Recently, a Scottish initiative made headlines: ‘Baby boxes to be sent out across Scotland from August’. When reading this, I couldn’t suppress a frown. It brought back memories of the long cold months I stayed in Scotland. Hadn’t I noticed many single (teen) mothers, families struggling to pay their bills, children on the street with clear features of Foetal Alcohol Syndrome? I wasn’t a midwife back then, but I remember my lawyer’s heart sensed some inequality in the start of life. And that is exactly what the baby box initiative would like to address. It wants to provide mothers and babies, irrespective of their background, with necessary supplies in order to give them a fairer and healthier startup in this world. However, is this box the right means to that end? Let’s dive into the box and explore the baby box concept and whether it can live up to its expectations.
The idea of supplying a baby box to expecting parents is not exactly new. It goes back to 1938, when the Finnish government introduced the concept and made it an established component of Finnish maternal health care, aiming at reducing the high infant mortality rate. At first, the boxes were distributed to poor expecting families, but after the Second World War this was broadened to all Finnish women expecting a child. Today, each pregnant woman in Finland is offered the choice between the box or 140 euros in cash. According to a BBC report, 95% of them chooses the box over the cash. The baby box has become one of the rituals surrounding the transition to parenthood in Finland.
The contents of the Finnish baby box have changed a lot over the years, as circumstances and ideas about maternity changed. In 2006 for instance, the traditional bottle was left out to encourage breastfeeding. Currently, the box contains more than fifty items such as diapers, sheets, toys, a sleeping bag, bodysuits and bathing products. What’s more, there’s a small mattress to be put at the bottom which turns the box into baby’s first bed.
Over the years, the baby box concept has expanded beyond the borders of Finland. Three Finnish fathers started a company that delivers boxes worldwide, and similar businesses have been started in at least two other countries, namely the United States and the United Kingdom. Ngo’s and governments across the globe have also started to introduce baby boxes in one form or another.
Reducing mortality rates?
An important selling point in introducing the baby box concept in countries - especially developing countries - throughout the world is the presumed causal relationship with lowering perinatal maternal and newborn mortality rates.
In Finland, these rates have indeed dropped dramatically since the box was introduced. The question remains to what extent the baby box can be seen as the leading cause of this. In fact, there seems to be no hard evidence for the claim that the baby box itself directly causes neonatal and maternity mortality rates to drop. Using the cardboard box as a safe crib may contribute to lowering the Sudden Infant Death Syndrome, but more research is needed to establish firm conclusions.
What seems far more important, however, is that from 1949 on, the Finns made obtaining the box and a maternity allowance dependant on visiting a health clinic. This allowed for regular health checks of pregnant women and new mothers and their children.
Doing the trick?
Put differently: just donating a box with useful items is very unlikely to do the trick. The choice of how and when to make the box available to parents and at what price (if any) is crucial. What seems to do the trick, is embedding the box in a wider program to improve perinatal health, in which it serves as a kind of incentive. Through the handing out of boxes, contacts emerge between parents and the pre- and perinatal health care system that may not have been there before. Regular checkups and giving birth in a clinic or in the presence of skilled midwife or doctor can be stimulated.
In many countries across the globe, baby box-like concepts have been introduced over the last years. Reviewing a series of them shows that many projects recognise the importance of a connection with health education and the local health care system, and ask some form of commitment of the (future) parents. Some commercially available baby boxes come with a teaching program.
The Scottish box that triggered my attention on the other hand, does not seem to be a particularly strong incentive, nor does it seem to have really strong ties to a basic support system (yet?), even though mothers-to-be need to register for a box through their midwife. Of course, families may warmly welcome the included items nevertheless, but if the box is not incorporated into a system that addresses at least some of the fundamental problems that affect the health choices of those families, it is indeed of little value in reducing mortality rates. Most of the health impact is expected to come from the connection between the box and some sort of care or mentoring program.
Incentives across borders
The use of incentives has already crossed many borders. In developing countries, it is often applied in the fight against perinatal maternal and newborn mortality and morbidity rates. In Kenya for instance, distribution of free, insecticide-treated mosquito nets was made conditional to attending prenatal care, while in India cheap food was used as an incentive for women to participate in immunisation programs. In one Kenyan county, the distribution of birth kits was linked to a program meant to stimulate parents to gently touch, make eye contact with and talk to their babies, as well as to train them in responsive feeding and caregiving and singing to their child which is crucial, among other things, for its early cognitive, language and emotional development.
