When Lucy Kaigutha read about a Finnish tradition that dates back to the 1930s, she was struck by a thought: Could the Scandinavians have a tool that would save the lives of newborn babies in Africa, in her native Kenya? Could a simple cardboard box doubling as a bed keep a baby safe in the first months?
“I remembered a student field trip to Marachi village in northern Kenya. There was a mum with a two-week-old baby who didn’t have much to take care of this child,” says Kaigutha, a graduate in public health and international development. “[It] really moved me. And I thought maybe I could also come up with a box, but one that will help mothers and babies in our poor areas.”
For that is what Finland’s welfare state has been doing for decades: giving every expectant mother a brightly coloured, sturdy cardboard box that is 74cm long, 43cm wide and 27cm high. It comes with a small mattress to turn it into a bed, and also sheets and clothes.
The box serves as an incentive to pregnant women to visit maternity clinics: only women who have a pregnancy certificate confirming that they had a health examination before the fifth month of their pregnancy receive a box.
Studies have shown that the earlier a pregnant woman visits a maternity clinic, the better the chances are that doctors will be able to save her baby, should something go wrong during her pregnancy.
As many women have more than one child, and therefore already have a box, they can also choose to rather receive a maternity allowance of about R2 200. But, according to Finland’s health department, only about a third of mothers choose the money.
Government statistics for 2014 show that 99.6% of Finland’s pregnant women visited maternity clinics before the fifth month of their pregnancy.
The country also has one of the lowest infant mortality rates in the world – two deaths in 1 000 live births of babies before their first birthday, data from the World Bank shows. This is a remarkable drop from the end of the 1930s, when nearly every 10th child born in Finland died under the age of one, according to Statistics Finland.
In comparison, South Africa’s infant mortality rate is 35 in 1 000 live births, according to the 2015/2016 Health Barometer. World Bank statistics show Kenya’s is 36 in 1 000.
Baby boxes go global
In July last year, after consulting midwives, nurses and mothers, Kaigutha used crowdfunding for the Toto Care Box.
“It is a crib for the first three months, but the box also comes with 18 essential items that protect the baby in its first 28 days,” Kaigutha explains.
This includes a waterproof mattress, baby clothes, a blanket and a mosquito net. The container looks like any brown storage box, although it boasts the bright Toto Care logo.
But these boxes are sturdy and specially commissioned from young men from poor areas, Kaigutha says.
The idea of baby boxes has spread across the world. Health professionals and local authorities have run pilot projects or adopted the boxes in efforts to cut infant deaths and to help poor parents. Businesses have caught on to the idea and are selling bumper designer versions to the well-heeled and trendy – the Baby Box Co offers a deluxe, if still cardboard, style stacked with products for $449.
In South Africa, a plastic baby box is being studied and trialled by the department of economics at Stellenbosch University and the health department is investigating a maternity package linked to baby boxes.
Japan, New Zealand, Mexico, India and Canada all have local variations of the maternity package and in the United Kingdom, where government statistics show there are four infant deaths in 1 000 live births, health chiefs in several hospitals have started giving the boxes to new families.
The Scottish government has confirmed all babies born on August 15 or after will get a box with essentials as a “welcome gift” and to help tackle deprivation. The box acts as a Moses basket, according to information on the Scottish government website, and is a safe and comfortable place for babies to sleep.
Simple solution may not stave off Sids deaths
But the Lullaby Trust, a British charity that provides sleeping advice and works to cut sudden infant death syndrome (Sids), has warned there is no evidence to suggest the use of the boxes will cut the risk of infant mortality caused by Sids.
“We support all efforts to promote safer sleep for babies,” explains Francine Bates, chief executive of the charity, in a statement. “However, we do have concerns about the baby boxes being marketed as products which will reduce infant mortality and Sids.”
The Lullaby Trust has also expressed concern about whether the boxes comply fully with safety standards because there is no “specific standard for the use of a cardboard box as a sleeping place for an infant”.
The Finnish government itself has cautioned that Finland’s low infant mortality rate has many contributing factors. The maternity package may not have had a direct effect on reducing infant mortality, Tuovi Hakulinen and Mika Gissler of the National Institute for Health and Welfare in Finland said in a recent blog.
“It is difficult to study what the impact of the maternity package actually is, because it has been in use for decades and everyone who wants it can have it,” Hakulinen and Gissler write.
A box with a history
It is important to understand the history of the maternal package, says Karoliina Koskenvuo, head of the research team at the social security service, Kela.
In the early 1900s, Finland was a poor agrarian society in which social support was available mainly from family, church and the local poor relief system, Koskenvuo writes on Kela’s website.
“Major public health challenges included the low standard of living and general hygiene, tuberculosis, epidemics and a high rate of infant and child mortality,” Koskenvuo explains.
It is against this background that Finland established maternity and child welfare clinics, expanded the healthcare system and the hospital network, launched vaccination programmes and raised the standard of living and education.
The maternity package was introduced in 1938 to disadvantaged mothers after childbirth. This was extended to all pregnant women in 1949 — but they were expected to see a doctor, midwife or the municipal maternity welfare clinic by the fifth month of pregnancy.
At the time, Hakulinene and Gissler stress, the poorest families could not always provide a newborn with a clean place to sleep and textiles were in short supply during the war. The box formed a hygienic and safe bed for infants and meant the baby would not sleep in the same bed as the parents, but in the same room.
The box was a tangible way of helping and of encouraging women to use maternity welfare services.
‘I can see it working for these mothers’
In Kenya, where Maigutha has handed 30 boxes a month to pregnant women who attend at least four antenatal visits, she explains that the success of the project lies in the incentive of the box.
“When they attend the clinic, we can educate expectant mothers to care for themselves and their babies. We can also spot health problems early on,” she says. “In the shacks, there is no place for a cot or a crib. With the box, the babies are kept dry and warm, which is important to protect them against pneumonia.”
In many cases, a family share just one bed and the box, which costs Maigutha about $30 or just over R400 to put together, is a cheap option to keep a newborn from suffocating.
The babies are put down to sleep on their backs and, with the infant fitting snugly in the box, Maigutha says they can’t roll over.
“I can see it working for these mothers,” she says. “I don’t have statistics yet, but I can see it.”