… PSS are not free baby beds for poor families. They are a central component of a comprehensive service that needs to be embedded into a SUDI prevention strategy and regional infant health plan. A Pēpi-Pod® service needs a project action group, coordinator, PSSs and bedding packs, referral processes and criteria, agencies and distributors authorised to distribute, a thorough recipient briefing, follow-up of and feedback from users, and systems for recording, monitoring, communicating etc.
Baby boxes – what’s happening in the rest of the UK (and elsewhere)?
In the discussion of the launch of the baby box pilot in Scotland last week, some references were made to schemes also being launched in England. This post gathers up information about what’s happening there, and in some other places, to help put the Scottish scheme in context.
It reveals that the explosion of interest in baby boxes would make a great case study for someone, into how ideas gain attention, how different people and organisations play a role, and the use of evidential claims. And that a mixture of enthusiastic support and scepticism about some of the claims made isn’t unique to Scotland.
Warning: this is very long. It’ll be of interest mainly to people fascinated by the inner workings of the policy process and/or interested in infant health; it may be a heavy read for others. You can skip to the end for some reflections on what we learn that might be useful for the Scottish project.
Baby boxes have been used in Finland since the 1930’s, but it’s only in the last few years that there’s been a surge of international interest. Many articles and interviews trace this back to a BBC piece from June 2013, which received huge attention worldwide, becoming one of the most shared and read stories the BBC had ever published, as discussed in another BBC piece here. Reflecting still later again on their coverage of baby boxes, a BBC editor said:
“What the original baby box story showed beyond doubt was that a story about parenting and public health policy can, in certain circumstances, go viral. I had not seen that coming.”
A follow-up BBC report in July 2013 noted that the article had prompted lots of immediate interest and approaches to the Finnish Government, and this in turn appears to have led the Finnish Government to send a box to Prince George, prompting further coverage. The original BBC article seems to have been a simple product of journalistic curiosity and research. The BBC ran a piece following up its original report in April 2016.
I’ll mention first, as an outlier, very specific research being undertaken at Durham University on using (clear plastic) boxes as sleep spaces.
The most publicised baby box scheme in England is one being piloted at Queen Charlotte’s and Chelsea Hospital, London, part of Imperial College Healthcare NHS Trust. There, 800 boxes are being given out to new parents first come, first served. Parents’ use is being monitored for 8 months and they are required to sign up to “the Baby Box University”, an on-line information resource (more on this below). The boxes and on-line resources are being supplied for free to the Trust by the Baby Box Co., a US-based company (again, more about them below). The educational element provided via the Baby Box University is persistently highlighted by the company as an important component of what it offers.
The publicity for this scheme also mentions schemes taking place at a number of other sites in England, all also using the Baby Box Co/Baby Box University model. This article gives the best overview of how the English initiatives are linked and Imperial College’s co-ordinating role. Further detail on some of the other sites here: Colchester, Sandwell and West Birmingham, North Middlesex (not all the places listed as possible pilots seem to have started yet). The Baby Box Co. has said:
The Baby Boxes which are now being delivered en masse to UK parents free of charge through community partnerships account for a much greater percentage of our operations [note: by comparison with commercial sales in the UK]. The products included in these Baby Boxes are unique to each hospital. For example, the contents included in the North Middlesex University Hospital Baby Boxes are slightly different than the items included in the Hillingdon Hospital Baby Boxes or the Sandwell and West Birmingham Hospital Baby Boxes. We believe that enabling hospitals to have input over content selection is significant, as is empowering them to create an exterior design which reflects their special community of patients.
In local English media coverage, a strong emphasis is placed on improving infant mortality – higher than average infant mortality in the areas taking part is a common theme.
It’s not clear whether the other sites are also getting their supplies for free at this stage, but it seems plausible that the company is investing in all these trials as a step towards increasing its presence in the UK. The annual report for Sandwell Child Death Overview Panel describes Sandwell as having been chosen by the company as one of its “starter sites in the UK” and other articles suggest an intention to expand the business here considerably (as does the very long list of English NHS accounts it follows on Twitter).