The use of baby boxes is not confined to governments or commercial parties alone. Ngo’s with all sorts of backgrounds and priorities also use them as part of their health programs. The christian ngo Compassion for instance, supplies them to mothers in several developing countries who take part in their Child Survival Projects. The baby box is part of a wider strategy that, among other things, involves initiatives to help women generate their own income and receive training and spiritual and emotional support. The boxes and the way of distribution are adapted to local culture and health care systems and linked to immunisation programs and often also nutritional support.
Although available literature seems to indicate that incentives might play a positive role in promoting both the use of healthcare and the making of healthier choices, profound research to sustain this claim still has to be done. Some prudence in our estimation of the possible impact of the distribution of baby boxes seems warranted.
Choice of contents
The choices made regarding the contents of the box and how these might influence the behaviour of the parents(-to-be) reveal something about the health policy and the goals that are being pursued.
For instance, by in- or excluding dummies, bottles or a tin of infant formula, an indirect statement on types of feeding is made. Including condoms and information on contraception and family planning makes a statement to parents that thinking about reproductive health is recommended. Adding immunisation calendars stimulates parents to participate in immunisation programs, while adding mosquito nets tries to raise awareness about their use in protecting the newborn against malaria. Including a toy and a baby book stimulates parents to pay attention to the interaction with their newborn and to take care of its cognitive stimulation. Designing the box as a crib stimulates parents to incorporate safe sleeping habits. In other words, the choice for a certain content serves as an incentive for parents to make certain choices. Thus, the choice of contents matters.
The choice of contents also matters with regard to certain target groups. What, for instance, with parents of preterm or disabled baby’s? Will the items be useful to them? Will they be negatively affected by being confronted with a box that was primarily designed for healthy, full term baby’s?
Developers of baby boxes for low- and middle resource areas or countries often emphasise how the contents and the design are being adapted to local needs and are made culturally acceptable. However, I feel there are some double standards being used here. First of all, one might ask if the baby boxes distributed in plural western countries are taking on board cultural sensitivities as well, and if not, why not? Secondly, with regard to the boxes distributed in developing countries, it seems that some items are adapted to the local context while others are definitely not. For instance, it is common knowledge that in some parts of the world condoms are not (fully) accepted, but most boxes seem to deliver them anyway. Are these sorts of incentives appropriate and justifiable? Can it be that we are we enforcing a western (reproductive) health agenda and using the box as a means to that end? I am not taking a position, but I feel we need to have a serious discussion about every item that is added, about what we are trying to reach and about whether this particular item is the the only and most advisable way of reaching the intended end.
Baby box hijacked?
Baby boxes are currently part of the health repertoire of (local) governments, ngo’s and commercial parties. With all three of these, some caution seems warranted, not in the least because the baby box concept is very ‘media friendly’: parents-to-be will, for obvious reasons, be happy to receive a free box with nice, useful items, while organisations might get positive attention for handing them out.
Governments therefore might be distributing boxes as a mere PR-stunt, as for instance some critics claim the Scottish government is doing. According to news reports, they feel that the distribution in its current form is a waste of public funds that could have been used to tackle the problem of perinatal mortality in a far more efficient way. Ngo’s on their part may walk into the same trap, especially since they often (partly) rely on positive media attention to raise funds. Furthermore, if an ngo is only active in a region for a limited period, the baby box concept may lose it’s strong point (the sustainable connection to health education and the local health care system) altogether. Thirdly, there are the commercial parties offering baby boxes. Again, possible pitfalls might be the lack of a prolonged presence in a given region and a lack of a wider health care program in which the boxes are embedded.
When governments or ngo’s involve commercial parties in composing the contents and in defining the incentives behind the baby box, they need to keep certain points in mind so as to prevent their initial health agenda from being hijacked. Baby box items should not be PR material, nor can they be added with the primary intention of creating consumer demand. The use of items made in an environmentally friendly way and out of safe materials should be encouraged. In low and middle income countries, local production is to be preferred above importation because of job creation and cost-effectiveness. Items included should not violate local regulations in any way and the design should incorporate the needs and wants of the local communities.
