Background and methods
This report presents the main findings from an evaluation of Scotland's Baby Box scheme, conducted by Ipsos MORI Scotland on behalf of the Scottish Government between June 2019 and Autumn 2020. The majority of fieldwork – including survey and qualitative research with parents – was conducted prior to the March 2020 lockdown due to COVID-19. The report therefore largely focuses on experiences and views of the scheme prior to COVID-19.
Scotland's Baby Box is a universal welcome gift for all new babies in Scotland, providing families with a range of essential items for their first 6 months, delivered in a sturdy cardboard box, which can itself be used as a safe sleeping space during the early months of a baby's life. Pregnant women are invited to register for the scheme during their 20-24-week antenatal appointment, and the box is delivered between 32 and 36 weeks of pregnancy.
The Baby Box scheme aims to contribute to improving child outcomes and to tackling deprivation and inequality, while recognising that it is only one of a range of Scottish Government policies that aim to give children the best possible start in life. The contents of the baby box are designed to inform and support positive parenting behaviours and it was also anticipated that the box would act as a mechanism for encouraging parental engagement with services. By offering the box universally, the Scottish Government also intended that the scheme would help foster a shared understanding of a society that values and supports all children.
The aim of this evaluation was to assess what, if any, impact the scheme may be having on its expected short- and medium-term outcomes. It also examines how the scheme is operating in practice, and parents' and professionals' views of the box being offered universally, to all expectant parents in Scotland.
A mixed-method approach was adopted, including:
- Analysis of data on registration and uptake (using anonymised registration data provided by the Baby Box delivery contractor, APS)
- A mixed mode (online and telephone) survey of 2,236 parents
- An online survey of 870 health visitors, midwifes and family nurses
- In-depth qualitative interviews with 36 parents, 24 midwives, 20 health visitors and four family nurses across six case study Health Board areas.
A key limitation of the evaluation was the lack of a control group to enable a definitive assessment of impact. As such, the focus was on perceived impacts, triangulating the views of parents and different health professionals to help ensure a rounded view. It is also important to note that it is not an economic evaluation, and cannot, therefore, comment on the cost-effectiveness of the scheme.
The Baby Box scheme has had a high take-up in Scotland and, from the perspective of both parents and health professionals, appears to be working well operationally. Parents who participated in this evaluation were generally very positive about the scheme – speaking highly of the quality and range of items received.
Parents were also positive in their assessments of how receiving the box had benefited their family, both financially and in terms of wider benefits, such as informing them about, or reinforcing, key child health and development messages. Those on lower incomes were more likely to report that receiving a baby box had a positive financial impact, saving them money on things they would otherwise have needed to buy. At the same time, younger parents, first time parents, and parents on lower incomes were all more likely to report that receiving a baby box had wider, non-financial benefits for their family, such as encouraging parents to read to their baby earlier than they would otherwise have done. Younger parents and first time parents were also more likely to agree that the box had encouraged them to talk more to their midwife, health visitor or family nurse – indicating the scope for the scheme to support parental engagement with services.
Although a majority parents who took part in the survey for this evaluation did not use the box itself for their baby to sleep in, among the minority who did not have an alternative sleep space when they received the baby box 69% had used it as a sleep space. Younger parents and parents on lower incomes were, however, less likely to have used the box as a sleep space.
A majority of the health professionals who participated in the evaluation felt clear on the Baby Box schemes aims and their role in the scheme and felt they had received sufficient training about this. However, there were clear differences by role and experience, with health visitors and less experienced professionals less likely to feel clear about their role or to feel confident discussing the box with parents.
While the evaluation findings are positive overall in terms of the take-up, operation, and perceived impact of Scotland's Baby Box, it did identify a number of questions for consideration in relation to the future development of the scheme. These questions were primarily centred around two main themes: identifying potential opportunities to clarify or enhance the role of health visitors and midwives to increase the impact of the scheme, and reviewing information provision to new parents through the box and other means, including information around safe sleeping. There were also questions around ensuring the registration, application and delivery process works as well as possible for all families, including foster families and bereaved families.
Uptake and operational processes
- Estimated take up of baby boxes in Scotland is high (over 90%). There is little variation in estimated uptake by area deprivation.
- The process for registering parents for a box was not always consistent in practice with the suggested process. However, it was nonetheless considered to work well by the vast majority of parents and midwives.
- At the same time, parents did identify a few potential issues, indicating that there may still be scope for improving the registration process to ensure no one misses out (including ensuring that foster carers are aware of how to access a box, if a baby comes into their care).
- No significant issues were reported with the delivery process, though there was a desire to be able to book specific delivery slots.
- There is scope to increase clarity among professionals on the process for cancelling a box in the event of bereavement.
Use of the box and its contents
- Parents were very positive about the quality of the box and its contents – 97% rated it as 'very' or 'fairly good'.
- While the research indicates that the contents are well used by families, there was some evidence that those who already had older children were less likely to use the full range of contents.
- The digital ear thermometer and bath and room thermometer were the items most likely to be rated by parents as among the most useful, and most likely to be seen by midwives, health visitors and family nurses as important to include.
- In comparison with the items parents feel are most useful, professionals (particularly midwives) appear to place relatively more importance on the box itself, as well as the blanket and guidance around safe sleeping.
- The items most commonly identified as 'least useful' by parents tended to be smaller, lower value items: the condoms (20%); the bath sponge (16%); the emery boards (16%) and the Royal Scottish National Orchestra App (16%).
- Items midwives and health visitors felt were least useful were somewhat different, and included: the reusable napppies voucher (31%); comforter toy (23%); nursing pads (21%); hooded bath towel (18%) and the leaflet on breastfeeding (17%).