Jay Hemingway, manager for UK Baby Box company said: “The idea is that every child has the same start in life and we want the boxes to be in every NHS hospital by this time next year.”
With plans to extend the initiative throughout the UK, Ms Clary said the diversity of the country’s population would be taken into account. ‘It won’t be a standardised Baby Box that’s the same across the UK”.
There are around 770,000 births every year in the UK. The wholesale cost of boxes isn’t easily found, but the Scottish Government’s basis for budgeting for its boxes seems to be around £100 per box, so complete adoption implies a total new annual commitment of around £75m for the NHS across the different parts of the UK. However, there might be off-setting savings, as argued here by Scott Johnston, Imperial College Healthcare NHS Trust head of midwifery:
When asked whether the cost of the scheme may be prohibitive for some Trusts, Mr Johnston said this was not a concern; the programme may actually bring benefits by engaging more parents with services early, thus saving costs later on. He added: ‘I think it’s more about the logistics. Within our service we have about 750 births per month, so actually storing [the boxes] and distributing them can be a bit of a challenge. But I can say, as head of service, it’s definitely worth it. It’s something we’ll get over.’
Abstract millions don’t mean much: one way of looking at this is that £75m is the equivalent of 2,500 FTE midwives or health visitors (or put another way, every 300 boxes equals one FTE person). If this were an intervention justified on its impact on SIDS (cot death) and governed by the NICE guidelines on cost-effectiveness (for England) it looks as though it would normally be required to be likely to reduce such deaths by a little under 15%. It’ll presumably be calculations about the opportunity costs (ie what the money would be spent on instead), what the trials reveal about overall benefits to children and parents, and potential savings, which determine how far trials in England lead to a publicly-funded roll-out there. The decision seems likely to lie with individual local NHS Trusts.
Note: The Baby Box Co
It is impossible to look properly at the rapid growth of interest in baby boxes without recognising the part played by the Baby Box Co. There are other suppliers around the world, but this company has been by far the most active in promoting boxes to public bodies and charities as part of more complex interventions. Most of the rest appear to concentrate on mail order to individuals.
The Baby Box Co. was started in California in 2013-14, is headquartered in Los Angeles, and since last year is also a UK-registered private limited company (it also has offices in Canada, Singapore, Ukraine and Australia). In this interview, one of the founders explains how she was inspired by seeing the 2013 BBC story about Finland. There’s a summary of their activity here:
While we sell Baby Boxes direct to consumers as a baby shower gift or new parent present, we focus most on partnerships with hospitals and other institutions such as nonprofits, government agencies and insurance companies. Through a single program with a large institution, we can get our Baby Boxes to thousands of new parents, so it really is the most effective method of distribution for us. We are currently working with 20 states through government agencies, hospitals, insurance companies, tribes, corporations and nonprofits to distribute our boxes. Organizations implementing Baby Box Co. programs include Cook Children’s Hospital System in Texas, Alberta Ministry of Health and Human Services in Canada, Mountain Park Health Centers in Arizona and Queen Charlotte’s & Chelsea Hospital in the UK among many others! We are also working globally with 12 nations on significant intervention programs and ship directly to consumers in 52 countries.
It has a clear strategy for growth:
… in the crowded space of parenting-related ventures, Jennifer has also been adept at growing The Baby Box Co., not only by selling the box to top hospitals and medical institutions, but also sealing partnerships with top players in the space, including organizations like Every Mother Counts, Children International, Room to Grow, Baby2Baby, and others…… For 2016, she estimates Baby Box Co.’s earnings to be 4.5 times higher than those of 2015 and she’s looking forward to growing the business more.
“We are on track to have a million Baby Box units in circulation by the end of 2016,” Clary said. She estimates that the company will have five million units in circulation by the end of 2017.
I can’t quickly find any information on the company’s most recent turnover or staff numbers, or where they manufacture, but they have evidently had a huge impact.
