Scotland's Baby Box pilot: qualitative research

Executive summary

Background

Scotland's Baby Box scheme is a Scottish Government initiative to provide a free Baby Box for all babies due in Scotland from 15th August 2017 onwards. Babies can sleep in the box itself, which is made of sturdy cardboard and comes with a mattress with protector, a fitted sheet and a cellular blanket. The box is delivered filled with a range of products for the child's first weeks and months, including clothes, baby care items, books and a play mat.

The Baby Box scheme aims to promote a fair and equal start for all children and to aid in achieving the best possible outcomes for all Scotland's children. The Scottish Government's brief for this research described intended benefits including:

• Reducing socio-economic inequalities by ensuring every family with a newborn has access to essential items, and
• Informing parental behaviours that will positively impact on outcomes for the child, including safe sleeping practices, attachment and parent-child interaction.

The Baby Box pilot

In order to inform the roll-out of the Baby Box scheme across Scotland, the Scottish Government carried out a three-month pilot between January and March 2017 in two local authority areas - Orkney and Clackmannanshire. In total, 160 boxes were distributed to families with a due date in the pilot period: 49 in Orkney and 111 in Clackmannanshire.

Research aims and methods

The Scottish Government commissioned Ipsos MORI Scotland to carry out qualitative research during the Baby Box pilot to inform the development and roll-out of the scheme in Scotland. The research focused on: the process for registering for and receiving the box; parental views and uses of the box and its contents; and initial insights into its potential benefits.

The research involved interviews (either face-to-face or by telephone) with:

• 34 parents who had received a pilot box
• 8 midwives
• 3 Health Visitors
• 2 members of staff at APS (the Scottish Government's contractor for providing Baby Boxes).

An online discussion forum was also used to gather feedback from parents who had received pilot boxes.

The research provides initial insights into the potential impacts of the scheme and possible barriers to achieving those impacts. However, the short timeframe and relatively small scale of the Baby Box pilot meant it was not possible to design a study that could robustly assess the impact of Baby Boxes on outcomes for children and families.

Views on the Baby Box concept

Parents interviewed for this research expressed enthusiasm about the idea of 'trying to give everyone the same start'. However, views among both parents and professionals were divided on the question of whether or not Baby Boxes ought to be offered universally. On the one hand, there was evidence of support for the principle that all families will qualify, regardless of income and a feeling that receiving the box shows that the government ' cares' about families. On the other, it was suggested that, given concerns about the perceived level of resources available to other services for families, eligibility ought to be limited, either to parents on low incomes or to first-time parents.

Parents and, to some extent, midwives and health visitors expressed a desire for more information on the aims, intended benefits and evidence behind the scheme.

Views on implementation

The pilot research explored parents' and midwives' perceptions of the registration and delivery process and their views on the contents of the boxes.

Registration and delivery

The timeframe for the Baby Box pilot meant that its implementation differed in a number of respects from plans for its operation when it is rolled out nationally. As such, some of the implementation issues identified by parents and midwives during the pilot may be less likely to occur as the scheme is rolled out.

Both parents and midwives would have liked to know more about the contents of the box and the aims of the scheme from an earlier stage. Parents would also have preferred to have received their boxes at an earlier stage before birth and to have received advanced notice of delivery. Plans are in place to provide information, register parents, and deliver boxes earlier as the scheme is rolled out, and to provide advanced notification of delivery slots.

Midwives did not always follow the intended process for registering parents, in some cases giving parents the form to complete and return themselves rather than the midwife completing it with them and returning it directly. This was attributed to both workload constraints and a desire to give parents more time to consider whether or not they wanted the box. When the scheme is rolled out, it is intended that parents will receive information about Baby Boxes at their first midwife appointment (much earlier than was possible in the pilot).

The registration form itself was generally viewed as straightforward, although the research identified a number of changes that may result in more accurate completion.

Contents

Parents' views of the contents of the box were generally extremely positive - they were impressed with both the quality and range of items included. Ear and bath thermometers were particularly popular inclusions, viewed as valuable items parents might not otherwise have bought.

