You may have seen this curious headline, or a similar version of it, in the news recently:
It certainly caught my eye. I read the BBC news article with curiosity, but little surprise. The gist of the story is that antenatal care in Finland includes a box filled with several hundred euro worth of baby clothing and supplies including a mattress and snowsuit for the icy Finnish winters (1). All an expectant mother has to do is visit an antenatal care clinic or doctor once in the first trimester of her pregnancy to receive the box for free. In itself, the box is brilliant piece of preventive public health care. It incentivises the receipt of crucial early pregnancy care with free essential goods. The end result is healthier, happier babies and mothers: good for the family and for the state.
The ‘Nordic Model’: nothing to do with fashion
Finland is among the five Scandinavian countries famous for their welfare states (also Denmark, Iceland, Norway, and Sweden). Hence, its provision of excellent antenatal care service is not surprising. Although there is variation between the Scandinavian countries in political and economic operation, all follow a principle of universality in their ‘Nordic Model’ of welfare provision (2). Taxes are steep for the countries’ residents, but social and health care spending are high. Evidence for the effectiveness of this equality-driven Nordic model is clear: Scandinavian countries rank among the highest in the OECD for life satisfaction, work-life balance, and life expectancy (3-5). So that’s some of the context at hand.
What do we all think?
People in other countries are tuning into the Finnish ‘baby box’ story with open ears. Reactions are a mix of mild interest to slight shock that the Finns would dress their babies in identical state-issued clothes and place them to sleep in a cardboard box; some appear jealous of the programme and wonder why it is not a common practice elsewhere. You see, the programme is almost a no-brainer. A person’s health as a baby is crucial to health in later life. Increasing evidence from epidemiological ‘lifecourse’ studies shows that in-utero and early life exposures may play a role in later health conditions such as asthma and some cancers (7-9). Furthermore, maternal health is a strong indicator of a country’s development. Improvement of maternal health in poor countries is one of the WHO’s Millennium Development Goals (6). So, what about using the Finnish model to promote antenatal and early life care in other countries?
Well, Finland is not like many other countries. Finland is highly developed, ranking at 21 out of 186 UN member-states for the Human Development Index in 2013 (10). Public health strategies that work in rich countries like Finland often don’t work in poor developing countries. With respect to maternal deaths, over half that occur globally are in sub-Saharan Africa and one-third in South Asia (11). Proper antenatal care, such as that promoted by the Finnish ‘baby box’, would help prevent maternal deaths in these places. The barriers to antenatal care in these regions of the world, as listed by the WHO, are poverty, distance, lack of information, inadequate services, and cultural practices (11). Obviously, all the baby boxes in the world won’t make a difference to removing the latter four barriers to antenatal care. However, the box would bypass financial constraints on purchasing many essential items for new mothers in poor countries.
…. and other rich countries?
What about the potential for baby boxes in rich, developed countries? It’s an interesting thought. Antenatal care is crucial for the lifelong health of all people, although it’s taken for granted in rich countries where services are high-quality and abundant. However, several countries do have a long way to go: infant mortality is twice as high in the United Kingdom as in Finland and three times higher in the United States than in Finland (from 2008 and 2012, infant mortality was 4 deaths per 1,000 births in the UK, 6 deaths per 1,000 births in the United States, and 2 deaths per 1,000 in Finland; 12). Unfortunately, the provision of ‘baby boxes’ in Finland is linked to a political ideology that, while not extreme, is unacceptable in many places. For example, the Nordic welfare state is too socialist to be compatible with American politics – the United States does not even have a public health care system. Furthermore, the individualistic attitude of people living in many countries like the United States probably precludes a desire for many to have their baby dressed up in the same clothes as all other babies born in the country in that year – which is one aspect of using the box in Finland.
No one likes logistics
Unfortunately, the ‘baby box’ costs money. This is a problem not only for poor, developing countries where infrastructure for basic services is a more immediate concern, but also for developed countries in the current global economic climate. Health and social spending is largely being reduced in most places; most governments are unlikely to be in positions to start providing boxes of free baby care goods, no matter how essential they are.