The Baby Box University is integral to the company’s model. Where there are specific projects, on-line educational material has been developed with each partner area. In the pilots underway using the Baby Box University model, some initial interaction with the online material is needed before the box can be taken up, but the larger aim appears to be to encourage continued engagement with the site, which the company describes as providing access to expert advice and research. The article here also states that the platform can be used to support interaction between health care workers and parents, and that free product offers and bonus draws are also included, which may indicate some sort of revenue stream for the company via sponsorship/advertising arrangements with product suppliers (the site can be accessed for free by anyone willing to register). Other articles mention the platform being a way for mothers in an area to communicate with one another.
The Baby Box Company is not directly involved in the Scottish pilots, but is following developments in Scotland. Between 12-14 January, its Twitter acount followed 5 MSPs and a Scottish local councillor, retweeted this STV story about a closure threat to a Scottish charity providing supplies for families in need, and also retweeted the tweet below saying that the boxes were “shown to reduce cot death” and describing some parties as having a politically-motivated bias against the SG scheme. (Note: a Labour MSP responded to say that Labour supports the baby box initiative, which is correct, but largely missed in coverage and debate; a commitment to a pilot also appeared in the 2016 Scottish Lib Dem manifesto.)
The Scottish Government is already committed to national implementation from summer 2017. The contract for that is not yet out to tender. It’ll be a decent-sized contract (for around 60,000 boxes a year: the budget allows for £7m annual cost to be covered by health funding). It’s not clear how many organisations will be capable of bidding – this company is clearly one.
A baby box scheme started in partnership with the Baby Box Co in Limerick in September 2016. As in the English pilots, local health professionals stress the educational element, noting that they have been given the chance by the company to produce their own educational materials, including videos. Further positive comment from local health professionals here. Around 5,000 boxes are expected to be handed out over a year.
There has been a lot of press coverage, much of it in identical terms and so probably reproducing the news release, all of which brings out the issue of infant mortality (on which it often reads quite similarly to the English coverge). I wasn’t able to find anything saying whether this was a short-term pilot or a permanent commitment, whether it was being evaluated, or how it was being funded.
Canada has several baby box programmes, including what seems to be the largest. All are recently started, so research and evaluation isn’t yet available.
Welcome to Parenthood is a scheme covering 1,500 families, closely tied in with a new programme of extra support and mentoring (see here and here) and funded by a $500,000 research grant from Alberta Human Services, agreed in 2014. The scheme went live this year, and is led by an assigned researcher (Karen Benzies, quoted below). The Baby Box Co appears to be the supplier for the boxes.
Mentors must record their interactions in a journal briefly describing time with the parent and baby, to help researchers in their evaluation of the pilot program.
Benzies said the goal of the project is to evaluate the impact of the various support mechanisms on the developmental outcomes of children and the health of mothers and families, in general.
Benzies isn’t jumping to any conclusions before the investigation is complete and the data is analyzed.
“As a researcher, I’m always skeptical,” she said. “We need evidence to say that this is the right thing to do to improve outcomes for children and families. The success for us and for society is around healthy parents and healthy children.”
The largest scheme anywhere seems to be in Ontario. It covers those having a baby between 1 August 2016 and 1 August 2017 (here), estimated to be 145,000 women. News reports here and here. At the end of this interview, the scheme is described as “being funded by the province”, but another piece suggests a more complicated fundingstructure:
[It] includes more than 60 agencies across the province, from midwife practices to family resource centres. Non-profits, charities and the organizations themselves will contribute resources, says Jennifer Weber, chief education officer at Baby Box Co., some through in-kind contributions such as transportation services, product storage and more.
The article below gives some further useful detail, including that some contents are provided by sponsoring companies:
In addition to The Baby Box Co.’s education department, which assists communities all over the world with Baby Box program development, the Ontario Baby Box program is organized by The Children’s Aid Foundation, The New Moms Project, and The Mary Berglund Community Health Centre Hub. A network of primary health care facilities spread throughout the province are supporting these groups with distribution to ensure the Baby Box program is accessible to all Ontario residents…..