Key suggestions from parents for improving the contents included:

• Removing the reusable nappies, viewed as 'wasted' items which most parents would not use
• Improving the quality of the maternity and breast pads
• Changing the colours of some of the clothes and ensuring they are seasonally appropriate, and
• A reduction in newborn items.

This feedback has been taken into account in revising the content (for example, sourcing alternative breast and maternity pads) for roll-out.

One issue about the contents which divided opinion among both parents and health professionals was what health information should be included in the Baby Box. Both parents and health professionals expressed concerns that too much information might 'overload' parents, unnecessarily duplicate information they receive elsewhere, and add to perceived 'pressure' on new parents around breastfeeding in particular. However, other parents indicated they had expected the box to include more information on child health topics. It was suggested that the box could include more information tailored to its specific aims and contents - for example, covering safe sleeping in general, explaining why cellular blankets are the safest option, or outlining how to interpret and act on readings from the ear thermometer.

Views on potential impact

As discussed above, this research cannot say whether or not Baby Box recipients have better outcomes than those who do not receive a Baby Box. However, it did explore parents' and health professionals' perceptions of impacts in key areas the scheme aims to influence: safe sleeping; parent-child interaction; and socio-economic inequality. It also explored possible barriers to the box having a positive impact in those areas.

Safe sleeping

The Baby Box is intended to provide a safe sleep space for newborn babies. Among the pilot parents we interviewed, some were using it as a sleep space, either at night time or for naps during the day, and reported that their babies slept well in their Baby Box. However, others had chosen not to use the Baby Box for sleeping.

A major factor influencing the use of Baby Boxes for sleeping was simply whether or not parents had already purchased a Moses basket or cot at the time they found out they were receiving a Baby Box. This may become less of an issue over time, if parents stop buying alternative sleep spaces when they know they will be receiving a Baby Box. However, parents also expressed some cultural and practical concerns about using the Baby Box as a sleep space. Cultural barriers related to feeling that sleeping your baby in a box was not something people in Scotland are used to. Although the pilot included parents who had got over this initial reticence, for others there was a view that you would only use a Baby Box in this way if you could not afford an alternative. Practical concerns included worries about placing the box on the floor and questions about whether it would still be useable if their baby was sick in it.

In terms of perceptions of the Baby Box as a safe sleep space, while some parents were able to identify features (e.g. the inclusion of a cellular blanket) which they thought contributed to safe sleeping, among others there was a lack of clarity about what made the box a safe sleeping space. Parents mentioned having heard the Finnish Baby Box scheme might have reduced cot death there, but were not able to say how or why, or to articulate what specific features of the box might make it safe.

Parent-child interaction

The Baby Box is intended to have a positive impact on parent-child interaction through the inclusion of books and a play mat to encourage attachment, early learning and play. While parents generally welcomed the inclusion of these items in the Baby Box, views on their potential impact varied. Some thought they encouraged them to read to or play with their babies earlier, while others felt they had no additional impact, as they would have read to and played with their babies from an early age anyway.

Financial impact

As pilot families tended to receive their Baby Boxes at a relatively late stage, discussion of the financial impact of the scheme was largely speculative - parents outlined what impact they thought the Box might have had, had they known about it in advance of purchasing much of what they thought they needed for their baby. Parents' views about the potential financial impact were divided. Some, particularly those in deprived areas, felt the savings associated with receiving the Baby Box were substantial and would have made a big difference to them personally had they found out about it earlier in pregnancy. Others, particularly those who already had children, commented that the box duplicated resources they either already had or could afford themselves without the scheme.

Conclusions and implications

A key aim of this research was to identify potential improvements to the registration and delivery process and to the contents of Baby Boxes in advance of national roll-out. The Scottish Government has already made a number of changes in these areas, informed in part by early feedback from this research. Other key issues that may need to be kept under review as the scheme develops include the nature and level of information included in the boxes and the effectiveness of wider communications about the scheme in conveying key information to both parents and midwives. The lack of clarity among some parents about what features of the Baby Box make it a safe sleeping space needs to be addressed. Finally, assessing the impact of the scheme on child outcomes and socio-economic inequality will require longer-term evaluation.