ST. LOUIS (AP) - Thanks to a long-standing practice in Finland and donations from two St. Louis entities, Billie Williamson and other mothers of newborns in Missouri’s Bootheel have a new tool to combat high rates of sleep deaths: cardboard boxes for their babies to sleep inside.
But there’s debate whether the “boxinettes” will reduce sudden infant deaths or introduce new dangers to areas such as St. Louis, where infants die at an alarmingly high rate.
The boxes are gaining popularity among health policy leaders. Just last week, public health officials in New Jersey announced a universal program to distribute the boxes to all new mothers in the state.
Finland has been giving out the boxes to new mothers since the late 1930s, and their prevalence in the Nordic country has been tied to its extremely low infant-mortality rate. The colorfully decorated boxes are filled with clothes and other baby care items, with a bottom lined with a thin pad.
The St. Louis Post-Dispatch (https://bit.ly/2k65bQa ) reports that parents can opt to use the emptied box and pad as a simple bassinet for the newborn. In Finland, many do, offering them a free alternative to more dangerous sleep practices such as sharing a bed.
In the Bootheel, the hope is to give all new mothers who want one their own free boxinette to deter them from sharing a bed with their infants.
“I think it would have been good if I had had one 12 years ago,” said Williamson, of East Prairie, who recently got the box for her third child, November, age 3 months. Williamson said more than a decade ago she had no idea she was putting her oldest son at risk when she shared a bed with him as an infant.
Beginning this month, the boxes have been sent home with new moms in the Bootheel at three hospitals and through a federally funded Healthy Start home visiting program for mothers and newborns.
With gifts and funding provided through Home State Health Care - a subsidiary of Centene - and the Missouri Foundation for Health, the groups have built an inventory of nearly 3,000 boxes.
“If one box saves a life, that’s great,” said Cynthia Dean, CEO of the Missouri Bootheel Regional Consortium, which runs the Healthy Start program.
Finland, with an extensive social welfare system, has one of the world’s lowest infant mortality rates, about two babies per every thousand.
In Missouri’s six-county Bootheel, the infant mortality rate is four times that of Finland and a third higher than the U.S. average of 6.1 deaths for every 1,000 births. In a recent 10-year span, 218 babies younger than 1 year died in the Bootheel, an area with a population smaller than Springfield, Mo.
But the Finnish sleep boxes are not universally accepted, with critics saying they should not be considered a silver bullet to prevent infant mortality.
Dr. James Kemp, a safe sleep researcher and pediatrician with Washington University School of Medicine, said the boxes in themselves provide a safe sleep environment for babies. But issues arise if parents don’t use them properly. Babies should be moved to a crib when they reach 15 pounds or if they are beginning to pull themselves up on the side of the box.
Kemp said the transition out of the box may be where the greatest risk lies. He said during forensic investigations in St. Louis, bassinets that babies had outgrown were often found in the same room where infants died while bed-sharing with a parent.
“My main concern, frankly, is when the child is considered too big for the box, the parents take the child into the bed,” he said.
Due to concerns over safety, the SIDS Resources of St. Louis does not support use of the boxes, said Executive Director Lori Behrens.
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Co-sleeping risks
The boxes cost about $80 and are marketed for sale online to individuals and groups. In addition to New Jersey they are being distributed for free in hospitals in Philadelphia and Seattle.
The boxes are meant to primarily combat situations in which parents who lack cribs share their bed with a baby, or use couches or adult beds.
Bed-sharing - along with the use of blankets, bumpers and pillows - increases risk of unexpected infant death, particularly through suffocation or SIDS, according to the American Academy of Pediatrics.
Dr. Alan Barnette, a neonatologist with St. Francis Healthcare System in Cape Girardeau - one of the hospitals now distributing the boxes - said more than a quarter of infant deaths in the Bootheel are due to unsafe sleep practices. Most of those are caused by bed-sharing.
“These mothers get in the habit of sleeping with their infants because it is easier to console them when they are crying. It becomes a pattern,” Barnette said.
Cheryl Nolen, a home visiting case manager with the Missouri Bootheel Regional Consortium, said many area mothers recently polled said they aren’t concerned about the risks of co-sleeping. It’s a cultural norm to repeatedly check on whether an infant is breathing, and co-sleeping makes that easier, the women report.
All of the mothers who receive the boxes in the Bootheel are provided training and watch videos on their safe use, either prior to leaving the hospital or through home visits.
The Bootheel programs also involve area health departments. They, too, can distribute the boxes and provide training through the federal Women, Infants and Children supplemental nutrition program.
Even so, Nolan said, changing habits is difficult.
“I had a mom and I took a baby box out to her, and her church had bought her something as well, and she’s still co-sleeping,” she said.
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Raising concerns
The popularity of the boxes in the U.S. comes at a time when public health officials are seeking solutions to combat poor infant mortality rates. The U.S. ranks 26th in a global study of the rates among larger developed countries.
In some urban St. Louis area ZIP codes, those infant death rates rival developing third-world countries.
As a result, St. Louis Treasurer Tishaura Jones has included baby boxes in her campaign platform in the city’s mayoral race. She said every expectant mother in St. Louis should be given a box with supplies and information on local resources.
“We need to do what we can to give our new moms the first best steps that we can, especially with the high infant mortality rates that are prevalent in our area,” she said. “So we need to let moms know about them.”
But Behrens, of the SIDS resources, said her group supports other approaches to addressing sleep deaths in St. Louis. That includes an existing initiative to distribute free Pack N Play-style portable cribs.
She said she worries policymakers are comparing disparate situations in Finland with the United States, where issues surrounding infant mortality, poverty and bed sharing are different and highly complex.
She also worries about sanitary issues with the boxes and general safety. She further called out the inequity issues, where poor people are given cardboard boxes for their babies and others get real cribs.
Others on the fence include the leaders of Flourish, a regional initiative to lower infant mortality.
Kendra Copanas, head of Generate Health St. Louis, which is sponsoring the Flourish campaign, said skepticism about the boxes has been shared in other communities outside Missouri.
“Older African-American women saw this as going backwards, like when they had to put their babies in dresser drawers,” Copanas said.
But she said there’s an upside to the boxes: “It’s got a lot of people talking about the importance of safe sleep, and that’s an important conversation to be having.”
Williamson, the new mother, was at first skeptical, but now is an advocate for the boxes.
She has a bassinet in her bedroom, but she likes using the box with her baby, November, during the day to keep her close. The boxes have also prompted discussion about safe sleep with family and friends.
Barnette, the pediatrician, said the baby box project is a pilot program that will be studied for its effectiveness. To that end, local pediatricians have been asked to use an iPad survey to track the mothers and the boxes. In the meantime, everyone is hopeful more babies will thrive in the Bootheel.
“I don’t think this an infant mortality rate anyone should find acceptable,” Barnette said.
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Information from: St. Louis Post-Dispatch, https://www.stltoday.com
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