Contents for the Ontario Baby Boxes are still being finalized, but CEO Jennifer Clary has confirmed that Pampers, which provided the diapers and wipes for Alberta’s Welcome to Parenthood Baby Box program, is supporting Ontario families as well. “We are thrilled Pampers is continuing their partnership with The Baby Box Co. and are so grateful for their contribution of diapers and wipes. ….
From the pieces I have found, it’s not clear what evaluation is planned in Ontario and what is expected to happen after the 12 months covered.
The situation in Ontario is complicated by the parallel presence of a separate local company, Baby Box Canada, offering free boxes of items (but the box cannot be slept in), the cost of which is covered by sponsors: see here.
A much smaller initiative (21 boxes) in a remote Ontario community preceded the current larger one: this was reportedly established by local health professionals who contacted the Baby Box Co for assistance, having earlier seen the 2013 BBC report. The goal was “to guide families toward local services and provide parents with basics that are difficult to attain in Ignace” (from TVO article above).
Separately Nunavut, which has a high rate of infant mortality, is also piloting boxes: here. 800 will be handed out, around one year’s worth of births in this very northerly territory. This is a government initiative, but being funded by donations from companies in Ontario.
There’s been some questioning in Canada about how far these schemes have departed from the Finnish original, and are too commodififed and not enough about support: see here.
The long article from which the extract below comes provides a particularly careful summary of the debates around baby boxes. The article quotes a number of those involved in Canadian projects cautioning about the relationship between lower infant mortality and boxes in a contemporary developed countries, while stressing that Canada still contains substantial numbers of disadvantagaged households.
…. The Ontario baby box initiative’s strength, then, is its commitment to community engagement and providing reliable information regarding infant health, particularly concerning safe sleep practices. …..
Benzies [in Alberta] questions the focus on infant mortality in Canada and the efficacy of some attempts at replicating the Finnish program: “We’ve done an amazing job in [providing] neonatal intensive care, reducing mortality,” she says. “Where we need to focus our efforts is morbidity.” That is, the likelihood of disease, illness and injury to infants. Like Clary, Benzies urges parents to carefully research baby box programs that have sprung up in Finland’s wake — albeit, many decades later — and if they choose to participate, go into such programs with the understanding that stashes of baby supplies can’t address the more systemic issues that affect infant health, such as health care access, poverty and infant care education. “They need to understand why people want you to sign up for something and what the expectations are for that.”
….In her practice [in Ignace], Graff says she sees social barriers to infant and maternal health more often than high-risk pregnancies requiring a neonatal intensive unit. Such barriers include housing concerns, low breastfeeding rates and a lack of resources that might be available in larger cities to deal with postpartum depression and other mental illnesses.
The Ontario baby box initiative aims to bridge the gap in some small way, taking the lead from communities – remote towns, new immigrants, young parents – to ensure the most success. “We’re not saying it will cure everything, but the families, they know who they can actually turn to sooner rather than later,” Baby Box Co.’s Jennifer Weber says.
In the US, pre-existing government-funded safe sleeping programmes with a strong outreach and education element who were already providing portable cots (versions of folding travel cots) have reacted variously to the advent of boxes.
This one in Chicago has added boxes to what it offers, but not wholly replaced their existing ones, saying boxes are “perfect for families that have limited space” and that “both types of beds will be distributed to families, based on the type of bed needed. Transient families likely will receive the lighter weight baby box.”
However a long-established non-profit organisation which operates across the US, Cribs for Kids National Infant Safe Sleep Initiative is strongly of the view that boxes are a less good option than the folding device it uses. Its unfavourable comparison of boxes to its established bit of kit is here (with some further comparison made here).
