Why babies in Finland sleep in cardboard boxes

When Heikki Tiittanen and his wife opened the "baby box" given to every expectant mother in Finland, it was only then that he truly realised he was going to be a father.

"There was so much stuff – it really hit me visually," he recalls of that evening, four months before their first baby's due date. They sat in the livingroom of their Helsinki home emotionally fingering the stash of tiny outfits in graded sizes for their child's first year.

With the Finnish flair for good design and high quality products, the box and its contents look almost like a curated work of art – as well as a very practical tool for parenthood – and the patterns and colours are changed annually.

Introduced nearly 80 years ago, the iconic baby box is embedded in Finnish family life. Containing 50-plus items, ranging from a sleeping bag and snow suit, vests and babygrows, to breast pads and condoms, the box is offered to every pregnant woman regardless of income.

It is symbolic of how the state system embraces families in a country that has been deemed the best place in the world to be a mother by the Save the Children charity.

"We want to show that every child is equal and every child can have the same start in life," says Olga Tarsalainen, a spokeswoman for Kela, the Social Insurance Institution of Finland, which distributes the boxes.

In addition to this generous baby “starter kit”, mere mention of the fact that fees for full-time, quality, public childcare do not exceed €290 a month per child – and those on lower incomes can expect to pay considerably less – is probably enough to make Finland sound like nirvana to many Irish parents. Not to mention the generous stretches of paid leave for mothers and fathers.

However the annual Save the Children rankings for mothers' wellbeing are based on statistics for risk of maternal death, under-five mortality rate, expected length of formal education, per capita income and participation of women in national government. (In 2015 Finland was toppled from top place to runner-up spot by Norway, while Ireland was ranked 22, down three places on 2014, out of the 179 countries assessed.)

Finland’s “maternity package” was introduced in 1938 at a time when the infant mortality rate was 65 per 1,000 births. To qualify for the baby box, mothers had to register their pregnancy before four months and attend antenatal check-ups.

While widespread use of the sturdy, patterned cardboard box as a crib – a mattress and sheets are provided too – may have been one factor in reducing “cot deaths”, it is regular engagement with the health services that has been key to improving maternal and child health. Nearly 80 years later, infant mortality is down to 1.8 per 1,000 live births in Finland, compared to 3.5 in Ireland (although the very restrictive abortion laws here at least partly explain the difference, as more babies with life-limiting conditions are carried to full term).

Today, mothers must still register their pregnancy before four months and first-time mothers are required to make a minimum of nine to 11 visits to their local “neuvola” – maternity and child health clinic – before the birth. One of those appointments will be an extended family health check, run by a nurse and doctor and attended by the father and other siblings if any.

Physiotherapy sessions and family coaching are also offered to expectant parents, involving fathers as much as possible. However, there is no provision for home births.

The aim of the entire maternity package is "improving health and well-being of children and families and to reduce inequality", says Helena Miikkulainen, chief nurse at the Paloheina neuvola. It is one of 24 in Helsinki, which has a population of 630,000 and 7,100 births a year. There is also a focus on strengthening parents' relationships before and after delivery.

“The baby is coming to the mother and the father and both want to know how to be with the child,” she says.

Continuity of care

Josefiina Iivana (24) is 28 weeks pregnant with her first child and is in the Paloheina clinic on a recent Thursday morning for an antenatal check-up. There is a big emphasis on the continuity of care so she can expect to see the same public health nurse (PHN), not only throughout her pregnancy but with her child for the next six years after that too. When children start school at the age of seven, they transfer to the school health service.

The quiet, unrushed atmosphere of the whole clinic is striking. There are no more than one or two parents and children in the waiting areas of what is a pleasantly airy, light-filled building.

Iivana will have between 30 and 45 minutes with the nurse today, longer if needs be. Her partner was here earlier for the scan and a chat with the PHN about becoming parents.

At this particular neuvola in north Helsinki, a first-time mother is offered 16 antenatal appointments – 12 with the nurse and three with a doctor, as well as an extended health check involving her partner, and a home visit if necessary.

Such extended health checks, focusing on the wellbeing of the entire household, are repeated when a child is four months, 18 months and four years old. Through the use of questionnaires, domestic violence, drinking and substance abuse are among the topics explored.

Although Iivana is still at university, studying to be a home economics teacher, she says that taking a year’s break from studies has been “very easy”. She will receive four months’ paid maternity leave and up to six months’ paid parental leave from Kela. After that, there will be low-cost daycare for her child.

In a nearby room, three-month-old Felix is happily hiccupping his way through tests to check his reflexes, and is clearly tracking a red rattle with his eyes as it is slowly swept through an arc in front of his face. Today he will get vaccination drops against rotavirus (a viral infection that causes vomiting and diarrhoea) and also a pneumococcal vaccine injected into his thigh. The latter is already included in the Irish childhood vaccination schedule, while the former is about to be introduced for all babies born from October 1st.

Felix is the second child of Ruusu Kuvanen, who also has a two-year-old daughter, and the family lives less than a kilometre away from the clinic. The services are excellent here, she says, and it is very easy to get an appointment quickly with a nurse or doctor.

