So-called "baby boxes" for newborns to sleep in were first introduced in Finland in the 1930s. The Finnish tradition has recently caught on in the U.S. (Claritza Jimenez/The Washington Post)

To prevent infant deaths in the District, lawmakers are considering a tool that has become synonymous with the record-low infant mortality rate in Finland — a cardboard box.

“Baby boxes” come packed with new baby supplies and are outfitted with a firm, foam mattress so they can double as a bassinet during the baby’s first months, offering a safer alternative to co-sleeping.

First offered to Finnish mothers in the 1930s, the low-cost beds are now being embraced by politicians, philanthropists and hospital administrators across the United States as a way to prevent sleep-related deaths for infants.

This January, New Jersey became the first state to launch a universal program providing every new mother with a baby box, along with training about safe sleep habits. Since then, statewide programs have been launched in Alabama, Ohio, Texas and Colorado.

D.C. Council member Brianne K. Nadeau (D-Ward 1), herself an expectant mother, this month introduced a bill that would provide all new parents with online training about safe sleep and a baby box to take home. “I believe every baby deserves a strong start, and that begins with a safe place to sleep,” she said.

A baby box sits in the office of DC Council member, Brianne Nadeau of Ward 1 at the John A. Wilson Building in Washington. Nadeau wants to provide baby boxes with supplies in them to new mothers. (Matt McClain/The Washington Post)

Already, the newly adopted programs are on track to distribute nearly 20 times the number of baby boxes the Finnish government supplies annually. The rapid pace of adoption is causing some medical professionals to urge caution.

A statement issued recently by the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome cited research on the outcomes related to baby boxes, even in Finland, where it’s not clear whether the nation’s low infant mortality is due to its baby boxes or broader system of prenatal care.

“There really is no evidence for these boxes,” the statement says.

Other doctors are questioning whether it’s safe to put newborn babies in a box to sleep. In the highly regulated marketplace for baby products, the boxes being mass distributed are not regulated by the U.S. Consumer Product Safety Commission, and doctors are questioning how air circulates in the box and what appropriate weight limits should be.

Jennifer Clary, co-founder and chief executive of The Baby Box Co., the for-profit company that is supplying the new statewide programs, said the boxes have undergone extensive safety testing and are the same boxes that have been used for decades in Finland.

No parent is given a box without learning about safe sleep habits and how to use the box safely, she said.

“Some people have an emotional problem with the concept of putting a child in a box,” she said. “The reality is that it’s every bit as safe.”

D.C. Council member Brianne Nadeau of Ward 1 poses for a portrait at the John A. Wilson Building. (Matt McClain/The Washington Post)
In D.C., progress and peril

Infant mortality has declined significantly in the District but hovered 27 percent above the national rate in 2014, with 7.6 deaths per 1,000 live births, compared with 6 per 1,000. The death rate for African American babies was even higher, at 10.5, compared with 3.7 for non-Hispanic whites.

The vast majority of deaths occur in the first weeks of life and are tied to chromosomal abnormalities, deformations or complications related to pregnancy. Most infants who die in the District are low-birth weight or preterm.

Anjali Talwalkar, senior deputy director for community health administration at the D.C. Department of Health, said it’s important to raise awareness about safe sleep, but she does not want to “distract” from the main drivers of infant mortality in the District. Significantly improving infant survival rates requires intervening earlier, she said, and improving the mother’s health care and education before and during pregnancy.

Obesity, chronic illness and a history of trauma are all factors that could contribute to a high-risk pregnancy, Talwalkar said.

The city also has a disparity in who is accessing prenatal care. Despite one of the lowest uninsured rates in the nation, 57 percent of African American mothers in the District in 2014 accessed prenatal care during their first trimester compared with 83 percent of white mothers.

Still, unsafe sleep practices are considered a major risk factor among infant deaths that occur after the baby’s first month. For young infants, co-sleeping with parents and sleeping on their stomachs or on soft beds puts them at risk for sudden infant death syndrome or accidental death by suffocation or strangulation.

The American Academy of Pediatrics recommends that babies be put to sleep on their backs in the same room as their parents but on a separate bed that has a firm mattress and is free of any loosefitting sheets or soft cushions.

Nationally, about 3,500 infants die each yearfrom sleep-related causes. Sleep-related infant deaths declined in the 1990s amid a national campaign to put babies on their backs to sleep, but they have plateaued since.

In the District, between 2014 and 2016, 48 infants died due to causes associated with unsafe sleeping practices, according to a report by the city’s Office of the Chief Medical Examiner.

One 5-month-old infant died after sleeping on an adult’s chest. He was later found on the floor between an air mattress and a couch, according to a 2015 child fatality report by the medical examiner. The death was classified as “undetermined.” The child also had been born premature and had a history of heart murmur, the report said.

In another case that was classified “accidental,” a 2½ -month-old infant died after she was placed on her stomach on a pillow in an adult bed with her parent. The report also noted that the mother was uninsured and did not have prenatal care.

The District has a long-standing safe sleep program that distributes about 1,000 portable cribs annually to new parents and caregivers who complete an in-person education session about safe sleep.

Nadeau said she hopes to expand on that program because the boxes would be offered universally. She wants to improve awareness about co-sleeping, which cuts across racial and socioeconomic demographics. Her bill also includes a provision that would study the outcomes of the program.

One small-scale study recently published at Temple University in Philadelphia found that sending mothers home from the hospital with baby boxes and face-to-face training about safe sleep reduced the rate of bed-sharing by 25 percent within the first eight days. For exclusively breast-fed infants, who are more likely to sleep with their mothers, the rate decreased by 50 percent.

“That was exciting for us to see,” said Megan Heere, medical director of Temple University Hospital’s Well Baby Nursery. “We know there’s a lot more work to be done, but we know we changed something in eight days.”

Finnish origins

The Finnish government began providing baby boxes, filled with newborn clothes and essential items, to new parents in the late 1930s, a time when nearly 1 in 10 babies died within their first year in the impoverished newly independent nation.

The box was conceived — and still serves — as a kind of welcome kit from the government that would incentivize women to access the public health care services, said Sanna Kangasharju, a press counselor at the Finnish Embassy in the District.

Expectant mothers can choose the box or a monetary award, currently the equivalent of about $180. To claim their prize, women first have to get a certificate from a health-care provider showing they have received prenatal care within the first four months of pregnancy, initiating a system of regular health care and counseling.

Kangasharju said 70 years later, many families never use the box as a bassinet, and focusing too much attention on the box “misses the point.”

“The boxes would not help very much if it were not for the help of doctors and midwives who could explain things like good hygiene and proper nutrition,” she said.

Clary traveled to Finland to study its baby box program after she started The Baby Box Co. She knew she could not replicate the country’s socialized health-care system, but she decided the company should focus its efforts on education.

So she launched Baby Box University. With every partner state, the company develops a syllabus and produces a series of short educational videos featuring local health-care providers and experts. The videos explain safe sleep principles, as well as information about immunizations, breast-feeding and such topics as finding safe child care. After passing a quiz, mothers can get a certificate to obtain their box.

“The baby boxes are not inherently magical,” she said. “But the way they are being distributed is having an impact.”