On the claims about the effect of boxes in Finland on infant mortality, it says:
It also questions claims that the boxes can be used as a bed for up to 8 months (this is included in coverage of the English schemes, for example, including on the Imperial College website), suggesting that 2 to 4 months will be more common, before babies can no longer use it safely. That looks like an important point to clarify for policymakers motivated by SIDS concerns, because it has implications for how much of the most risky period for cot death is covered, and for equality campaigners, because the shorter the period for which it is useful, the less practical help it offers parents.
The Baby Box Co. has produced its own comparative summary: here. It’s not a point-by-point rebuttal, so the issues above about research and potential length of use aren’t addressed. It focusses instead on whether the devices used by bodies such as Cribs for Kids are in fact suitable for overnight sleeping, their greater cumbersomeness and higher cost.
Many organizations are transitioning from Pack n’ Play distribution to Baby Boxes. Baby Boxes wholesale for less than 50% of the cost of Pack n’ Plays, thereby allowing non-profits, hospitals, governments, and other institutions to reach double the number of new parents without increasing their program budgets. An extended reach = more lives saved and that is a huge factor in the increasing rise of Baby Boxes’ popularity.
Another US non-profit organisation, Babies Need Boxes was founded in 2015 and sources its boxes from The Baby Box Co and uses the Baby Box University model. The Baby Box Co lists partnerships in a number of other locations in the US.
The views of Cribs for Kids deserve the same careful scrutiny as the case put forward by those promoting the use of boxes – existing schemes could after all be argued to face competition from new arrivals (equally, they may be reacting to perceived pressure to switch suppliers). Even though organisations such as Cribs for Kids are non-profit, it is possible that in some cases the viability of their model of outreach might be reduced if box schemes became very popular, or they might lose funding from public sources. Also, some of their practical concerns have to be put alongside the successful use of boxes in Finland for decades.
But the strength of Cribs for Kids’ scepticism about boxes, and the detailed way they make their case, bears including here, not least because it’s the only reference I’ve seen anywhere to anyone doing a literature review about the Finnish case: none of the references I’ve seen to studies/proof/evidence of the boxes’ effects have provided any links or references, and attempts of my own to locate research on the Finnish box scheme also drew a blank. When reports say that the Finnish box scheme” is credited with” reducing deaths, which is a very common phrasing, they never say who is doing the crediting.
A number of commercial Australian baby box companies turn up on a search, who are simply selling boxes and their contents on-line. But there are also pilots reported as starting in Victoria (again involving the Baby Box Co.) and Western Australia (involving an Australian charity). Both seem to be targeted on those deemed especially in need, whereas most of the pilot box schemes described above appear not to be targeted in that way. Some further Australian press coverage here.
There has been press interest there in the claims made about infant mortality. In Queensland, Professor Jeanine Young, a neonatal nurse and midwife who devised the Queensland Health Safe Infant Sleeping guidelines, reportedly “said the company [the Baby Box Co.] was making money by playing on parents’ fears over sudden infant death syndrome (SIDS)” and Fair Trading officers were reported to be investigating claims. Prof Young is separately involved with a “Pepi Pod”programme in Queensland targeting particularly high-risk cases for SIDS, which includes use of a plastic box bed from New Zealand (more on the Pepi Pod programme in the New Zealand section below).
“I have a real problem with this,” Prof Young said. “It is not appropriate for this company to be telling people that the boxes help prevent SIDS because there is no evidence that this is the case.”
The same piece carries the company’s response:
But when contacted by The Courier-Mail, a spokesperson for the company said online education was more important, and blamed the media for reporting the link because it “makes for a simple and palatable feel-good story”.
The spokesperson said: “Baby Boxes distributed thoughtlessly are not a cure for infant mortality.” The company is calling for Australian hospitals to go into partnership with The Baby Box Company in order to issue the boxes to new mums.