Personally, I feel there are also some more fundamental issues at stake regarding the baby box. Women often take pride in preparing for the arrival of their baby. While collecting (or even creating) all the items they undergo an important natural mental preparation for motherhood. Preparing, and probably even saving for, the necessities, creates a place in their life and their heart for this child. It is an essential part in their “nest-building” and adds to the prenatal bonding of parents with their baby.
These days, a lot is being said about empowering women. However, I don't believe in empowering others that much, but rather in creating conditions that allow people to empower themselves. We have to ask ourselves if we really are empowering women and parents by giving them a baby box. If a more fundamental social equality would exist, all parents would be able to afford, collect and compose the nesting materials of their own choice. This would not only create a priceless parental pride, but it would also give them strength and a sense of responsibility. These are the components that make strong and capable parents who are really involved in their family’s health choices.
If mothers accept a box because they really can’t afford the items themselves, they might also be made to accept the health policy program connected to it. Is that empowering a woman to freely make her own (health and life) choices? The risk is that we direct people in their health care choices instead of educating them about the advantages and disadvantages of existing options and helping them to make their own informed choice. I do not doubt the sincere motivation behind the concept of baby boxes and their functioning as incentives, but we need to be aware of the risk of derailing towards a kind of paternalism.
In essence, the baby box seems to be a good idea, that can bring joy and carries the promise of an added value in terms of improving perinatal health. It definitely seems to offer opportunities, especially in creating a link between women and health care workers.
Much however, seems to depend on how we go about with the idea. In order to raise above the level of a mere donation of useful items, some things are needed. The box should always be embedded in a wider maternal health care program, in which it serves as an incentive for parents-to-be to get involved in making their own healthy choices.
To truly reach this, we, as health care providers, should keep the discussion going on what is included in the box and why it is included. Whether in developing countries or in the West, baby boxes should also be cost-effective and sustainable in economic, environmental and societal terms. And of course, both the boxes and the items included should be safe to use. In Argentina, it turned out that the baby bed that was included in the box, did not meet the relevant safety standards.
What’s more, to see whether the concept actually fulfills its promise of improving maternal and neonatal health, more research is needed on the impact of this community-based intervention. Whether the baby box is the magic solution to tragic situations, remains to be seen.
* * *
Baby Boxes Across the Globe
Now let us make a short exploration across countries where baby box-like concepts have been introduced.
In South-Africa, two fathers took the lead in launching a birth package called the Thula Baba Box. It is meant to support newborn families during the first 1000 days of their life. Founders Ernst Hertzog (of Action Here Ventures) and Frans de Villiers hope that the concept of the baby box will be integrated into the national health insurance system which will be rolled out by 2020.
Basically, the Thula Baba Box rests on three pillars: essential items, an incentive to antenatal follow up and behaviour change, and providing necessary information on a healthy maternal and newborn life.
Hertzog and Villiers’ kits have been adapted to the South-African context in terms of physical environment and cultural norms. For instance, the box is made of plastic so that it can serve as a tub as well as a baby cot, since co-sleeping with babies is a deeply rooted habit that probably won't change overnight. The items in the box are adapted to local conditions (clothes for instance are tailored to specific weather conditions) and fine tuned on the level of health literacy.
The box focusses on enabling survival in areas that lack basic services like electricity, clean water and sanitation and face the challenges of infectious diseases like HIV, malaria and TB. Apart from a mattress, blankets, towels, nappies, baby and health products (such as soap, a toy, a mosquito net, medication) and other items (like condoms), the box also gives information on breastfeeding, the newborn vaccination program and contraception. Furthermore, it provides medical advice for emergency situations and infant care.
The Thula Baba Box makes use of a rewards system to encourage families to visit health care clinics for check ups. In order to qualify for the box, low-income expectant mothers have to register at antenatal clinics early on in their pregnancy, have to go for regular check-ups and have to give birth in a hospital or clinic. This helps for instance HIV-positive mothers who will not only receive useful antenatal advice but also treatment and monitoring during pregnancy and delivery. This will reduce both the health risks for the mother and the chance of transmitting the virus to the newborn.
