medical Center in Anchorage. "That's probably how they grew up." Hirschfeld is one of the medical professionals who evaluate baby deaths through the state's maternal and infant mortality review committee.
Patient care and education must be tailored, he said, for a mother who may be consumed by the question of how to get an unsavory character out of her house, for a homeless family that is couch-surfing, for lives so chaotic that talk about cribs and separate sleeping areas may seem irrelevant to survival.
Southcentral Foundation, an Alaska Native health care provider in Anchorage, runs a program that sends nurses into homes to help pregnant women and their young children. It's called Nutaqsiivik Nurse-Family Partnership, using a Yup'ik word for "place of renewal." The goal? Work with mothers "where they are" -- both literally and figuratively -- to reduce infant deaths. Nurses check sleeping spaces and emphasize that it's best for babies to sleep alone.
Some 60 percent of the babies who died were Alaska Native, a disproportionately high figure in a state where about one-fourth of the babies born each year are Native.
No criminal charges
Almost all of the sleep-related deaths are preventable, health officials say.
"We know a lot of them occur in what we just say are unsafe sleep environments," said Margaret Young, manager of the state's maternal and child health epidemiology unit. "So there's a lot of pillows, heavy blankets in the bed with the baby or they are not in a safety approved crib, or are not on a flat surface."
Small infants shouldn't sleep under any blankets at all, she said. Babies can get dangerously overheated.
Law enforcement struggles, too. Even when parents have been drinking, fall asleep and smother their child, unless the police can show they were dangerously intoxicated, there's no crime, said Anchorage police Sgt. Cindi Stanton, who heads the department's crimes against children unit. Last fall, investigations of baby deaths were transferred to the city's homicide unit but until then her detectives handled them.
No adult in any of the recent sleep-related Anchorage baby deaths has been charged criminally. Alaska State Troopers say the same holds true of recent trooper cases, though one has been referred to Bethel prosecutors. The state Department of Law can't easily assess infant cases statewide. Charges in infant deaths, if any, would be mixed in with all other homicides: murder, manslaughter, and criminally negligent homicide, according to John Skidmore, criminal division director. Every homicide file in cases spread across 13 offices would have to be reviewed to come up with a number, he said.
In the Anchorage deaths, "there was no evidence of anybody staggering stupid drunk or so blatantly intoxicated that they wouldn't have been left alone to take care of their kid anyway," Stanton said.
No one wants to unnecessarily hurt parents who have just lost a baby.
"Some of them, they woke up and said 'oh my gosh, my arm was over my baby's face,' " the sergeant said. "How horrific, whether you had a drink last night or were just exhausted from working or taking care of the kids."
At a legislative hearing earlier this month, state Rep. Cathy Munoz, a Republican from Juneau, questioned Christy Lawton, director of the state Office of Children's Services, about infant deaths in "identified at-risk families."
"In the last six weeks, there's been at least 10 infant deaths, largely due to unsafe sleeping situations," Lawton told the House finance subcommittee for health and social services on Feb. 2.
Were those deaths in "identified at-risk families?" Munoz asked.
The families all had troubles including substance abuse and prior involvement with OCS, Lawton said.
Does OCS then push for prosecution? the legislator asked.
"It's a giant gray zone," Lawton said. "When we are talking about infants that have been accidentally rolled over because a parent has drank too much or perhaps was under the influence of medication whether prescribed or not prescribed, it's difficult to determine the intentionality there, in a tragedy such as that."
Signs of trouble
Overall, Alaska's rate of infant deaths has dropped markedly in recent decades, just as the rate has in the nation. In 1970, more than 2 percent of Alaska babies died in their first year -- and almost 3 percent of Alaska Native babies. By 1992, there were routine vaccines for infants and it had became standard for Native women to have hospital births rather than village births.The rate dropped below 1 percent. By 2010 it was below one-half percent.
Then it started back up. New annual rates haven't yet been calculated, but epidemiologists and a medical panel last year noticed the numbers were increasing.
The state's long-standing maternal infant mortality review committee, which includes pediatricians, nurses and other medical professionals, usually takes a couple of years to gather materials and thoroughly review each unexplained baby death to understand what happened and recommend ways to prevent others from dying.
