Scotland's Baby Box pilot: qualitative research

3 Views on implementation

Key points

• Due to the timeframe, the implementation of the Baby Box pilot differed in a number of respects from plans for operation of the scheme when it is rolledout nationally. Some of the logistical issues that arose during the pilot may, therefore, be less likely to arise as the scheme is rolled out
• Both parents and midwives would have liked to have known more about the contents of the box and the aims of the scheme from an earlier stage. When the scheme is rolled out nationally, it is intended that parents will receive information about Baby Boxes much earlier, at their first midwife appointment.
• When registering parents for the scheme, midwives sometimes gave the registration form to parents to complete and return, rather than completing it with them, as intended. This was attributed to both workload constraints and a desire to give parents more time to consider whether or not they wanted the Baby Box (as noted above, parents will receive information earlier when the scheme is rolled out).
• The registration form worked well in general. However, a number of changes to the layout and question wording may result in more accurate completion.
• Parents would have preferred to have received their boxes at an earlier stage before the birth and to have had advance notice of its delivery - plans are in place to address both these issues when the scheme is rolled-out.
• Parents were extremely positive about both the quality and range of items included in the Baby Box.
• The ear and bath thermometers were particularly popular inclusions.
• The reusable nappies were largely considered 'wasted' items since most parents did not plan to use reusable nappies.
• The question of whether or not more information should accompany the box divided opinion among both parents and midwives.
• Both parents and health professionals expressed concerns that including too much information might 'overload' parents and unnecessarily duplicate information received from other sources.
• However, it was suggested that the box could contain information tailored to the 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.

3.1 This chapter summarises findings on the implementation of the Baby Box during its pilot phase, identifying potential issues for improvement to the registration and delivery process, and to the contents of the box, from the perspective of parents, health professionals and, in relation to the registration form, APS staff.

3.2 The implementation of the Baby Box pilot differed in a number of respects from plans for operation of the scheme when it is rolled-out nationally. These differences reflected the fact that the pilot had to take place in a fairly compressed timeframe to allow for roll-out to proceed from Summer 2017. Where differences between pilot implementation and roll-out have implications for the interpretation and relevance of the pilot research findings, this is noted in the relevant section of this chapter.

Views on the registration process

3.3 The Baby Box scheme was introduced to parents by midwives in the two pilot areas. For parents expecting a baby in February or March 2017, midwives were asked to complete a registration form with families, containing details of their due date, address, how many babies they were expecting and their midwives' registration number (as a guard against fraud and to encourage women to engage with their midwives). This form was returned (via Freepost) to APS, the Baby Box contractors, who entered it into a spreadsheet before boxes were confirmed for despatch.

3.4 Pilot research interviews explored the process of finding out about the boxes and registering, from the perspective of parents and midwives.

Information received before registering

3.5 Parents interviewed for the pilot research indicated that they had received fairly limited information about the Baby Boxes from their midwives in advance of registering. In some cases, they reported that information was limited to being told they were eligible for a box containing essential items for a newborn, and asking if they wanted to receive one. Parents appreciated that this lack of information, in part, reflected the fact that they were taking part in a pilot and midwives had little time to become familiar with the scheme. However, there was an appetite for more information about the contents of the box, the aims of the scheme, and delivery arrangements.

3.6 Parents also wanted to receive this information earlier in the pregnancy (although there was no consensus about exactly when would be the best point), so that it could inform their own purchases for their baby. In general, the timeframe for the pilot meant that the scheme was raised for the first time with eligible families from a few weeks to a few months before the due date. Once it is rolled out, the intention is that parents will receive initial information about the Baby Box scheme from their first appointment with a midwife, reinforced by further information at subsequent appointments.

3.7 Midwives' own accounts of introducing the scheme to parents during the pilot confirmed parents' views. Although in some cases midwives indicated that they had felt more comfortable introducing the scheme towards the end of the pilot period, they indicated that they would have appreciated a more detailed briefing about the scheme earlier on. They also felt that, if they had received more information about the aims of the scheme and the contents of the box, they would have been better able to reinforce links with other public health messages that they aim to get across.

From a team perspective, we did get the public health message around safe sleeping, we did, over time, receive the leaflet we could give to parents. (But) we didn't maybe receive this early enough to get our head around it, and some of the messages were a bit vague.

(Midwife)

3.8 Midwives suggested that, without further information, the scheme risked coming across as simply a 'box of free stuff', and there may be a missed opportunity in terms of engaging parents with wider safety and health messages. However, others felt the information provided was enough and suggested a need to balance providing sufficient information to inform decisions about the Box, with avoiding overwhelming prospective and new parents, who already receive information from many sources.