Paternity leave

A cell biologist working in molecular medicine at the University of Helsinki, Kuvanen went back to work when her daughter was 13 months old. “We have a big mortgage,” she smiles. She pays less than €300 a month to have her in full-time, public daycare and when Felix joins her sister it will be no more than €500 for both.

No wonder then that she seems a little perplexed to be asked if she had any reservations about affording to have children. “I never thought that way,” she replies. “It is not an economic issue.”

While she took the baby box the first time around, after Felix’s birth, she opted for the alternative €140 payment. With less than two years between the two children, she could reuse many of the clothes from the box, which are all gender neutral. And, she adds: “On the first one, I got so many clothes from friends.”

Some 95 per cent of mothers avail of the baby box – valued at up to €400 – and its contents are reviewed every year. A look back at how these have changed over the years gives a snapshot of parenting trends.

For instance, initially it contained fabric because mothers made their own baby’s clothes. Disposable nappies featured for the first time in 1969 but decades later it was back to cloth nappies as the more environmentally responsible option for the 21st century.

Feeding bottles have also been removed, to support breastfeeding, which the vast majority of mothers in Finland start with – and about 40 per cent breastfeed exclusively until their baby is six months old as recommended by the World Health Organisation (compared to six per cent in Ireland). And a new addition this year is a cuddly toy – a long-eared bunny.

In Felix’s first year he will have nine check-ups at the clinic – three by doctors. Between ages one and six, there will be at least eight more appointments. If any special development needs are picked up, the child is referred to other professionals such as therapists, psychologists and social workers.

Health care guarantee legislation, which came into force in March 2005, outlines the maximum waiting times for referrals to, and treatment in, specialised medical units. For example referrals must be assessed within three weeks, the need for treatment assessed within three months and surgery, if needed, must be within six months of the assessment.

The one exception to this is child and adolescent psychiatric care (for patients under 23), which must be provided within 90 days of the assessment.

Referrals for child services are prioritised according to need, says Sari Lahti, a senior lecturer in public health nurse education at the Metropolia University of Applied Sciences in Helsinki. She reckons a child referred to a speech therapist, for instance, would wait no more than a month, maybe two, for non-urgent cases.

Now the plan in the Helsinki municipality – by far the most populated of the country’s 300-plus local government regions – is to bring all these child health services under the one roof, to make it easier for families. By the end of 2018, the region’s 24 maternity and child health clinics will be consolidated into six “family houses”, where there will be three levels of service: the universal ones that are currently in the neuvolas; early support services such as speech therapy, and “corrective” services, eg child welfare.

“This will combine our strengths,” says Miikkulainen, whose Paloheina clinic is one of those due to close. “It will be easier for the families, with all the services in the same place.”

Meanwhile, six years after the momentous first sight of the baby box in his living room, Heikki Tiittanen is now father of three children. What’s more, he is CEO of a company that he and two other fathers set up in 2014 to produce commercial versions of the baby box for export.

Finnish Baby Box Oy supplies customers through its website (FinnishBabyBox.com) and has shipped boxes – costing €399 for the original and €599 for a Moomin-branded edition – to more than 75 countries, including Ireland. Contents are customised according to climate and due dates, taking seasonal factors into account.

Tiittanen, who spent 14 months at home with his children, says there has been a dramatic change in attitudes in recent years towards paternity leave and fathers availing of the home care allowance for under-threes.

Two weeks’ paid paternity leave was introduced in 1978 – something Irish fathers have had only since the beginning of this month.

Now, Finnish fathers get nine weeks’ paternity leave during a baby’s first two years. Up to three weeks can be taken during the mother’s maternity leave. They can also avail of some, or all, of the six months’ paid parental leave available to either parent.

Surely one of the best countries in the world to be a father too.

Next week: Daycare and early childhood education, the Finnish way.

swayman@irishtimes.com

Ireland v Finland

Population

Ireland 4.6 million

Finland 5.4 million

Life expectancy

Ireland 81.1 years

Finland 81.1 years

Births in 2015

Ireland 65,909

Finland 55,472

Birth rate per woman

Ireland 1.98

Finland 1.72

Infant mortality

Ireland 3.5 per 1,000 live births

Finland 1.8 per 1,000 live births

Caesarean sections

Ireland 285 per 1,000 live births

Finland 158 per 1,000 live births

Employment

Ireland 61% of people aged 15 to 64 have paid job

Finland 69% of people aged 15 to 64 have a paid job

Average earned income per person*

Ireland €47,460

Finland €36,288

Average household net-adjusted disposable annual income per capita*

Ireland €20,458

Finland €25,151

Child poverty**

Ireland 6.9

Finland 3.7

Suicide

Ireland 12.1 per 100,000 people

Finland 15.6 per 100,000 people

Life satisfaction

Ireland Average self-evaluated rate 6.8 (on scale 0-10)

Finland Average self-evaluated rate 7.4

Sources include OECD Better Life Index, other OECD figures, Unicef Innocenti Report Card 2013.

*OECD Better Life Index gives income figures in US dollars (here we have used the exchange rate of $1 = 89 cent.

**Child poverty is measured as the percentage of children in households with incomes below 50 per cent of national median income (after taking taxes and benefits into account and adjusting for family size and composition)