It is exactly this connection between the box and the antenatal follow up that is expected to lead to better health outcomes for mothers and babies and even lowering the costs for health care in the long run. In March 2015, the first 50 boxes were distributed for free from two public clinics, with the University of Stellenbosch studying the effects.
A recent award winning start-up in the field of baby boxes for the South Asian market is the Barakat Bundle-project in India. ‘Barakat’ means blessing and that is also what it hopes to bring: low-cost life saving solutions for mothers and newborns.
The boxes are specifically designed for the South Asian context. By applying human centered design and running (prototype and evaluation) pilots the makers try to ensure to offer solutions and necessities that not only are of added health value but also culturally acceptable and adapted to the contextual needs. For instance, initially, illiteracy turned out to be a barrier to families in understanding the functionality of the items and the educational materials. This was addressed by providing audio-info pamphlets. The use of ghodiyus, a kind of hammock, as a baby crib turned out to be deeply rooted in cultural practice but not so favourable from the perspective of safe sleeping. This challenge is addressed by the design of a Barakat Bundle crib, that incorporates safe sleeping while keeping the functionalities of the ghodiyu (for instance the capability to rock the crib).
The Barakat Bundle includes a clean-delivery kit for perinatal infection prevention with medical items, a package with newborn essentials (like clothing, a blanket, a mosquito net and items that stimulate cognitive development), a prenatal essential (folic acid supplements) and parental education on topics like breastfeeding and hygiene. Expectant women receive the Bundle on the condition that they attend prenatal medical examinations to guarantee maternal care and safety. The goal is to make the Barakat Bundle affordable, accessible and educational.
Barakat Bundle works with local partners like the Public Health Foundation of India and the Society for Education, Welfare and Action to distribute the boxes and provide the accompanying care. For at least one of the pilots, the box came from the US based Baby Box Company while the clean birth kit was supplied by Ayzh, that is located in both the US and India. A future goal seems to be to have local sources for their goods. The fabric and frame of the Barakat Bundle crib were both made in India.
In the mean while, the baby box has also reached Australia. The Baby Box Company has opened an office Down Under and partnered with charities. Organisations such as the Caroline Chisholm Society and Bundle of Life have started local projects for handing out baby boxes to women and families as a means of getting them involved in support programs. Through the boxes the Baby Box Company also offers access to its Baby Box University, an online educational program “for the purposes of reducing infant mortality and empowering parents”.
The Baby Box Company also teamed up with the authorities of the Canadian state of Alberta and the University of Calgary. Under the flag of the research program ‘Welcome to Parenthood’ 1500 baby boxes were handed out to new mothers. Apart from useful items such as a sleeping bag and a thermometer, the boxes also contain breast pads to stimulate breastfeeding and information leaflets for both the mother and the father. A book on brain development of young children is also included, to raise the awareness of parents. ‘Welcome to Parenthood’ is designed to study a broad system of support for new parents, which aims at improving the health and wellbeing of vulnerable children. At the heart of it lies a mentoring system, in which mothers- and fathers-to-be choose someone from their social network as a mentor. In total, they meet twenty times in the period between the 32nd week of the pregnancy and the sixth month after the baby is born.
The Scottish box is said to be inspired by the Finnish baby box. It is a sturdy cardboard box that can be used as a crib for the baby and is meant to stimulate safe infant sleeping habits. Apart from encouraging rooming-in of the baby in its first months of life (which is supported by the latest research), it encourages giving up co-sleeping of parents and newborns in the same bed. Besides, the box is small in size which prevents the baby turning on its stomach. This way the use of the box is meant to contribute to preventing Sudden Infant Death Syndrome. Apart from a mattress, blanket and cot sheets, the box contains 40 different items altogether, among which baby clothes for different types of weather, a play and changing mat, a reuseable nappy and liners, an organic sponge, a digital ear thermometer and a room thermometer, a bib, nursing pads, a soother toy, a baby book and a poem.
After a 3 months pilot in two clinics (Clackmannanshire and Orkney), free baby boxes will be distributed in het whole of Scotland from August, 15 on. There is criticism however, in particular that the Scottish box is just a government PR-exercise instead of a “good piece of public policy”. Furthermore, contrary to many other boxes, it does not seem to be a particularly strong incentive to link up with the health care system, nor does it seem to have really strong ties to a basic support system (yet?), even though mothers-to-be need to register for a box through their midwife.
