Scotland's Baby Box pilot: qualitative research

4 Views on potential impact

Key points

• There is potential for the Baby Box scheme to impact on safe sleeping, parent-child interaction, and socio-economic inequality. However, the research also identifies challenges that will need to be overcome for these impacts to be realised.
• The Baby Box is intended to provide a safe sleep space for newborn babies. Some parents had chosen to use it in this way and felt that their babies slept well in the boxes.
• However, other parents had chosen not to use the box for sleeping, either because they already had a cot or Moses basket, or because of practical or cultural concerns.
• Although some parents were able to identify features of the Baby Box (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 makes the box a safe sleeping place.
• In relation to potential impacts on parent-child interaction, parents tended to welcome the inclusion of books and the play mat in the box.
• However, views on the impact of including these varied from those who felt they had no additional impact as they would have played and read to their babies from an early age regardless, to those who felt it had encouraged them to do so earlier, or that its size encouraged older siblings to join in with play.
• Some families, particularly those in deprived areas, believed that the savings that could be made by receiving the Baby Box were substantial and would have made a big financial difference to them had they known about the scheme at an earlier stage in their pregnancy, before having purchased the things they needed.
• However, other families (particularly those with older children), who already had many of the items, commented that the box largely duplicated what they already had. (Parents offered the Baby Box can opt out of the scheme if they wish).

4.1 This chapter explores the views of both parents and health professionals on the health and social outcomes that the Baby Box scheme aims to influence (as set out in the research brief), namely:

• Safe sleeping
• Parent-child interaction, and
• Socio-economic inequality.

4.2 When reading and interpreting the findings in this chapter, it should be borne in mind that the findings are comprised of qualitative evidence of parents' and health professionals' perceptions of short-term impacts in the areas noted above. At this stage, there is no definitive evidence that Baby Box recipients have better outcomes than non-recipients. As already noted, robust assessment of outcomes would require much longer-term evaluation. Longer-term evaluation is also needed to understand frequency of use of the various items in the Baby Box and how this may affect outcomes. The short timeframe for the pilot research meant that in some cases parents were interviewed shortly after receiving their Baby Box. This precluded consideration of frequency of use of the Box and its contents and what, if any, difference this might make to potential impact.

4.3 However, the research can provide evidence, based on the accounts of parents and professionals, of the potential for the Baby Box to make a difference to parental behaviours and financial/material resources - key routes by which it could impact on health or social outcomes and reduce socio-economic inequalities. It can also explore possible barriers to the box having a positive impact in those areas.

Potential impact on safe sleeping

4.4 As noted in Section 1.1, the Baby Box itself is designed to be a safe sleeping place for a baby. The box contains a new mattress, a mattress cover, a fitted sheet and cellular blanket. Its potential impact on safe sleeping practices will depend on three factors: whether parents are using the box for sleeping; whether they are using it in a safe way; and how they would have slept their baby if they had not had a Baby Box (specifically, whether or not this would have been a more or less safe option). This section discusses the potential for the scheme to impact on the first two of these in particular. ^[13]

Use of the box for sleeping

4.5 Among parents interviewed for the pilot research, four distinct groups were apparent in terms of their use of the baby box for sleeping:

• Those who had not used the box for their baby to sleep in and did not intend to. These parents tended to be using Moses baskets and cots instead.
• Those who used the Baby Box as the main night time sleep space for their baby, next to their own bed (and tended to use another sleep space, for example a Moses basket, in the living room during the day).
• Those who were using the Baby Box as a secondary sleep space, either for daytime naps downstairs and/or for visits to friends or family (and used a cot or Moses basket as their main night time sleep space).
• Those who had not tried using the box for sleeping but were considering doing so for future visits to family or friends or a when their baby is too big for a Moses basket.