Many of the company’s press quotes emphasise the importance of education, and that the box is not a solution in itself. Its website says carefully and only that the box has “helped” Finland reduce infant mortality:
The Baby Box program has helped Finland achieve one of the world’s lowest infant mortality rates. The initiative, which enables every expecting woman in the country to claim a free Baby Box once she receives prenatal care and parenting information from a healthcare professional, is credited with helping to decrease Finland’s infant mortality rate from 65 deaths for each 1,000 children born in 1938 to 3 deaths per 1,000 births in 2013.
These comments by Jennifer Clary are also typical:
Q: HOW DO BABY BOXES HELP TO DECREASE INFANT MORTALITY?
A: I love the Baby Box concept but think the media has a tendency to romanticize and simplify the tradition. Kela, the Finnish social service, should be commended because they established an incredible foundation upon which to build their Baby Box program: every expecting mum in the country has to visit a healthcare facility for prenatal care and basic educational information in order to be eligible for a free Baby Box. This is a fact that frequently gets left out in media coverage, and it’s a shame as this is arguably central to Finland’s statistical success.
It’s not the Baby Box product that decreases infant mortality, it’s the Baby Box program.
What we know is that there are numerous research studies linking increased parenting education to a reduction in infant mortality outcomes, as well as to an increase in breastfeeding, positive nutrition choices, and improvements in maternal mental health. Therefore, my personal philosophy—and our corporate mantra—is to tie Baby Box distribution to parenting education and ongoing community supports to actually have an impact.
However, stronger claims about the link with reduced infant mortality have appeared in material from the company. These 2016 slides are credited as copyright to the company and have a reference “BBC Presentation” in the document name. They are titled “A 75 year-old life-saving tradition” and on page 6, after a more general reference to boxes “helping” bring down infant deaths, do also include the sentence, “In Finland, Baby Boxes decreased the infant mortality rate from 65 deaths for each 1,000 children born in 1938 to 3 deaths per 1,000 births in 2013.”
The process by which the nuance Jennifer Clary argues for so strongly gets lost in reporting would be an interesting study, because the experience of reading so many stories from different places in a short space of time brings out that it’s a widespread phenomenon.
New Zealand is a very different case. Health professionals had been providing safe sleeping spaces (in the form of woven baskets called Wahakura) for new babies in Maori communities since 2006, because of concerns about particularly high infant mortality rates in New Zealand, with deaths concentrated in Maori communities. More recently, the emphasis has been on the use of clear plastic boxes developed in New Zealand, called Pepi Pods.
This document gives a lot of background. Pepi Pods were first used as an emergency response to the 2011 Christchurch earthquakes and then targeted on those at increased risk of accidental suffocation. They are cheaper and easier to supply in large numbers than the Wahakura. Pepi Pod programmes appear to operate under the umbrella of an organisation called Change for Our Children, which describes itself as a “social innovation company”, which it explains here is a private profit-making company, but where the profits are used for community benefit. It says:
PSSs are not for all babies. They are a public health response to the higher risk of sudden infant death for babies who are more vulnerable due to exposure to smoking, especially in pregnancy, being born before 37 weeks or weighing less than 2500 grams, or in family environments where use of alcohol and drugs are prevalent. These babies have a predisposing vulnerability to hypoxic challenges.
There is some actual research available from New Zealand.
On use after earthquakes:
- Cowan S, Bennett S, Clarke J, Pease A. An evaluation of portable sleeping spaces for babies following the Christchurch earthquake of February 2011. J Paediatr Child Health. 2013 May;49(5):364-8. doi: 10.1111/jpc.12196.Epub 2013 Apr11.
On use in high risk communities:
- Young, Jeanine, Craigie, Leanne, Hine, Helen, Kosiak, Machelle. Trial of an innovative Safe Infant Sleep Enabler—The Pepi-Pod. Citation: Women & Birth, 02 October 2013, vol./is. 26/(0-0), 18715192
On the relationship with overall falls in infant mortality:
- Mitchell, Edwin A. ; Cowan, Stephanie ; Tipene‐Leach, David. The recent fall in postperinatal mortality in New Zealand and the Safe Sleep programme: Acta Paediatrica, November 2016, Vol.105(11), pp.1312-1320
This last concludes that
The recent fall in postperinatal mortality has not happened by chance. It is likely that the components of end-stage prevention strategy, a focus on preventing accidental suffocation, the education ‘blitz’, the targeted supply of ISSDs [infant safe sleep devices] and strengthened health policy, have all contributed to varying degrees.
