Reimagining Safe Sleep: Using Participant-Generated Photography and Community Insight to Address Infant Mortality Inequities in New York City.

BACKGROUND: Sleep-related infant deaths disproportionately affect Black non-Hispanic families in New York City, representing a critical perinatal health equity issue. Traditional safe sleep messaging can fail to reflect the lived realities of structurally marginalized communities, creating disconnects between clinical recommendations and caregiving practices. OBJECTIVE: To demonstrate how participant-generated photography can reimagine perinatal care by centering Black maternal knowledge in infant safety interventions. METHODS: We conducted photo-elicitation interviews with 30 Black non-Hispanic mothers of infants aged <12 months in New York City. Participants documented their infant's sleep environments through photography (n = 86 images), which were then used to elicit in-depth interviews exploring decision-making processes and lived experiences. Selected photographs and quotes were incorporated as role-playing scenarios in training sessions with infant home-visiting staff. RESULTS: Nearly all photographs depicted sleep environments with multiple risk factors according to traditional guidelines; however, participants demonstrated sophisticated reasoning rooted in love, survival, and contextual safety. Key themes included: (1) multiple caregivers and sleep locations reflecting housing instability and extended family networks; (2) daytime and unplanned sleep driven by work schedules and practical constraints; and (3) knowledge-practice disconnects, where mothers understood clinical recommendations but adapted them to structural realities. When used in staff training, 97% of 165 home visitors and health care staff found these authentic images to be helpful for identifying real-world risks. CONCLUSIONS: Participant-generated visual methods can transform perinatal care by revealing wisdom embedded in marginalized communities' caregiving practices. Rather than viewing deviations as "non-compliance," this approach illuminates how structural inequities shape infant care and points toward more equitable, community-informed interventions.