The Baby Box: An Opportunity, Not A Magic Bullet

In the past few months, you may have seen increasing attention around the use in the U.S. of Finnish baby boxes to promote safe sleep environments. Some are hailing it as the solution to the U.S. infant mortality problem. But, the circumstances around the success of baby boxes in Finland are much different than in U.S. today. It is raising concerns from public health and quality improvement experts, like NICHQ, about wide adoption of the baby boxes without evidence of their value in reducing infant mortality rates in the U.S.

Sabrina Selk, ScD

The baby box began in Finland between the first and second world wars as a service for low-income mothers. It provided necessities that all families would need in the early days after the birth of a child, including clothing, diapers and basic hygiene supplies, and in the 1940s the box itself was redesigned to act as a crib. In 1942, the care packaged became available to all Finnish moms as the country recovered from World War II. From that period on, Finland saw a rapid decrease in the overall infant mortality rates among babies in the first year of life, dropping from over 60 infant deaths per 1,000 live births in 1945 to an estimated 2.5 in 2016.

While the baby box certainly contributed to these decreases, the similar trends seen across countries, including the U.S., suggests other factors were also at play. Access to antibiotics, improvements in obstetric practices and increasing medical knowledge in how to keep the most vulnerable babies alive all played a part. In fact, the widening gap between the infant mortality rate in the U.S. and peer countries didn’t factor in until the 1980s.

Despite the lack of direct evidence that the baby boxes alone without additional maternal and family resources address the current infant mortality disparity between the U.S. and peer countries, it has gained increasing traction as a potential solution in different states for creating safe sleep environments and reducing sleep-related mortality. While the baby box can be seen as an innovative product and a promising practice, it does not meet the requirements of an evidence-based initiative.

A number of professional organizations, including the American Academy of Pediatrics and the Consumer Product Safety Commission, have addressed this concern by putting out a number of statements recommending a critical view towards the rapid spread of this intervention and its potential impact. In summary, the connection between the baby box and infant mortality has been made primarily by the media, rather than evolving from observed data and research-backed evidence.

That said, there is evidence policies that address the quality and accessibility of early, comprehensive maternal and child care leads to reductions in infant mortality. For example, many countries that maintained or increased their reduction in infant mortality rates implemented policies for paid maternal leave, which is linked to improved maternal and infant outcomes.

Country  Year Maternal Leave Policies Were Implemented
 Norwary  1909
 Mexico   1917
 Finland  1963
 Canada  1971
 Switzerland  2004

A look at when other industrialized nations implemented paid maternal leave policies.

The enthusiasm and interest that the Finnish baby box has garnered for infant mortality efforts is an important way of elevating the cause of infant mortality more broadly. However, providers and policymakers should take care to consider the wider context of necessary supports and resources that families need for these initiatives to have a demonstrable, positive impact. In addition, it will be crucial to collect data as baby boxes are distributed to determine whether they support the goal we’re all working towards: more babies reaching more birthdays.

NICHQ is leading the effort to prevent sleep-related infant deaths. Learn how in this interactive toolkit from the Collaborative Improvement and Innovation Network to Reduce Infant Mortality.

Sabrina Selk is an Associate Director of Applied Research and Evaluation at NICHQ.