Change for Our Children has elsewhere said cautiously, “no claims can be made of cause and effect but the statistics are encouraging.”
Up to now, funding of Pepi Pod schemes appears to have been cobbled together locally from a number of public and private sources. However, in August last year the decision was made to make national funding available for a safe sleeping programme including Pepi Pods. The reporting isn’t clear, but this petition suggests the national programme is intended to continue a targeted approach, and is not an all-population approach. The move to national funding has involved the Minister over-ruling advice from officials, who are reported to have cited concerns about insufficient evidence and possible safety concerns. Both these points have been strongly challenged by Prof Mitchell (author of one of the articles above), a meeting with whom is reported to have been important in persuading the Minister to make funding available. Some articles here, here, here and here.
In August, the likely annual cost was estimated at around NZ$1.5m (about £900,000): the emphasis in New Zealand is on the pod as a sleeping space, so the extra cost of other items may not be relevant.
South Africa and elsewhere
The 2016 BBC story above refers to other projects, including one in South Africa using clear plastic boxes. However, these are used as baths rather than beds.
Back to the source: Finland
For those interested, there’s an English language Finnish government website which has details about their box, the wider support schemes in which it sits, the obligations to engage with services which are required of parents in order to receive the box, and even quite a lot of detail about its tendering process: all here. It’s referred to as the”maternity package” in what comes over as a deliberate move to reduce emphasis on the object in its own right. There’s a (non-official) video about the Finnish baby box at the foot of this piece as well.
There was a bit of discussion last week on Twitter between Suzanne Zeedyk and Elizabeth Jarman, who are interested in child development and children’s environments, on the design of the box, both arguing that busy patterns inside the sleeping space should be avoided. Interestingly, one commercial supplier based in the UK points out that the Finnish box has no pictures on the inside (see under “Is it safe?”), although it presents that more as a safety point.
In line with guidance from the Finnish manufacturers of the baby box (the same supplier as to the Finnish Government’s Baby Box Maternity Kit) we have not printed the inside of our box. The manufacturers of the box are chosen through a rigourous safety process, and do not print on the inside of the box.
The Scottish boxes used in the current pilots follow instead the Baby Box Co. model of internal decoration.
Reflections and conclusions
This is an astonishing story. It is only three and a half years since the BBC’s original article. In that time, baby box schemes have begun around the world, some of them on a huge scale. Many more commercial companies have emerged than are mentioned here. Huge numbers of boxes have been sold, direct to individuals or to public or third sector organisations. Public health officials in many places have embraced box-based programmes. An enormous number of articles have been published. Someone should do some Google stats on the on-line incidence of references.
The impact of the BBC piece and the extraordinary energy , impact and growth of The Baby Box Co are both remarkable features of this story. The latter’s belief in what it does is evident, and its ability to pitch what it offers, to form positive relationships with public health officials and to understand what to offer them, is impressive. And absolutely fine. In turn, citizens just need public health officials making decisions about resources to keep their analytic heads, confronted with a whirlwind of enthusiasm, claims and proffered help. Journalists too, maybe. That’s all.
What do we learn that might be useful, as Scotland also goes down this route?
I think we’ve done the right thing funding our own pilot. Although it will carry a cost, it has the advantage of not tying anything learnt into a very specific model run by one provider. In England, the pilots are at no cost to the NHS, but if they are found to be beneficial, the integration of the Baby Box University into the scheme means that it may be difficult to find another supplier: I’m always wary of the public sector ending up in sole supplier situations. It’s not clear whether the NHS retains the intellectual property for the education materials produced by its staff (I hope so): if not, then it’s easy to see that professionals may be very unhappy to lose access to things they have made with huge local care and enthusiasm, and got used to using, after just a year.