Registering parents for Baby Boxes

3.9 The intended process for registering parents, as described above, is that midwives should complete the forms with parents and return them on their behalf. However, this did not always happen during the pilot. Midwives in both areas reported that in, at least some cases, they were simply filling in their own registration number and then handing the forms to parents to complete and return themselves. They cited two main reasons for doing so: first, the process of completing and returning the registration forms was seen as adding unnecessarily to midwives' workloads; and second, it was suggested that it was better to give parents longer to think about whether they wanted the box. The latter reason should become less relevant as the scheme is rolled out, since parents will be informed about the scheme from their first midwife appointment and so will be able to consider whether they want a Baby Box well in advance of actually registering. It is also worth noting that earlier research conducted to inform the design of Scotland's Baby Box scheme found that parents indicated a clear preference for finding out about the scheme via their midwife. ^[11]

3.10 Other than issues relating to the process for returning the form, neither midwives nor parents identified any particular suggestions for improving the form itself, other than a request from midwives that it be provided in alternative languages (reflecting cases where parents with English as additional language had completed the form incorrectly - something that should not happen in cases where the midwife completes it with them). However, APS, the contractor responsible for the Baby Box scheme, cited issues where parents had apparently been confused by some of the questions in the registration form - for example, they had mixed up their own date of birth and their due date, or they had entered the number of children they already had rather than the number of babies they were expecting.

3.11 APS also noted that handwriting could be difficult to read. With this in mind, there is scope to consider whether particular fields within the form could be simplified or clarified, and whether the layout could be altered (e.g. using individual boxes for each letter/digit of the response for key fields, like postcode, phone and email) to ensure that information is entered correctly.

3.12 There is also a need to consider what information should be collected at registration and how this data is collated and quality assured to support ongoing monitoring and evaluation of the scheme. For example, checks should be built into the data entry template to ensure that only valid postcodes, email addresses and phone numbers are entered. The Scottish Government has developed a new registration form for the main roll-out, informed by this feedback.

3.13 Midwives in Orkney suggested that the perceived speed and reliability of postal services from the islands could have implications for returning registration forms (although they did not identify specific instances where forms had been delayed during the pilot), and suggested it would be useful if parents could be registered online instead. Electronic registration is being considered going forward.

Ensuring hard-to-reach parents register

3.14 While the registration process was, in general, considered straightforward, midwives discussed some potential challenges around ensuring harder-to-reach parents engage with the scheme. Although midwives stated that in general they did put considerable effort into contacting parents who do not ordinarily engage with maternity services, they nonetheless raised this as a potential barrier to take-up of the scheme. They also identified a need to ensure that high risk patients who are seen at consultant clinics rather than midwife units are receiving the same information about the scheme, and to provide some spare Baby Boxes for 'concealed pregnancies' where women have not had any contact with services prior to birth (again, we understand that this is being implemented for national roll-out).

Views on the delivery process

3.15 As discussed in the introduction, 160 baby boxes were delivered during the pilot - 49 to families in Orkney and 111 to families in Clackmannanshire. Parents and professionals interviewed for the pilot research did not identify any issues with the condition of the boxes on arrival - they reported that they were well wrapped and arrived in good condition.

3.16 However, parents did comment on the timing and process for delivery. In some cases, they received their boxes after the baby had been born (meaning they could not use some of the newborn items), and they often arrived after parents had already bought many essential items for their babies. As already discussed, this largely reflected the compressed timeframe for the pilot - when the scheme is rolled out, families should find out about the scheme at their first midwife appointment and receive their Baby Boxes at least four weeks before the baby is due.

3.17 Parents also indicated that they would have preferred to receive advance notice of delivery - in some cases boxes had arrived while they were out which, while it had not caused any particular problems for the parents we spoke to, they felt might cause problems for others and could have been avoided. We understand that APS are working with a national partner (who will deliver the boxes) to develop systems to notify parents in advance of planned delivery slots.

3.18 Although neither midwives nor health visitors have any formal role in the delivery process, they reported that they were often fielding queries from parents around delivery. With this in mind, they wanted clarity about the process for referring queries and complaints. They also identified a need for a clear protocol for ensuring that boxes are not sent out inappropriately in cases of pregnancy loss. The Scottish Government has developed a Midwife Guide and Q&A leaflet for health professionals aimed at answering queries like this as the scheme is rolled-out.

