by Rebecca Holliman
Over dinner one evening with our friends (who are expecting their first child), Allee and I got into a discussion about Finland’s funny habit of putting their babies in cardboard boxes. Our friends are on a tight budget and live in a very small apartment in the city. They do not have the spare room in their home or their budget for a crib, but they found a way to make it work. They told us that the “Finish baby box” was the best solution for their needs. I will not judge them for choosing to put their baby in a cardboard box, but I was a little taken aback when I learned that they were paying almost $450 for the privilege. Granted, the box comes stuffed with baby clothes, bedding, and necessities, but still, is seemed absurd that the “low cost” solution to baby bedding was $120 more than the average American family’s monthly grocery bill. Still, I planned to dismiss it as an interesting habit of my slightly off-beat friends, until I started scrolling through an article on the Finnish baby box, and I came across this graph:
As a data-driven biomedical policy analyst, this is the sort of graph that makes my eyes go wide. These are stunning, almost inexplicable, results.
The Finnish government began the program in 1938 for low-income families, and expanded it to all families in 1949 (1). With the expansion, the Finnish government added the requirement that all expectant mothers had to seek prenatal medical care by their fourth month of pregnancy to receive the box (Finland has socialized medicine). The box worked as a crib for the first months of the baby’s life, but it also contained safe bedding, warm clothing that suits the cold Finnish weather, and basic essentials to help mothers get everything that they need (1).
“Mika Gissler, a professor at the National Institute for Health and Welfare in Helsinki, gives several reasons for this – the maternity box and pre-natal care for all women in the 1940s, followed in the 60s by a national health insurance system and the central hospital network.” –BBC News
This got Allee and me wondering, would something like this work for the United States? So, the next day we started exploring infant mortality statistics in the United States. The CDC reports that there are about 3,500 Sudden Unexpected Infant Deaths (SUID) each year. This includes Sudden Infant Death Syndrome (SIDS), accidental suffocation and strangulation in bed (ASSB), and unknown causes.
As you can see from the graph above, those rates have been dropping since the 1990’s. The CDC attributes the decrease in the combined SUID rate to the 1992 American Academy of Pediatrics safe sleep recommendations, the Back to Sleep campaign in 1994, and the Sudden Unexplained Infant Death Investigation Reporting Form in 1996 (2).
SIDS rates in particular decreased significantly between 1990 and 2014. We went from 130.3 deaths per 100,000 live births in 1990 to 38.7 deaths per 100,000 live births in 2014 (2), for the same reasons that the combined SUID rate declined.
Upsettingly, the incidents of unknown causes and (ASSB) have been on the rise since 1990. The statistically significant increase in rates began in 1998 and has been steadily climbing. This was after the interventions of the 1990’s that the CDC has attributed to the decrease in cumulative SUID rates (2). It is unclear whether the recent rise is attributable to higher incidence or to better reporting. Clearly, however, these public health campaigns, though they were very effective at impacting cumulative rates, have not been able to get rid of the problem altogether.
Then, we turned to the CDC’s SUID statistics based on race/ethnicity
SUID does not affect racial groups equally across the board. In fact, two racial groups in particular (American Indian/Alaskan Native and Non-Hispanic Black) (2). Granted, there are well-documented racial disparities between healthcare outcomes and mortality rates between whites and minorities in the United States (3), but SUID seems to have something different going on. The Non-Hispanic White population falls right in the middle of the graph. Hispanic and Asian/Pacific Islander populations have much lower rates. Allee and I took these statistics to our colleagues at AREA, and suggested that we try to figure it out.
We decided to work on this issue because it fits the criteria that we laid down to ensure that we hold to our mission. We want to tackle under-addressed public health challenges, where broad public health interventions do not work for particular populations. For some reason, the nation-wide interventions are not translating to action on one specific cohort of people. On our project to combat antimicrobial resistance, the cohort that we identified was “patients in the outpatient setting presenting with symptoms of an upper respiratory infection.” We found that the public health education campaigns and the recommendations from the medical community were not having as much of an impact on this one group of people. We set out to find out why, and then to find a way to address the challenge. SIDS fits our selection criteria perfectly. It is a problem where broad national interventions have not been effective with certain cohorts (American Indian/Alaskan Native and Non-Hispanic Black), and for those populations, SIDS is under-addressed.
We decided to focus on rates among American Indian/Alaskan Native populations first because American Indian/Alaskan Native populations and Non-Hispanic Black populations have dramatically different circumstances and cultures, leading us to believe that the drivers of both populations rates of SIDS are likely different. Therefore, we decided that addressing the challenges of both populations as distinct and unrelated problems was the most appropriate and respectful approach.
If we discover, in the course of our research, that there are drivers that overlap both cohorts that we can address, we will do our best to make those solutions available to all applicable populations. We hope that, as we progress with our project to address SIDS rates among Native populations, and we can spare more resources to look outside of that one cohort, that we will be able to address SIDS rates among Non-Hispanic Black populations and others in the future.
- Lee, H. (2013, June 04). Why Finnish babies sleep in cardboard boxes. BBC News. Retrieved from http://www.bbc.com/news/magazine-22751415
- CDC SUID/SIDS Data and Statistics. (2016, February 08). Retrieved March 07, 2016, from http://www.cdc.gov/sids/data.htm
- Matthew, D. B. (2015, December 11). Just medicine: A cure for racial inequality in American health care (1st ed., Vol. 1). New York City, NY: NYU Press.