Where we compare less well, firstly, is in having a pilot period that can’t be more than a very few months, given the full national programme is due to start this summer. Lots of the clothes will still have been too big even to try, when the SG is already drawing up the contract for the national box. The peak danger period for SIDS will not be past when the pilots finish. Many parents only emerge in a coherent state to reflect on anything some time after 3 months (if then). Everywhere else doing a pilot is running it for 8 months upwards, which seems to me a better length of time to understand how far the box’s contents are useful, how much and how long it’s been slept in, the SIDS incidence in the cohort (though with only 200, statistically – and happily – there were anyway very unlikely to be any cases) and how it may have helped parents, and aided engagement and education more generally.
We’ve also made a mistake (I think) commiting to a national scheme, regardless of what happens. I understand the arguments that there’s something of symbolic value (I really do) that transcends its measurable public health impact. But the reality is that the health budget (from which this is funded) is under huge pressure: and so are all the others it might be moved to. Right now, it’s right to demand some more substantial benefits from a long-term commitment to anything which will cost £7m every year. Or more? The £7m budget is for a project starting part-way through the financial year, after all. It would be preferable to let a one-year national contract and treat it as a much more extensive trial, and build in decent evaluation: if any opposition politicians, or oppositional types, or journalists, or indeed people who like and have defended this scheme, are reading this, if the SG go down that route, please welcome it. It would be a wiser approach to using scarce public funds. They could even contract for two years, so that people go on getting boxes while the evaluation is pulled together and considered. Just build in an easy exit route.
We are also less strong than others on the box as a means to engaging people with education and human support. The publicity has been very much about “the box”. Most recently there’s been some reference to there being wider support alongside, but what this means remains vague, compared to other places (Ontario is perhaps the next nearest for vagueness of those mentioned here: but it’s at least using The Baby Box University).
There’s nothing here like the detailed safe sleep programme developed to go with the Pepi Pods or the Alberta mentoring scheme developed to go with the box pilot there. The wider support part still comes across as an afterthought here: it’s not clear that the £7m budget assigned includes anything for developing new safe sleeping programmes or other new materials to support new parents. We’re also unusual in not tying receipt of the box (as far as I can tell) to parents engaging with services in any particular way.
The model which I think emerges best from this is Alberta, with a research based, self-funded pilot, with clear aims, which keeps complete control of the design and delivery of the education and support programme and doesn’t over-stress infant mortality goals, as opposed to broader ones of physical and mental health. And New Zealand has an interesting story to tell about targeted intervention in cases where the risk factors for SIDS are known to be especially high. I think it’s a shame we’ve committed entirely to cardboard boxes, and not piloted Pepi Pods as well. There’s still time to keep the inside unprinted like the Finns, though.
My final comment is about debating this at all. When people (like me) suggested when the pilot was launched on 1 January that there were some fair questions to ask, not least about the claims made about infant mortality, and the decision to commit so completely to this, without more evaluation, when budgets are so tight, one of the reactions was to see this as a depressing further symbol of the schismatic state of Scottish public debate. People seemed depressed at the inability of everyone simply to come together to celebrate something nice.
This exercise has revealed that anywhere in the world where there’s already been a sharp drop in infant mortality since the Second World War (that includes us) and where these schemes aren’t funded by the supplier, especially where a link to reduced infant mortality is made, there’s been a debate. That there’s no controversy in England may be due to the fact that it appears not to be costing the NHS anything, and the pilots are all relatively small scale (Ireland ditto?). People in Scotland are raising points made in Canada, the US, Australia and New Zealand. If the NHS in England were, as the Baby Box Co hopes, to commit to a nationwide publicly funded programme while its NHS budget buckles, you know, I think there’d be questions there, too. It’s if we stopped hearing people asking questions about high profile (and not free) public policy choices that seem to come almost out of nowhere, that we’d have real cause to worry about the unusual state of debate here, I think.