Baby Box: evaluation

2. Uptake and operational processes

Key findings

• 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, the process of registering for a box 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.

If the Baby Box scheme is to deliver the benefits outlined in Chapter 1, take-up of the offer needs to be high – both overall, and across socio-demographic groups. In particular, take-up needs to be high among those who might be expected to benefit most from the box financially, such as those on lower incomes. To support high take-up, registration and delivery processes need to be simple and effective.

This chapter summarises uptake of the scheme to date and assesses how well registration and delivery processes are working in practice. It draws on anonymised registration data, combined with data on births from National Record Scotland, and on data from both qualitative interviews and surveys of parents and professionals.

Outcomes

• High numbers applying for a box across all socio-economic groups
• Smooth application process
• Boxes delivered on time

Research Questions

• How have parents found the registration process and arrangements around receiving their baby box?

Uptake of baby boxes

Estimated take up of baby boxes in Scotland is very high. Dividing the number of parents registering for a box (based on their due date)^[9] by the number of births recorded for that year^{[10] [11]}, an estimated 89% of new parents registered for a box in 2017 (15^th August to end December), 93% in 2018 and 92% in 2019. Further analysis of uptake by SIMD^[12] showed similar rates of uptake across SIMD quintiles (see table in Appendix E).

Registration process

The Scottish Government's recommended process for registering families for a baby box is that midwives complete the registration form jointly with pregnant women at their 20-24-week appointment and post it on their behalf. However, findings from the surveys of both parents and health professionals showed that, in practice, the process varies, with parents often given the form to take away, complete, and post themselves. Half of parents reported completing the registration form on their own (52%), while 42% said they had completed it jointly with their midwife (42%) and 6% said their midwife completed it by themselves. Meanwhile, 72% of midwives and family nurses responding to the professionals' survey said that they usually gave the mother the form to take away and post back herself.^[13]

Qualitative interviews with midwives indicated that common practice was for parents to be given the registration form at an early midwife appointment (e.g. their booking appointment around 13 weeks), asked to complete their sections, and to bring it back to their 22 week appointment, where the midwife would check, sign it and give it back to the mother to post. Workload was the primary reason midwives gave for adopting this approach – they simply did not feel they had time to add posting forms to their to-do list. It was also suggested that it was appropriate to give mothers ownership and responsibility for posting the form, and that doing it in this way prevented anyone from feeling pressured to take the box if they did not want to.

Notwithstanding some variation in approach, however, the registration process was generally felt to work well by both parents and midwives. Almost all parents who responded to the survey (99%) said it was 'very' (90%) or 'fairly' easy (9%) to register for their baby box.^[14] Similarly, almost all midwives and family nurses involved in registering parents for boxes (>99%) felt the registration process worked well (76% 'very well' and 24% 'fairly well'). The fact that uptake is high further supports the view that the registration process is generally very effective.

Parents interviewed for the qualitative research also generally felt the registration process worked well and that they were able to complete and post the form without any problems. However, there were a few examples where asking parents to post the form themselves had caused difficulties, or potential difficulties, due to:

• Parental health issues (e.g. back problems or severe morning sickness) making it difficult for them to go out to post it themselves
• Administrative issues (e.g. one participant received conflicting information from two different midwives about who was responsible for posting the form, meaning they had to request a new form to post themselves)
• Parents coming close to forgetting to post their form, particularly if it had been included in a pack of leaflets rather than being given to them separately.

Thus, while overall the registration process is seen as effective, there may nonetheless be scope for improvement to reduce the potential for families to inadvertently miss out on a box.

Question for consideration: Is there a need to encourage midwives to routinely double-check whether parents are comfortable posting the form back themselves, and/or to clarify that they can post it for them if parents would prefer?

As part of the registration process, at the 20-24 week antenatal appointment, midwives also give parents a leaflet detailing the full list of box contents^[15]. The vast majority (95%) of parents who took part in the survey said they had enough information about the box before receiving it. Nonetheless, among the minority who indicated they wanted more information, the most common request was for information about 'what would be in the box' (followed by 'when the box would be delivered' and 'the purpose of the scheme'). Parents who took part in the in-depth interviews also described having duplicates of some items, as they had started to buy things for their baby before they became aware of what they would receive in the box.

Question for consideration: Is there an opportunity for midwives to more actively highlight the range of things the box includes at the appointment at which it is introduced, and/or for parents to be directed to the list of contents at an earlier stage?

Finally, a specific set of issues were raised by foster parents interviewed for this study around the way the registration process works for babies who are going to be looked after by foster carers. They felt very strongly that the box ought to 'follow the baby' rather than be given to the birth parent, as the box and its contents did not always come with babies who had come to them for foster care. In their experience, birth parents sometimes only sent a few items from the box with their baby and not the box itself.^[16] They felt strongly that, if they did not receive a baby box, this was another way in which foster children miss out – not only while they are babies, but potentially as they are older, since baby boxes and their contents may become part of the 'memory store' of this generation of children. Foster parents and Kinship carers are eligible to register for a baby box through their appointed social worker if they are fostering a child between 0-6 months. However, the experience of the Foster parents interviewed for this evaluation suggests that in practice they may not always be aware of this.

Question for consideration: Is there a need to review how the way the scheme is intended to work when a baby is not being looked after by their birth parents is communicated to carers, including foster carers?

Delivery process

Baby boxes are generally delivered between 34 and 36 weeks of pregnancy, with mothers receiving text updates with details of when the box will arrive. The delivery process was not asked about specifically in either of the surveys. However, parents responding to the survey were able to give suggestions for improvements to the Baby Box Scheme. Of the 47% who gave suggestions, 9% (5% of all respondents) gave suggestions relating to delivery, such as delivering the box earlier or allowing the option to select a delivery date or time. Parents who took part in in-depth interviews were very satisfied with the delivery process and timeliness, but again suggested it would be helpful to be able to select delivery slots.

Question for consideration: Is it worth exploring the feasibility of adapting the registration/delivery system to allow parents to select a delivery slot?

Cancelling boxes in the event of bereavement

Another element of an effective delivery process is being able to quickly stop the delivery of boxes in the event of baby loss. The survey of health professionals found that over half (56%) of midwives, health visitors and family nurses were unclear about the process for cancelling a baby box in the event of a bereavement. A further 18% said they were not sure or preferred not to say – just 17% said they were clear about the process.

As might be expected (since it is midwives rather than health visitors who have most contact with pregnant mothers at the time leading up to delivery of boxes), midwives were much more likely to report being clear on the process of cancelling a box (40%, compared with 7% of health visitors/family nurses). However, a sizeable minority of midwives (37%) still felt unclear about the process. The length of time professionals had been practicing also played a role, with those who had been practising for 10 years or more most likely to feel clear on the process (23%, compared with 6% of those who had been practising for under three years).

Midwives who took part in the qualitative interviews had not themselves had to cancel a box due to the loss of a baby. However, they reported that they were either clear on the process or felt confident they would easily be able to find out what to do if necessary – by asking colleagues or by calling the baby box helpline. Midwives also noted that they would need to consider the wishes of the parents in this scenario, as they may not necessarily want to cancel the box. However, although midwives appeared to feel it would be straightforward to find out how to cancel a box, the fact that over half are currently unclear on the process suggests that there may be scope for increasing understanding around how to ensure delivery is stopped in these instances.

Question for consideration: Is there a need to consider how best to ensure that all relevant health professionals who may be in contact with a bereaved family are aware of the process for cancelling a baby box?