Views on the contents

Overall impressions

3.19 The pilot Baby Box included around 40 items of clothing and other essentials (see full list in Appendix B). Parents were extremely positive about both the quality and range of items included in the Baby Box. They commented, for example, on the softness of the fabrics used for the clothing and the fact that items like the ear thermometer were a welcome surprise.

It covers all bases, babygros, muslins, nappies, mattress - it was really good, and we are really impressed. For a government initiative, we didn't have high expectations but this was very good.

(Clackmannanshire parent)

I thought it was excellent quality, very good. Everything was really nice, and we felt very spoiled. It was a lovely thing when you've just come home with your baby to be presented with this lovely box.

(Orkney parent)

3.20 Ear and bath thermometers were particularly popular inclusions, with the former in particular seen as a high value item that parents might not have otherwise thought to buy themselves, or might not have bought until their baby was ill for the first time.

3.21 Key suggestions from parents for improving the contents included:

• Removing the reusable nappies - these were viewed as a "wasted" item, since most of the parents we interviewed did not plan to use them, and even if they would consider using them, it was suggested that there were too few in the box to try them out properly.
• Improve the quality of breast and maternity pads - Although overall the quality of items was felt to be high, the quality of the breast pads and maternity pads was thought to be lower. Alternative products have been sourced for main delivery.
• Some changes to the colours/suitability of clothes - While the range and quality of clothes was generally viewed positively, there were some negative comments about some of the colours (particularly the mint green and brown items), and the suitability of particular items for the season (e.g. providing snowsuits that would only fit during summer). Items included in the Baby Box for full roll out have been selected to be more varied in colour and more suitable across seasons.
• Reduction in newborn items - It was suggested that newborn clothes could end up not being used if you had a big baby, so the number of newborn items could potentially be reduced.

Information within the box

3.22 While, in general, parents were very positive about the boxes' contents, one issue that divided opinion among both parents and midwives was whether or not there needed to be more information accompanying the items in the box.

3.23 As discussed above, some midwives and health visitors indicated that there needed to be more guidance around how to introduce the scheme to parents, as well as consideration of how to link the Baby Box to other initiatives and public health messages. In discussing the tension between overloading the box with information on the one hand, and avoiding missing opportunities to provide important information on the other, one health visitor suggested that greater clarity about the main aims of the box, and linking any information to that, might help strike an appropriate balance:

It's just making it clear what the purpose of the box is and not blurring its focus. You know, if they're looking at it from a safe sleeping initiative then I would be concentrating on that … So I would just try and keep the purpose of the box as simple as possible and not overdo it with lots of information.

(Health visitor)

3.24 While some parents suggested that they had expected (and wanted) the box to include more information around issues like breastfeeding, safe sleeping and general child health, others expressed a strong view that they already get a lot of information on these issues from other sources (particularly midwives). Including this information in the box was viewed as unnecessary duplication, and was seen by parents as having potential to add to a perceived pressure on them (around breastfeeding in particular).

3.25 Similarly, parents made suggestions around including information that links specifically to the contents - for example, explaining why cellular blankets are the safest option, how to interpret and respond to readings from ear thermometers (including when to call a doctor), or explaining how to dress babies appropriately for sleeping (so that they do not overheat). When the scheme is rolled out, the Baby Box will contain materials directing parents to resources such as Ready Steady Baby and the feedgood.scot and Parent Club websites ^[12] for parenting and baby care advice and will also include further information on safe sleeping.

Policy implications

3.26 As noted in the introduction to this chapter, a number of the findings in relation to implementation reflect the compressed time frame of the pilot. In particular, the timeframes for informing parents about the Baby Box scheme, registering them and delivering the box, will all be brought forward as the box is rolled-out. Issues that relate to not finding out about or receiving the box early enough for it to be useful should therefore be less likely to arise as the scheme is rolled out. However, other findings may require consideration for the scheme as it is rolled out nationally, including:

• What kind of information do midwives need to help them introduce the box confidently and effectively? Including information about the aims as well as the contents.
• What is the most effective process for registering parents? A longer lead-in time and the change in timelines for registration should address some of the issues raised in the pilot. However, it will be important to continue to monitor any issues around registering all parents, including those who might be harder to reach.
• Are delivery protocols working effectively? In particular, how well are planned systems to notify parents in advance about delivery dates working from parents' perspective? The Scottish Government and its partners may wish to pay particular attention to monitoring any delivery issues in the early stages of roll-out and identifying any necessary improvements to the process.
• What, if any, additional information should be included in the box? While there is a need to avoid overwhelming parents with leaflets that duplicate information received elsewhere, there may nonetheless be scope to enhance the impact of the box by developing clear, concise information that links health-related and safety messages to the box itself and its contents.