Every time a baby is put down to sleep it needs to be safe, says Rotorua Hospital paediatrician Dr Johan Morreau.
He wants parents to heed warnings about the dangers of bed-sharing with young babies.
In the past five years, 26 babies in the Rotorua region have died as a result of bed sharing.
Recently, Rotorua mother Ngaire Kura Tukiwaho, 30, pleaded guilty in the High Court to the manslaughter of her 2-month-old son Tahi Elvis Edwards who died while sleeping in the back of a car with her last year while she was heavily intoxicated.
A Maori grandmother at another recent Rotorua inquest said she had slept with all eight of her children, as her mother and grandmother had done, without any issues until a grandchild suffocated while sharing a bed with siblings. She said it was common practice in the family even though they knew it was unsafe.
"You see, well, nearly everyone else doing it around you and nothing happens to them. You just do not really see an issue," she said.
This seems to be how many parents feel even though doctors, midwives and Plunket nurses don't recommend bed-sharing with a young baby.
Many mothers The Daily Post spoke to said they had had their babies sleeping with them at some time or another.
Dr Morreau and Dr Bain both say if there is a chance of the mother falling asleep while baby is in bed with them, it is unsafe and they shouldn't do it.
In one finding regarding a baby death, Dr Bain said it was clear the parents loved their babies but the message that it was a dangerous practice needed to get through.
"Although loving their babies dearly and thinking they are doing the very best for them, they are in fact unwittingly 'killing' them. This is a very, very sad state of affairs and it seems to me can only be rectified by education and on the ground assistance for mothers," he said in the findings.
The deaths were avoidable, Dr Bain says.
"It is an unacceptable risk ... co-sleeping should be classified as a dangerous practice and should be clearly brought to attention of parents."
Dr Morreau says medical professionals explain the importance of a safe sleeping environment for baby to parents. Like Dr Bain, he believes education is the key to getting the message through.
Babies need to always be put to sleep safely in their own bed, on their back with their face clear of obstruction from blankets or clothing, Dr Morreau says.
He advises that a baby's bed should be in the parents' bedroom but in their own sleeping space like a bassinet, cot or pepe basket.
"A small baby doesn't have the muscle tone to move around as a large baby. If there is any pressure on them they are more vulnerable, especially if the mother has been drinking alcohol or is a large person, then there is the potential of her being in a deep sleep. Mothers by definition are tired people anyway, they are breast feeding three hourly. The potential for overlaying on a baby that already has a small airway is high," he says.
"It's a tragedy in the making. That's dangerous. Have the baby in cot in the room with family where mum is able to breast [feed] baby then pop them back into their cot once baby has finished their feed. That's really, I believe, the safest way to manage baby."
Swaddling babies to stop them from rolling was best, he said.
If parents don't have a cot or pram, they could use an alternative like a box with an appropriate mattress.
"It's better to use a commercial arrangement but there are a lot of things that can mimic or mirror a little bassinet," Dr Morreau says.
He believes the main reason parents sleep with baby is for ease of breast feeding.
"I suspect people have to find ways to make it easy on themselves so that's really the key thing. I guess people feel it's a nice thing to have baby cuddle up with them. That's fine while they are awake but as soon as you plan to go back to sleep, baby needs to be separated.
"Most of the time people get away with it. Unfortunately, as we can see, there are times when they don't. Nobody wants this to happen but probably people get a false sense of security and haven't quite realised how important it is until it happens to them."
Parents should never put a baby to sleep on a couch, cushions or a car seat either, Dr Morreau says.
"People need to be getting the same message - babies need their own bed next to their parents."
Rotorua Hospital is this winter running a programme which should see new mothers provided with their own pepe pod basket.
SAFE SLEEP
Always put baby in their own bed
Place baby on their back
Ensure face is clear of blankets, clothes or stuffed toys
Never pull baby into bed with you or with other adults or siblings
Don't use a pillow
Place baby where they can't wriggle under blankets
Make sure baby can't become wedged between mattress or blankets