Parents' attitudes to using the box for sleeping

4.6 Parents who had used the box for sleeping were positive about it and outlined a number of perceived benefits to doing so:

• First, it was seen as offering a potential cost saving by removing the need to purchase a Moses basket - an item which was considered expensive.
• Second, parents commented on perceived benefits of the slightly larger size of the box (in comparison to most Moses baskets). This meant they thought it could be used for longer than a Moses basket ^[14] . It was also suggested that the intermediate size of the box, between a Moses basket and a cot, could make it a useful transitional option between the two. Parents who were using both a Moses basket and the Baby Box, commented that their babies tended to sleep well in the box. It was suggested that there was more space around the baby than there would be in a Moses basket, which made it a more comfortable option since babies were not waking themselves up by hitting their hands off the sides.
• Third, simply having another sleep space was valued by parents. For those using the Baby Box at home, in addition to a Moses basket or cot, not having to carry the Moses basket from room to room or up and down stairs for daytime naps was appreciated (particularly by one mother who had given birth by Caesarian section). The portability of the Baby Box was also viewed as a positive feature for trips to visit family or friends - it could be used to pack things in and then to sleep the baby in when there.

4.7 The only negative points made by parents who were using the box for sleeping related to it being used on the floor. This was considered to be potentially less safe than a Moses basket on a stand, particularly when there were older children in the household who might trip over the box. There was also a perception that it could be colder for the baby to be on the floor, particularly in a draughty house.

Parents' reasons for not using the box for sleeping

4.8 A major factor influencing whether or not the box was used for sleeping was whether parents already had Moses baskets and/or cots - either from previous children or because they had already purchased them before finding out they would be receiving the box (which, as already noted, happened at a later stage of pregnancy during the pilot than is planned when the scheme is rolled-out nationwide). These parents did not necessarily have any objection to using the box, they simply had no need to or did not have space to use both (it was pointed out by both health professionals and parents that not all families have space to accommodate the box as well as other sleep spaces). This may become less of an issue over time, if parents stop purchasing Moses baskets because they know they will be receiving the box.

4.9 Where parents expressed reservations about using the box for sleeping, the perceived barriers can be divided into cultural and practical concerns. In terms of cultural barriers, parents commented that sleeping your baby in a box was not something that people were used to in Scotland. Some, like the mother quoted below, had overcome this initial reticence.

(It's) still a funny feeling, putting your baby to sleep in a cardboard box. It's just a psychological thing, because there is nothing wrong with it and, as I say, he is really happy in it.

(Orkney parent)

4.10 For others, however, there was resistance to the idea. These parents felt that it was something you would only do if you were unable to afford to buy a Moses basket or cot.

I just find it odd putting a baby in a box. It's alright for someone who can't get the funding to get a Moses or a cot.

(Clackmannanshire parent)

4.11 More practical concerns were related to the box being on the floor. Parents with older children or pets cited worries about the possibility of people tripping over the box, or pets jumping into it. Having the box on the floor was also viewed as potentially problematic for women who were finding it difficult to bend down after giving birth, particularly those who had had a Caesarean section. (The instructions for use included in the Baby Box suggest that the Box could be placed in a cot, which might avoid this difficulty).

4.12 Parents also mentioned being unsure if the box (which is made of cardboard) would still be useable if their baby was sick on it - they did not know whether it would be possible to clean it effectively. Finally, it was also suggested that the material of the box might make it a colder space for babies to sleep in than a Moses basket.

Views about Baby Boxes and safe sleeping

4.13 Current online NHS guidance on safe sleeping includes the following advice to parents:

• Place your baby on their back to sleep, in a cot in the same room as you for the first six months.
• Don't smoke during pregnancy or breastfeeding and don't let anyone smoke in the same room as your baby.
• Don't share a bed with your baby if you've been drinking alcohol, if you take drugs or you're a smoker.
• Never sleep with your baby on a sofa or armchair.
• Don't let your baby get too hot or cold.
• Keep your baby's head uncovered. Their blanket should be tucked in no higher than their shoulders.
• Place your baby in the "feet to foot" position (with their feet at the end of the cot or Moses basket). ^[15]

4.14 To date there is no conclusive evidence on the role of cardboard baby boxes in reducing infant mortality. ^[16] However, the Baby Box - and its associated bedding - is intended to offer a safe sleeping place if used in accordance with the other safe sleeping practices listed above.

4.15 In order to explore any potential influence of the box on safe sleeping practices, parents were asked why they thought the box offered a safe place for their baby to sleep.

4.16 Some parents talked in positive terms about the fact that the box included cellular blankets, which they knew to be safer than other types, ^[17] (and indeed one parent had learnt about the importance of using cellular blankets through their inclusion in the box) and a new mattress, which they felt might prevent some parents from having to use a second-hand one.[18] In relation to the box itself, it was described as safe because it was a 'simple' or 'clean' space, with a flat surface, similar to basinets used in hospitals. There was also a perception (though this does not reflect NHS guidance) that cots are too large for newborn babies, and that, for those unable to afford both a cot and a Moses basket, a Baby Box would be a safer option than a cot for a newborn.