But this time "there was an urgency," said Jared Parrish, a senior state epidemiologist working in maternal and child health.
State epidemiologists worked last fall with the committee to draw on police records, child protection reports, public assistance records and other materials in a quick examination of recent deaths.
They determined that 53 deaths in the 33-month window ending Sept. 30 were sleep-related.
Thirteen cases involved babies who died while sleeping on a sofa, 11 of them while lying there with someone else. Of the 31 deaths on a bed, mattress or floor, 25 were sharing the space with someone. Just nine babies died in a crib or bassinet, where loose bedding or being put to sleep tummy down may have elevated the risk.
Sleeping poses a danger for new babies, in part, because they do so much of it and don't yet have the muscle strength to reposition themselves if something interferes with their air supply, Parrish said.
The deaths referenced by Lawton all came after the study period and have not yet been analyzed in depth, he said.
Some situations are complex, with multiple risks. One Anchorage infant was born to a mother who drank, according to the Anchorage police summary. Fetal alcohol syndrome may have made him vulnerable, and he had serious health issues. He had had heart surgery. The day he died last August, his mother was drinking again, but not drunk, police were told. She put her baby, then 4½ months old, to sleep on a bed of blankets on the floor, an arm's length away from her. When she woke up at 10:30 that morning, he was stiff and not breathing.
"In a lot of cases we don't know exactly what caused the death even after a thorough death investigation, an autopsy," said Young, the state maternal and child health epidemiology manager, who was speaking generally. "We might suspect there is asphyxia (through suffocation) but it is still not clear. There's not physical evidence of that."
The state review found that more than half the cases involved caregivers who had been drinking, using drugs or using tobacco -- all of which epidemiologists say present a danger to babies.
Tobacco is a concern for several reasons, health officials say. Research shows that a baby in a home where adults smoke may have less ability than other babies to push away from a wall or a blanket, and adults who smoke may sleep more deeply, just as those who drink do, though studies on that point aren't definitive, Parrish said.
The state review found that almost all of the families who suffered a recent baby death were low income, with 92 percent either receiving benefits from Medicaid health insurance or the Women, Infants and Children nutrition program, or both. But separately, surveys of new Alaska mothers have found many caregivers sleep with their babies, no matter their income.
None of those who died were born to mothers who had graduated from college, the review found.
Half had histories involving domestic violence, substance abuse or legal troubles. In about as many, someone in the family had had contact with the Office of Children's Services before the death for concerns about child mistreatment. Some of the parents themselves had been endangered as children and involved with OCS.
It's unknown whether Alaska has a worse problem than other states with babies dying where they sleep. Death certificates here don't have a box to check for "sleep-related."
Nationally, there's a push to come up with a standard definition so these deaths can be tracked state to state, said Jay Butler, a pediatrician and infectious disease specialist who serves as the state's new chief medical officer and public health director. Alaska epidemiologists are part of that effort, he said.
Message in flux
The state has been worrying for years over the best public health message for new parents on safe sleeping for babies.
Alaska has stopped short of telling parents not to sleep in the same bed with their baby, though that's the recommendation of the American Academy of Pediatrics.
"Part of the struggle here is the message can sound very black and white, but there are a lot of moving parts," Butler said. Health officials want to encourage breastfeeding, for instance, which many mothers find easiest if they share a bed, he said.
"The issue of co-sleeping is something the department has been grappling with," said Valerie Davidson, the Walker administration's new health and social services commissioner. "The thing we have to be mindful of is that co-sleeping for many families is a cultural norm." Some families don't have anywhere else for the baby to sleep, she said.
Davidson, who is Yup'ik and spent some of her childhood in Bethel and upriver in Aniak, said she shared a bed with her younger children when they were babies.
But: "I'm fortunate. I don't drink," she noted.
The state now is looking at how to calibrate the current "Safe to Sleep" initiative to better reflect the reality of Alaska life.
State posters and brochures that went out to Alaska hospitals in 2013 promote what health officials call the ABC strategy: "Alone. On their Backs. In their Cribs."
But the materials also suggest options. If babies don't sleep in cribs, they need to be on their backs on a firm surface "in places where there is nothing nearby that could block their breathing, like a blanket, pillow, toy, or person -- especially one under the influence of alcohol, drugs, or medications," the poster says. The environment also needs to be tobacco free.