Sari Lathi, a lecturer in nursing (at the Helsinki Metropolia, University of Applied Science) said in the Daily Record that the box alone is not responsible for reducing infant mortality in Finland but it made mothers attend clinics and qualify for maternity allowance and the follow up of mother pre- and postnatal. She considers the Scottish baby box, if not embedded in a wider maternal health care program with incentives to behaviour change and education, just as much as giving them a nice gift. “In terms of helping the health of pregnant women or unborn children it would be worthless”.
A similar critical voice can be heard from Colin Pritchard, professor at Bournemouth University. He told the BBC Magazine that this box makes some “theoretical sense” as it might improve safe sleeping habits, but that he believes that the effect on reducing mortality rates in general will be marginal in Scotland. In order to reduce infant mortality he says more fundamental problems need to be addressed such as “alleviating poverty, stopping parents smoking, and improving education and antenatal care”.
Perinatal kits of various shapes and sizes are not uncommon in Zambia. As of 2015, the aforementioned Baby Box is being distributed among the country’s poor parents and baby’s by One Zambia, an ngo run by Zambians living abroad. Through the Churches Health Association of Zambia they provide the parents with a box filled with a mattress, a waterproof cover, a cotton sheet, a swaddle blanket, a lovey, two onesies, two pairs of socks, three organic washcloths, one pair of newborn mittens, one newborn cap and one cloth diaper kit.
These are not the only kits provided to Zambian parents. In a drive to enhance the number of deliveries in health care facilities, the authorities offer women a small incentive if they go there to have their child. This ‘mama kit’ consists of a cloth, a diaper and a blanket. The first studies into this program seem to indicate that its both cost effective and achieving its goal. In a report evaluating the use of mama kits, it is stressed that “[l]ow-cost mama kits are unlikely to provide a complete solution to safe delivery challenges”, but that they can be “embedded in larger maternal and child health programs”.
Compared to other wealthy countries, the United States struggles with a relatively high infant mortality rate. For instance, over the last years, the number of cases of Sudden Infant Death in Bexar County, Texas, has increased to 16 in 2015, with suffocating being one of the leading causes. Infant suffocating can occur due to co-sleeping with parents or as a result of an unsafe sleeping environment (like cribs filled with fluffy blankets, bumpers and stuffed animals, or through sleeping on the belly or the side instead of on the back).
In January 2016, the University Health System Foundation started a small pilot study. With financial support of the local Rotary Club, the Junior League of San Antonio and the Texas Diaper Bank, 135 baby boxes were distributed for free to low income parents. Just like the Finnish box, the cardboard box with its mattress (with waterproof cover) and cotton sheet can be used as a safe baby crib up to 3 months of age.
The box is filled with diapers, clothing, first aid kits, wipes, lotion, a teddy bear and other essentials. After receiving a box, the parents will be followed up to check if they made use of the items and if the box was used as crib for the baby. The idea is also to connect new parents to more experienced parents.
Apparently, the pilot was successful. In May it was announced that a range of Texan institutions has teamed up with the Baby Box Company to distribute free baby boxes to parents-to-be. They will get one after completing an online course one safe sleeping habits at the Baby Box University. The company is able to deliver the boxes for free due to the revenues of its other activities and due to donations made for the project.
In 2016, the Temple University Hospital in Philadelphia has started distributing free baby boxes to parents of newborns. It is the first time that a baby box project of this scale was launched in the US. The project is a result of a collaboration of Temple’s pediatrics and maternity nurses and aims at reducing Philadelphia’s high infant mortality (10,5 deaths on 1000 live births, more than twice the national average). The director of nursing services told ABC News suffocation is the leading cause of infant deaths.
The design of the box offers a safe sleeping environment for the newborns, discourages co-sleeping and is hoped to serve as an important tool in preventing Sudden Infant Death. The box also offers other essential baby supplies, representing a worth of 80 to 100 dollar. For the first batch of 3000 boxes, half of the costs were covered by the hospital and the other half by a private fund. If the project turns out to be effective, it will be scaled up.