4.17 Notwithstanding the points above, it was also clear that confusion existed among parents as to what (if anything) made the box a particularly safe sleeping space. There were mentions of Finland and mentions of a claimed reduction in cot deaths. However, these parents were not able to articulate what features of the box might make it safe, as the following quote illustrates.

Well, I believe from the information in the box and the advertising around the box, it is better than a Moses basket or a crib that attach to the side of the bed, because it prevents cot deaths. I just believed the information that I read, and the Government is giving us the box for the baby to sleep in, so it must be the right thing to do.

(Orkney parent)

4.18 A lack of understanding among parents around the link between the box and safe sleeping raises a number of issues. First, it may result in parents using the box for sleeping but not always in accordance with other safe sleeping best practice. Indeed, researchers carrying out the pilot observed instances of the Baby Box being used for sleeping but in combination with other practices that might be considered less optimal from a safety perspective - for example, using fleece rather than cellular blankets and, on one occasion, having soft toys at the top of the box, close to the baby's head.

4.19 Second, the research showed that, in some cases, the box was used as one of a number of sleep spaces. If parents are unclear about what constitutes safe sleeping, they may be using the box safely but be using another space less safely (for example, using cot bumpers or not sleeping their baby 'feet to foot' in a larger cot).

4.20 Finally, a lack of clarity about the precise role of the box in relation to safe sleeping has the potential to introduce unwarranted worry or guilt among parents who are not using the box, but are practicing safe sleeping regardless, as the following quote illustrates:

I: Have you learnt anything from the box?

I guess the whole mortality thing in Finland, it's obviously lowered that. That kind of sunk home. I mean it's not something you want to think about, you've got a newborn baby, you're happy, it's a joyous time but at the same time it's on your mind. When you put them down (to sleep) you think 'are they okay?' It has to be on you mind. So, I guess for a little while I thought 'oh my, now that I've realised that, should I be using that box? Is it the wrong thing I'm not using the box?'. …

I: What is it about the box that makes it safe?

I don't honestly know. What is the difference to lying flat on your back in the box compared to lying flat on your back in a pram? You're still well ventilated, you're still flat on your back. I don't know.

(Orkney parent)

Potential impact on parent-child interaction

4.21 The Baby Box is intended to have a positive impact on parent-child interaction. Numerous studies have highlighted the importance of early parent-child interaction and play in children's emotional, social and cognitive development. ^[19] For this reason, the pilot Baby Box included materials designed to promote attachment (books, Bookbug materials and a play mat) which might encourage parents to read and play with their babies from an early stage.

Reading

4.22 The parents we interviewed understood the importance of reading to their babies and were enthusiastic about doing so. They also tended to be positive about the inclusion of books in the Baby Box. However, parents' views differed in relation to the potential impact of including books in the box. Four main views were apparent:

• It encouraged parents to read earlier than they might otherwise have done - some parents said that having books included in the box did make them read at an earlier stage than they had planned to.
• It introduced parents to a different type of book - these parents said they would have read to their babies anyway but would not have thought to buy a sensory book, like the one included in the box, and liked the fact that this type of book could be used from a very early stage.
• It served as a prompt - these parents commented that, while they had the best of intentions to read to their babies from very early on, the inclusion of the books served as useful prompt when they were caught up in the caregiving required for a newborn baby. It was also noted that, when there is so much to buy for a new baby, books might not be top of the list of things to buy before the baby is born.
• It had no additional impact - these parents already had books and thought they would have read to their babies from a very early age anyway.

4.23 The Bookbug calendar and a set of baby books are currently given to parents across Scotland at the 4-month health visiting appointment. When asked if this 4-month Bookbug bag could in the future be included in baby boxes, Health visitors suggested that incorporating this within the baby box might mean they lost the opportunity to discuss with parents the importance of reading with their babies. They felt that parents might feel overwhelmed by receiving so much at the one time.