Efforts to guide parents on safe sleeping stretch back decades. A national "Back to Sleep" campaign began in 1994 to urge parents to put babies to sleep on their backs as a response to sudden infant death syndrome. SIDS now is a subset of sudden unexpected infant deaths, which the U.S. Centers for Disease Control says includes sleep-related deaths, although medical examiners still classify them in a variety of ways.
In Alaska, a new public service announcement crafted after the July spike in deaths features former Channel 11 reporter Andrea Gusty and her baby, Wilson, or Will.
"Breaking news," an announcer says as Gusty looks down at her tablet screen. "Another infant death and a plea from the state: Don't share a bed with your baby, especially after using drugs or alcohol." She then picks Will up from an adult bed and puts him in his crib on his back.
"To make sure Will is safe, we use a crib. That is the safest way to sleep," Gusty says in the announcement.
Gusty, who is Yup'ik and Athabascan, grew up in Aniak on the Kuskokwim River hearing stories of people whose babies died suddenly.
"It's a real scary thing," said Gusty, who now works for The Kuskokwim Corp., a corporation for 10 villages on the middle Kuskokwim River. She and her husband, Clinton Bennett, decided from the start that Will would sleep separately, but in their room, she said.
The new public service announcement has led people to recognize Will and her in the grocery store, she said.
"I actually get into these safe sleep conversations with grandmothers, with mothers, sharing their safe sleep stories," Gusty said. Some just thank her for starting the conversation. One grandmother said she was trying to get her granddaughter to use a crib. But she recognizes the challenge, too.
"There's a fine line to walk between trying to keep Alaska babies safe and trying not to alienate people," she said.
Baby in a box
In Southeast Alaska, a clinic manager at PeaceHealth Ketchikan Medical Center is trying something new, modeled after a successful program in Finland.
Gail Jones started a nonprofit, Little Alaskan Dream, that will ship baby starter kits to the community's new parents, boxes that include a snowsuit and mittens, a sleeping bag and a quilted suit, hats and socks, rompers and bathing supplies, bibs and a first aid kit. The main item is the sturdy, decorated cardboard box itself, which comes with a firm mattress and fitted sheet, a place for a baby to sleep.
"We have patients who live on boats, that live in fish camps, that live in logging camps," Jones said. The program mimics the one in Finland in which the government gives every new parent a baby box as a way to ensure every child gets an equal start in life.
In Ketchikan, pregnant women who take a half-hour class on safe sleeping will get the box and all its goodies, said Jones, who said the program is finally getting going after fits and starts. Now she is preparing to turn her nonprofit over to the hospital to run directly.
The class materials and tests use pictures to ensure that even patients who don't speak English as a first language will understand. Stickers for the boxes show a baby face-up with a green circle and one face-down, crossed out in red.
Southeast Alaska has the fewest infant deaths of anywhere in the state. But Jones, who responded as a paramedic in Kansas to baby deaths, said she and others want to do all they can so that no baby dies for lack of a safe place.
In Anchorage, most of the families who suffered a baby death had a crib, said Stanton, the police sergeant. But they often were full of clutter.
"That might not be the answer we are looking for," she said.
State officials say they are working on new ways to reach parents. Health officials just presented new information on safe sleeping to public health nurses.
Child protection workers have been trained to check sleeping areas. They knock on doors with public health handouts for parents in their bags. OCS now is looking at how it can better guide its work force, Lawton said Friday. It may create a webinar or other system to reach "every new staff person who comes in the door," she said.
"Every one of these deaths is a tragedy. We can get lost in the numbers sometimes," said Butler, the state medical officer. "We really just need to come up with the best ways to help people be able to create the safest sleep environment for their children that is realistic for where they live and their social situation."
In January, a mother in Aniak fell asleep with her 5-month-old on the couch around 2:30 one morning. When a relative stopped by around 7:30 a.m., the mother awoke and found that her baby girl had stopped breathing. Troopers, volunteer medics and clinic workers were unable to revive the infant. Troopers investigated the death and referred the matter to the Bethel district attorney.
Alcohol was involved, troopers say.
Reporter Nathaniel Herz contributed to this story.