Hope – and the bigger picture
I don’t mean to imply that Finland is the only country in the world with amazing antenatal and infant care strategies. Apparently Boot’s (a British pharmacy) provides a similar baby box that at least used to be redeemable with a voucher from a GP (I could not find current evidence for this). Countries with public health care systems such as Canada and the UK provide antenatal care and support through their health systems, although you must be self-motivated to access much of it.
And let’s not forget that the ‘baby box’ is only small piece of public health care within a broader mosaic of political, economic, and social conditions in Finland. Finland has emerged from a poor economic climate in the 1930s, when the box was introduced, to being among the richest and most developed today. This shift likely has had a bigger impact on infant mortality and maternal health than the ‘baby box’.
However, let us keep the Finnish ‘baby box’ in mind as an aspirational piece of legislation. The box is inscribed with the line ‘Every child matters. Every family matters.’ (13). While corny, this message of equality is one of the Nordic Model that every country in the world should be listening to with keen attention.
1) Lee H. Why Finnish babies sleep in cardboard boxes. The BBC. June 4 2013. http://www.bbc.co.uk/news/magazine-22751415 (accessed 8 June 2013).
2) The Nordic Council. The Nordic Welfare Model. http://www.norden.org/en/about-nordic-co-operation/areas-of-co-operation/the-nordic-welfare-model (accessed 8 June 2013).
3) OECD. “Work and life balance”, in How’s Life?: Measuring Well-being. OECD Publishing. 2011. http://dx.doi.org/10.1787/9789264121164-8-en
4) OECD. “Health”, in OECD Factbook 2013: Economic, Environmental and Social Statistics. OECD Publishing. 2013. http://dx.doi.org/10.1787/factbook-2013-109-en
5) OECD. “Subjective Well-Being”, in How’s Life?: Measuring Well-being. OECD Publishing. 2011. http://dx.doi.org/10.1787/9789264121164-14-en
6) WHO. Health topics: Millennium Development Goals (MDGs). http://www.who.int/topics/millennium_development_goals/en/ (accessed 9 June 2013).
7) Zhou C, Baiz N, Zhang T, Banerjee S, Annesi-Maesano I. Modifiable exposures to air pollutants related to asthma phenotypes in the first year of life in children in the EDEN mother-child cohort study. BMC Public Health 2013;13(1):506.
8) Park SK, Kang D, McGlynn KA, Garcia-Closas M, Kim Y, Yoo KY, et al. Intrauterine environments and breast cancer risk: a meta-analysis and systematic review. Breast Cancer Res 2008;10(1):R8.
9) Franco-Lie I, Iversen T, Robsahm TE, Abdelnoor M. Birth weight and melanoma risk: a population-based case-control study. Br J Cancer 2008;98(1):179-82.
10) Malik K, Human Development Report 2013 team. Human Development Report 2013: The Rise of the South: Human progress in a diverse world. United Nations Development Programme. 2013.
11) WHO. Fact Sheet No. 348: Maternal Mortality. May 2012. http://www.who.int/mediacentre/factsheets/fs348/en/index.html (accessed 9 June 2013).
12) UNICEF, WHO, World Bank, UN DESA, UNPD. Mortality rate, infant (per 1,000 live births). http://data.worldbank.org/indicator/SP.DYN.IMRT.IN/countries?display=default (accessed 9 June 2013).
13) Picard M. Why Canadian babies should sleep in cardboard boxes like Finnish babies do. The Globe and Mail. June 7 2013. http://m.theglobeandmail.com/life/parenting/why-canadian-babies-should-sleep-in-cardboard-boxes-like-finnish-babies-do/article12371884/?service=mobile (accessed 8 June 2013).
Baby: Cindy Smith at New Art Funny Wallpapers Jokes
Northern Lights: Chirag McEwan at Go to the World
Crib: Donna Virginx at Cribs