An essential part of the box is the information it supplies to parents on topics like feeding, fire safety and creating safe and baby friendly environments. The hospital wants to stay in touch with the parents after they leave the hospital, to back them up when they have health questions and to stay available to them when they have certain concerns.
Other US initiatives
Texas is not the only state where a range of institutions has teamed up with the Baby Box Company. In fact, it was only the fourth, after previous initiatives in New Jersey, Ohio and Alabama. In the state of Minnesota, the ngo Babies Need Boxes has also started to spread the baby boxes.
Six years ago, Chili started a baby box project called “Ajuar”, also popularly referred to as ‘Fkentrousseau’. The baby box is one of the key components of the Newborn Support Program (PARN) of the government initiative Chile Crece Contigo (Chile Grows With You), an integral system for child protection. The box is offered for free to all parents (including immigrants) when they are discharged from the maternity ward of a hospital that is part of the Public Health Network. Conditional to receiving the box is the participation in prenatal workshops and consultations and group education on issues like breastfeeding, secure attachment and on the use of the items in the baby box.
In 2012, the box was modified. The current box contains 3 packages with basic tools, practical items and educational items to stimulate attachment and improve parenting skills. The first package, ‘Safe and Secure Attachment and clothing’, provides a breastfeeding cushion and a baby carrier (Mei-Tai) with user guides, 3 cotton diapers, a baby bath towel, a bag for baby items, different types of baby clothes and a renewed education card. The second package, ‘Basic Care and Stimulation’, provides hypoallergenic soap, massage oil, cream, a rubber playground and a plastic shifter. The third package, ‘Crib Equipment’, offers a portable playpen, a mattress, a blanket, a set of sheets, and a guilt.
In 2011, a study on the baby boxes showed that most parents were very happy with the contents of the box. The existence of educational materials and workshops in hospitals however, was not known that well, which led to an integration of these materials into the actual box. In 2015, more didactic elements were added, like a dvd on how to properly use the items in the Ajuar, a toy to stimulate the baby visually and motorically, a book that encourages parents to stimulate their child visually, tactilely and motorically, and a storybook stimulates them to make their child familiar with books as early as possible. The baby box has a strong educative component and includes leaflets on how to give the care a newborn needs and how to use the items included in the box.
‘Chile grows with you’ seeks to help families in raising children and supports their integral development in the broad sense of the word. Its goal is to create equal chances and safe and secure places for all children. It wants to promote attachment during parenting and encourages fathers to play an active part and take responsibility for the upbringing of their child. In the first 5 years of the program, no less than 766.000 Chilean families received a baby box. The Quilpué hospital alone has distributed 10.000 of them since 2009.
Pell, L.G., et al. (2016). Effect of provision of an integrated neonatal survival kit and early cognitive stimulation package by community health workers on developmental outcomes of infants in Kwale County, Kenya: study protocol for a cluster randomized trial. BMC Pregnancy Childbirth, 16: 265. doi: 10.1186/s12884-016-1042-5. See: https://www.ncbi.nlm.nih.gov/pubmed/27608978
Wang, P. et al. (2016). Measuring the impact of non-monetary incentives on facility delivery in rural Zambia: a clustered randomised controlled trial. Tropical Medicine and International Health, 21 (4), 515-524. doi:10.1111/tmi.12678. See: https://www.ncbi.nlm.nih.gov/pubmed/26848937
Turab, A., et al. (2014). The community-based delivery of an innovative neonatal kit to save newborn lives in rural Pakistan: design of a cluster randomized trial. BMC Pregnancy and Childbirth, 14:315. See: www.biomedcentral.com/1471-2393/14/315
Wang, P. et al. (2016). Measuring the impact of non-monetary incentives on facility delivery in rural Zambia: a clustered randomised controlled trial. Tropical Medicine and International Health, 21 (4), 515-524. doi:10.1111/tmi.12678. See: https://www.ncbi.nlm.nih.gov/pubmed/26848937
Tres informes del INTI -encargados por el gobierno de Cristina Kirchner- señalaron diferentes aspectos, como el espacio entre los barrotes de las cunas y la efectividad de los dispositivos para sostener a los recién nacidos. La Nacion. February, 16, 2016. See: http://www.lanacion.com.ar/1871615-plan-qunita-inseguros-cunas