Winter in Mongolia can be cold. Brutally cold. During a particularly harsh winter - or 'dzud', Mongolian for 'white death' - temperatures at night can plunge to -50 degrees centigrade. These temperatures, together with harsh arctic winds, produce some strange sights: cattle and horses covered in snow and ice and frozen solid, and people with patches of blackened, frost-bitten skin on their faces.

It's not a place for the faint-hearted. But that's hardly a description applicable to Dr Semira Manaseki-Holland, who has been carrying out a Wellcome Trust-funded trial into the effects of swaddling on babies in Mongolia's capital, Ulaanbaatar.

Dr Manaseki-Holland first visited Mongolia during 1992/93, just after completing her medical training in the UK. At that time, Mongolia had just begun its long and difficult journey out of communism and was reeling from the abrupt reversion to a former way of life: decentralisation, democratisation and privatisation were bringing an end to the communist system of collective farms and centralised ownership of herds - and nomadic herders were resuming their traditional roaming of the steppes in search of pasture for their herds.

However, the Iranian-born Dr Manaseki-Holland was no stranger to political and social turmoil, having experienced a forced and violent return to tradition first-hand a decade previously. She was 12 years old when the 1979 revolution broke out in Iran and, as a member of the Bahai religious group persecuted under Ayatollah Khomeini, was in danger of eviction from her school. To enable her to continue her education, her parents sent her to England to live with a Bahai woman in Gloucestershire, intending to join her later. They never did. "My parents' passports were taken away and mine was invalidated," she recalls. "I didn't see my family again for 17 years. But at least they weren't executed or imprisoned like many of my friends' families. And the British Bahais in England were very supportive, they gave me a second home there."

Unlike Iran in 1979, Mongolia in 1992/93 was reverting to freedom, rather than to religious oppression, and was therefore open to new ideas and opportunities. "I was interested in international medicine, so I turned up at the UNICEF office there and asked if they had any work. I was there at the right time. Mongolia was undergoing massive change, and UNICEF was looking to develop their ARI [acute respiratory infections] programme. But there were not many people available to travel at short notice - partly because Mongolia was unknown, partly because the winters were so harsh. So when I turned up, with a medical qualification and an intercalated research degree, they gave me an ethnographic study looking at the knowledge, attitudes and practices of parents and carers of infants."

Swaddling clothes

One of the childcare practices she was particularly interested in was swaddling. More than 90 per cent of Mongolian mothers used tight, prolonged swaddling to keep their babies warm. It makes sense, when half of Mongolia's 2.5 million population live in gers - traditional nomadic tents made from layers of white felt and canvas covering a wooden frame - with the heat from a coal or wood stove placed in the middle, to keep the cold at bay. "But," says Dr Manaseki-Holland, "as a doctor, it's an instinctive reaction to ask yourself, what effect does that have on the baby?"

A small pilot study in Turkey in 1990, which reported a nearly threefold increase in pneumonia in swaddled babies, alerted Dr Manaseki-Holland to a possible link between swaddling and chest infections - corroborated by the fact that Mongolia has unusually high rates of acute respiratory infections. "Tight swaddling could restrict chest movement, making it harder for the baby to breathe during challenges to the respiratory system, and excessive insulation could increase a fever," she explains. "Also the parent or caretaker might not notice signs of distress, like rapid breathing, under the swaddling. So I asked a lot of questions about pneumonia and swaddling while I was doing the UNICEF study and the grassroots community work."

The data she gathered were to form the groundwork of the first large-scale randomised controlled trial ever to investigate an association between swaddling and acute respiratory infection. Ten years after leaving Mongolia for the less dramatic political and meteorological climate of Birmingham, followed by a year working for the WHO in Geneva, Dr Manaseki-Holland returned to Mongolia for the winter of 2002/03, armed with a Wellcome Trust grant, to conduct her trial.

In September 2002, just before the winter cold set in, her team recruited 1250 newborn infants from poorer families in Ulaanbaatar, and allocated them randomly to swaddling and non-swaddling groups. All were then followed-up for seven months with regular home visits from field staff to ensure compliance and gather additional data.

Traditions

Compliance is the most crucial - and often the most problematic - element of any trial, particularly one dealing with deep-rooted traditional practices. Although the non-swaddling group were given adequate, warm baby clothes as a replacement, seven months is a long time to ask a mother to abstain from a custom she, and her mother and grandmother before her, have always practised. "Swaddling is integral to countries with cold climates. It's prehistoric - there are pictures thousands of years old of swaddled babies," says Dr Manaseki-Holland. "It's closer to home than you think too: swaddling was common practice in the UK right up until the early 1900s, and in parts of Europe till recent decades."

The reluctance to let go of age-old customs - particularly strong in grandparents - needed to be handled with great sensitivity. The work Dr Manaseki-Holland carried out in Mongolia ten years ago has proved vital to this trial, not only in terms of providing preliminary data, but also in helping her gain insights into the wider cultural and emotional issues. "It's important for researchers to get involved in the real life of the people they want to study, see how they look at things and understand their sensitivities," she says. "Especially if you are looking at childcare, which is close to everyone's heart all over the world. Everyone wants to do their best for their children - and it's hard for people to accept that the ways in which their mothers and grandmothers cared for them are being questioned."

Moreover, she is keen not to be seen to have a preset agenda. "For example, around the world, people believe that swaddled babies sleep better, and there are some data to back that up. Other benefits might be that reduced movement and maintained warm temperature could conserve energy and give a better growth rate." Collecting these data is important and demonstrates that the research team is taking an unbiased view. "Understandably, it is not right that someone coming from the West should advocate that swaddling is wrong full stop, and without looking into the possible positive effects. Mongolians should see that we're taking a neutral standpoint and looking at all the different aspects, good and bad. Once we've analysed the data from this study, we might be able to say swaddling has no relation to chest infection - but it does have these positive effects."

Whatever the outcomes of the trial, Dr Manaseki-Holland's ultimate aim is to provide an evidence base to inform the development of public health policies and interventions - both in Mongolia and other countries with cold climates. "If we find swaddling, as it is practised now in Mongolia, is detrimental, we'll try and find less severe methods of swaddling or child clothing that are still culturally acceptable. We can get local businesses to make baby clothes that are warm enough for -50 degrees centrigrade winters, or get aid agencies to subsidise them. On the other hand, if we find that swaddling is beneficial, we'll have evidence to prevent derogatory attitudes towards this practical way of childcare. This is something we've never had before."

External links

• Dr Semira Manaseki-Holland at the London School of Hygiene and Tropical Medicine, University of London: Research interests including details on the Mongolia swaddling project