- 39% of parents had used the box for sleeping, while 61% had not.
- Most parents (87%) already had another sleep space when they received their baby box. However, among the 13% who did not, 69% had used the baby box for their baby to sleep in.
- Younger parents and parents on lower incomes were less likely to have used the box as a sleep space.
- Parents' reservations about using the box for sleeping included perceptions (for example, feeling it was 'wrong' to put a baby in a box), and practical issues (for example, discomfort bending down to pick the baby up from a box on the floor).
- The benefits of the box most commonly identified by parents and health professionals were financial or material – saving money on things they needed for their baby and providing useful things they would not otherwise have bought. However, parents did also recognise other benefits, around learning and support.
- Nine in ten (91%) parents agreed that 'Getting a baby box has saved me money on things I would otherwise have had to buy', while 76% of health professionals agreed that the scheme is an effective way of ensuring that every family has access to newborn essentials. Midwives were more likely to agree with this than were health visitors / family nurses.
- 37% of parents felt they had learned about bonding with their baby through playing, talking and reading as a result of receiving the box. This figure was higher among younger (57%), first-time (46%), and lower income (42%) parents.
- Most (84%) said they had read the books included in the box with their baby. Over half (60%) of parents felt the inclusion of books in the baby box had encouraged them to start reading with their baby earlier – again, younger, first-time and lower income parents were particularly likely to say this.
- 84% of parents surveyed said they had found the leaflet on safe sleeping useful. Findings from the qualitative research provided evidence of parents learning about safe sleeping from the leaflet in the box and/or being empowered to challenge inappropriate views among family members around safe sleeping, even when they had not used the box itself as a sleep space.
- Health professionals also gave positive examples of the potential impact of the box on safe sleeping even where it was not actually being used as a sleep space – for example, where they felt that the baby box had helped support conversations around safe sleeping, and therefore helped to increase or reinforce parents' understanding of this topic.
- A quarter (26%) of parents surveyed felt the box had helped support breastfeeding, but higher numbers (66%) said they found the leaflet on breastfeeding useful. A similar proportion (68%) said they had found the leaflet on post-natal depression useful – younger parents and those on lower incomes were more likely to say it had been 'very' useful.
- Other things parents reported learning from the box included: 'monitoring my baby's health or temperature' (50%), 'how my baby can sleep safely in the box' (42%) and about sources of support for new parents (35%). Again, younger and first-time parents were more likely to say they had learned about each of these areas.
- 47% of parents surveyed had signed up for Parent Club emails, most commonly (64%) at the same time as registering for a baby box. Most parents (79%) who read the emails reported they were useful. However, younger parents were less likely than older parents to read Parent Club emails.
- Parents and health professionals were divided on the impact of the box on facilitating professional/parent engagement. 35% of parents agreed that 'Getting a baby box encouraged me to talk more to my midwife, health visitor or family nurse about things I wasn't sure about', while 23% disagreed and 41% neither agreed nor disagreed. 45% of health professionals agreed that the box was a useful tool in supporting conversations with parents in general, while 18% disagreed and 33% neither agreed nor disagreed.
- Younger parents and first time parents were more likely to agree that the box had encouraged them to talk more to their midwife, health visitor or family nurse. There was also some evidence from health professionals that the box had supported conversations with parents experiencing particularly challenging circumstances.
Workforce training and role in the Baby Box scheme
- The vast majority (88%) of health visitors, midwives and family nurses felt clear on the aims of the Baby Box Scheme.
- When asked about the main ways the scheme was intended to contribute to positive outcomes, the most common answer among professionals was that it did so by helping families financially by providing items for their new baby (44%). This was followed by 'helping to reduce inequalities in health between children from different backgrounds' (37%) and 'helping to reduce inequalities in health between new mothers from different backgrounds' (34%). Far fewer professionals singled out the idea that the scheme was intended to contribute to positive outcomes by increasing opportunities for them to engage with parents (6%).
- A majority of health professionals (61%) felt clear about their role in relation to the Baby Box scheme. Fourteen per cent said they were unclear and 22% that they were 'neither clear nor unclear' about their role.
- Training on the scheme most frequently took the form of informal discussions with colleagues (41%) and written information (35%) rather than more formal training (2%). 28% said they had not received any training or information about the scheme.
- Among the 72% who had received information or training, 37% felt it had been sufficent.
- There were clear differences by both profession and length of time in role, with midwives and more experienced professionals more likely to feel clear about their role, report that they had received sufficient training, and to feel confident discussing the box with parents.
- The main topics professionals were unsure about or wanted more information or training on were: the contents of the box (59%); practical elements of how the scheme operates (for example, 51% of those who felt training was not sufficient wanted more training on the registration process while 44% mentioned the delivery process); and the aims of the scheme (50%). Qualitative interviews with health professionals also identified a desire for more information about the purpose and evidence behind the scheme, and the main messages they should get across to parents about the box. The evaluation also indicates the scheme may benefit from providing further information for professionals about using the box for safe sleeping (mentioned by 40% of those who felt their training on the scheme was not sufficient).
Views on universal availability
- Parents across all income groups were, in the main, supportive of the scheme's universal availability as a way of promoting an equal start for all children in Scotland.
- Parents and health professionals reflected on the advantages of universal schemes in terms of reducing stigma and conveying benefits beyond the purely financial.
- When asked how the scheme could be improved, only 2% of parents mentioned any changes relating to means-testing or universality. However, during qualitative interviews with parents some questioned whether items were potentially being wasted by parents who did not need them. Questions were also raised over whether providing boxes to parents on high incomes was necessarily the best use of scarce resources.