Playing

4.24 The pilot Baby Box also included a large 'PlayTalkRead' play mat on which parents could sit and play with their baby. Parents indicated that they did not consider the play mat to be an 'essential' item in the same way as some of the other items included in the box (for example, the clothes and blankets). However, it was something that they would not always have bought themselves and was, therefore, a welcome inclusion. In comparison with other play mats, parents commented on the fact that its large size meant that older children could also join in with play.

It has also brought our three children together as they all sit on the PlayTalkRead mat so, no matter what we are doing on it, the bairns all appear to enjoy sitting together.

(Orkney parent)

4.25 The fact that the play mat also shows where the parent should place themselves on the mat was noted by one parent, who felt that this was a subtle way of making parents aware of the fact that they should place themselves close to their baby when playing with them. The one negative point raised in comparison to other play mats was the absence of any sensory elements.

4.26 Parents' views on the impact of receiving the play mat were again divided, however: one view was that it would encourage them to play with their babies from an earlier stage than they might have otherwise, while other parents said they would have played with their babies from an early age regardless and did not think the play mat had any impact on this.

Potential impact on reducing socio-economic inequalities

4.27 Establishing whether the Baby Box scheme contributes to addressing socio-economic inequalities requires a larger-scale study, comparing outcomes for families in different socio-economic groups. This was beyond the scope of the pilot research. However, interviews with parents did explore whether or not parents believed receiving the box had saved them money, which gives some indication of the potential for the scheme to have a financial impact.

4.28 In practice, as discussed in Chapter 3, because of the late stage at which pilot parents were informed they would receive the box, many of the parents we spoke to had already purchased most of the items they thought they would need for their baby before finding out about the box. Therefore, parents were generally only able to speculate on what financial impact the box might have had, if they had found out about it earlier. Views on this were again divided.

4.29 There were parents - first time parents in particular - who felt that it would definitely have saved them money as they would not have needed to buy as many things themselves. Some of these parents said they could have afforded things relatively comfortably and viewed the items in the box as more of a 'bonus' rather than having a significant financial impact for them. However, others - particularly those living in more deprived areas - said they had struggled financially to buy everything they needed for their baby and felt that it could have made a real difference to them, as shown by the quote below.

Of course, I was worried about it. Everything is so expensive. Sometimes when I was checking what I needed I was almost crying because it costs a fortune.

(Clackmannanshire parent)

4.30 Further, for some parents, the box had provided them with items that they would otherwise have gone without - and in some cases would not even have thought to buy. One example of this was the ear thermometer, which was viewed as an expensive but important item. There were also examples of parents who had decided not to buy a Moses basket when they found out they would be receiving a Baby Box.

We were contemplating buying a Moses basket, but when we heard we would be receiving the box we thought we could try that and then if it doesn't work out then we can always go out and buy one.

(Clackmannanshire parent)

4.31 However, other parents felt the potential financial impact was less clear cut. For parents who already had children, the potential impact was lessened by the fact that they already had most things they needed. While some appreciated having new things for their baby which they would not otherwise have bought, others considered it to be a waste of resources when they already had, or could otherwise afford, what they needed. Indeed, there were parents in our sample who had either donated the box or who felt that, with hindsight, that they should have declined it. There was also some evidence of parents choosing to buy different versions of items contained in the box which they considered to be 'better' or 'nicer', such as a different type of sling or a different colour of snow suit.

Policy implications

4.32 This chapter has explored early indications from the pilot of the ways in which the Baby Box has the potential to impact on sleeping practices, parent-child interaction, and parent finances, as well as some of the possible barriers to it having a positive impact in these areas. In terms of implications for the national roll-out of the scheme, the Scottish Government may wish to consider what it could do to mitigate some of these challenges and barriers. For example:

• Is there a need for more accompanying information about safe sleeping, to ensure that parents use both the box and other sleep spaces as safely as possible?
• Is there a need for a campaign to accompany roll-out, to help address potential cultural barriers to sleeping babies in boxes?

4.33 The issue of duplication of parental resources - both in terms of knowledge and attitudes to things like reading and play, and financial resources to purchase things for their babies themselves - inevitably arises with a universal scheme. The question of whether or not the duplication associated with a universal scheme is justified by the wider benefits, particularly in ensuring resources reach those who need it most, touches on much wider political debates. However, the views reported here highlight the need to consider how the rationale for the scheme is communicated (to parents, professionals and the wider public), and to ensure that future evaluation includes an assessment of impact on outcomes for children and families and of value for money.